The Journal Of The American Medical Association(113)

1374

RESPONSE TO DRUGS— NELSON

Jour. A. Jr. A.
Oct. 7, 1939

the expected mortality if all the members of a series
were injected with the dosage corresponding to that
particular point on the abscissa. Experimentally it has
been found that the predicted results are most nearly
obtained for the middle part of the curve. Today the
accepted expression for toxicity is the L. D. 50; that is,
the dose that will kill 50 per cent of a group of animals

Chart 1. — Frequency polygon showing the distribution around the mean
value of the lethal doses of digitalis for different cats. Numbers of cats
are shown on the ordinates; on the abscissa 0 represents the mean value,
with deviations from this shown as percentages plus and minus (alter
de Lind van Wijngaarden *).

sufficiently large. One may interject parenthetically
that when digitalis is examined in this fashion it is nec-
essary to standardize the anesthetic, the rate of injec-
tion, possibly the dilution, and other factors. The cat
unit” in the sense often used today varies not only
because of variations in potency of digitalis but also
because of variations in pharmacologists. Theietore,
as an expression of an absolute value it is of somewhat
restricted significance except in the laboratory where
it has been determined.

The second method of determining toxicity by use
of the fatal dose determination is one in which the
individual dose for each animal is not determined In
the application of this method, groups of animals ns
comparable as possible as to weight, sex, state of nutri
tion and other factors are used. For obvious reasons
small animals, frogs, mice, rats, insects and goldfish,
are commonly employed. Into all the llie F lbers •
several such groups are injected doses of increasing
amounts, each member of a particular group > howeve
<rettiiw the dose previously decided on for that group.
If thcold conception of the minimum lethal dose were
correct” all of the groups below a certain dose level
would survive, all above that point would be killed.
This is not the case, as has been shown many times
with many different substances. For example, in
S* r of the toxicity of strychnine sal key ate for ™1e

TtteT h" he same'fashioJi’ asldTc.tcd for digitalis
•ill, the percentage killed on the ordinate apt. mat .the

■'Tl^^tSefr^rSr^frLISSch

these data ar'c taken, quite different -does acre reported

f 0 een“e"'« S ere f found 'mo“ sTept'iblc than males, and
the toxicity decreased with age. _

Thcrap. 3S:239 (Nov.) 1930.

These curves, which after all are only the graphic
expression of the variability of response of animals to
these particular toxic substances, are not unique.
Similar curves can be plotted for the actions of a variety
of drugs in which the end point is definite enough to
be clearly recognized. There may be less symmetry
than is here shown; the curves may rise more rapidly
or be more flattened, but in a general way it may be
said that the variability that underlies the records is a
biologic phenomenon; it is the behavior that one has
come to expect.

What is the concern of the physician with such exper-
iments — with curves that are derived often from toxic
actions? Often, it is true, he is unaware of such vari-
ability because of the difficulty in recognizing degrees
of effect, of establishing comparable levels of action. In
other cases, in the induction of anesthesia for example,
variability is recognized but correction is at^once made
for it. The anesthetist modifies the concentration or
the respiratory activity until the desired end point is
reached.

A number of years ago Hanzlik 3 gave salicylates to
a large group of patients to the point of induction of
symptoms' of intolerance. When his data are arranged
in the fashion indicated for the toxicity of digitalis for
cats, the sigmoid curve results. Clark, 4 in an address
to members of the British Medical Association on this
same subject of variability in response, cites other
studies, for example of the amount of sodium amytal

1

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m

i

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1

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m

m

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ft!

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i

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r

fis

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in

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3 4 5 6 7

DOSAGE

lr , 2 — Frequency distribution of individual lethal doses ./Vh^'sTine
0 ;.ouTd ra0 ctresp r on C dTo n Wosace units. ‘This is an ideaiired

mired to produce analgesia for labor and of cvip
uble for anesthesia, which yield similar curves
hal dose s of diethylene glycol for human being

3. Hanzlik, P. J.t A Study of .1. Toxicity SalicyU.es Ilased .
JcStAT 1 individual Variation in Response to Drugs, IJr.t.

j. 2 : 307 (Aug. 14) 1937.

Volume 1 1 3 - *
Number 15

1375

farm accidents— powers

compiled by Galvcry and Klumpp, 5 6 have a similar dis-
tribution' When tlicir data are published there will be
available for the first time an L. D. 50 for the human
species, or at least a value approaching it. A moment s
consideration will reveal why the present lethal closes
{or man of different poisons given in toxicologies differ
so much. They merely represent the results on a few
of the members of the group that must lie used to give
anything approaching an exact value. Put differently,
they arc definite evidence' of the variability that forms
the’ subject of this report.

Recently the extensive use of metrazol for the pro-
duction of convulsions in human beings has made pos-
sible compilation of data. Hitchcock 0 in my laboratory
has shown that the doses required have the typical dis-
tribution and yield the sigmoid curve. Further examples
need not be given. It is evident from those cited that
the variability found by the pharmacologist working in
the laboratory with populations as uniform as possible
as to sex. weight and nutrition is to be anticipated m
the human species. As a matter of fact the lack of
uniformity in human populations with respect to age,
weight, sex and physical health would lead one to expect
an even greater degree of variability. Not a great deal
of exact knowledge exists as to the effect of these
factors. It has been clearly shown that there are sex
differences, as for example in the case of strychnine.
Some years ago McGrath showed that it was much
easier to produce gangrene of the tail in male rats than
in females by the use of large doses of ergotamine. He
further noted that injection of theelin protected the
otherwise susceptible males/ When differences in age
are- considered, even the simplest determinations are
complicated by variations in weight as well. In the
laboratory, dosage is commonly calculated on a weight
basis, but evidence for the correctness of this practice
is largelv wanting. Indeed the studies on metabolism
on both laboratory animals and man indicate that, for
this particular determination, corrections are more prop-
erly made in relation to surface area, which is not a
function of weight.

Finally, when one faces the variability- introduced by
the presence of disease, quantitative studies are almost
wholly lacking. There is here an almost unexplored
field of pharmacology, which is surprising in view of
the immediate significance of the results to therapeutics.

In all this discussion there has been presented noth-
ing that is new. Every- physician is aware of course
that there exists the type and degree of variation that
has been described. Yet there are implications that are
not recognized, if one may judge by the questions that
come to the pharmacologist from his clinical colleagues.
For example, the spread of response described means
that any fixed dose system of anesthesia is unsound. If
a series is large enough there will inevitably be a num-
ber of dangerous or even fatal reactions from what are
ordinarily considered safe doses. If normal cats vary
as has been described in their susceptibility to digitalis,
it is certain that in the administration of massive doses
of digitalis for prompt action there will be instances of
patients representing the lower part of the curve,
poisoned by amounts of digitalis not dangerous to the
greater number of patients. If alcoholic intoxication
is diagnosed on the basis of blood alcohol alone, some
drivers will be charged with a degree of intoxication

5. Calvery, H. O., and Klumpp, Theodore: Personal communication
to the author.

6. Hitchcock, \V. P. : Personal* communication to the author.

L, 7. McGrath, E. J. G.: Experimental Peripheral Gangrene; Effect of
Estrogenic Substance and Its Relation to Thrombo-Angiitis Obliterans,
Arch. Int. Med. 55:942 (June) 1935.

that is either greater or less than their degree of motor
control justifies. If local anesthetics are injected for
surgical operations, an occasional patient will show
alarming reactions.

Because one must recognize that variation is a bio-
logic fact, one should not therefore fold one’s hands
and accept the situation without an attempt at clarifica-
tion. Even variability must have an explanation. But
if the experience of those who work with populations
rather than with individuals, under more rigorously con-
trolled conditions than are usually possible in the prac-
tice of medicine, can at all be-translated into the clinical
field, then occasional untoward reactions which are not
due to idiosyncrasy or thymicolymphatic constitution or
air emboli or improperly prepared solutions are to be

anticipated. conclusion

It is urged that, when the practicing physician is
working with material that could be treated by the
pharmacologist to gain further insight into the degree
and extent of human variability,. he should report his
data in detail. When more knowledge is available, when
the pharmacologist can with some assurance predict the
safe ranges in human pharmacology, then perhaps he
can at the same time add something to the safety and
effectiveness of human therapeutics, which after all is
one of his chief reasons for existence.

THE HAZARDS OF FARMING
JOHN H. POWERS, M.D.

COOrERSTOWN, N. Y.

During the past quarter century the hazards of indus-
try, transportation, mining and construction have been
recognized; the economic value of safety has become
clearly apparent and measures have been adopted to
insure its promotion. For agriculture, because of its
primarily individualistic character, there has been no
such recognition or supervision, and farming, though
the oldest occupation in the world, remains the most
hazardous.

Having lived and practiced surgery in a rural com-
munity during the past eight years, I have become inter-
ested in the hazards to which the farmer is daily exposed
and the accidents which result therefrom. In central
New York, small dairy farms are numerous and farm-
ing is often an occupation of necessity rather than
choice. Many of the farmers are poor, their equipment
is inadequate and frequently out of repair, wages are
low and hired help is difficult to find and often incom-
petent. Because of these circumstances, carelessness and
inefficiency are common and serious accidents are prone
to occur.

This report is based on a review of 310 accidents of
this type sustained in a rural section of New York
State. The patients were treated at the Mary Imogene
Bassett Hospital in Cooperstown, N. Y., during the
years 1929-1938 inclusive.

An analysis of the records has disclosed numerous
interesting facts relative to farm injuries which seem
pertinent for presentation to the Section on Preventive
and Industrial Medicine and Public Health. The only
other data on agricultural accidents of which I am aware
have been collected by the Kansas board of health from

From the Department of Surgery of the Mary Imogene Bassett Hos-
pital.

Read before the Section on Preventive and Industrial Medicine and
Public Health at the Ninetieth Annual Session of the American Medical
Association, St. Louis, May 17, 1939.

Jour. A. M. A.
Oct. 7 , 1939

1376 FARM ACCIDENTS— POWERS

f-fy «» n^itate admission of X“atl t ToT atoed. " y «** “““ * 0' definitely

Summer is the most dangerous season on the farm:
ate winter the most secure. The curve representing
t ie seasonal distribution of all farm accidents (chart 1 )
1S comparable to that for all rural accidents reported

■ o^ C r Cra r on RuraI Medicine in Cooperstown
m 1938. Accidents m the course of routine chores are
moie or less constant throughout the twelve months;
those due to logging occur most frequently during the
late tall and winter, while those incidental to haying
are naturally much more numerous during July and
August (chart 2). The summer peak is composed
largely of haying accidents and accidents due to unclassi-
fied activities, including the playing of children.

2. Location. — Exactly one half of these 310 farm
accidents occurred in the barn or barnyard, 13.5 per
cent in the woods, 12.6 per cent in the surrounding

hospital or to require major surgical treatment in the
operating room.

ANALYSIS OF 310 FARM ACCIDENTS

1. Incidence, Liability and Seasonal Distribution.

Many seemingly irrelevant conditions have a direct
influence on the admission of patients to hospitals. The

Activity

Chores

Logging

Haying

Playing of children

Repair and construction of buildings .

Assault or suicide

Others

Total

Number

99

66

50

31

22

13

29

310

Per Cent
31.9
21.3
16.1
10.0

7.1

4.2
9.4

100.0

any discussion of the incidence of farm accidents in a
given district on this basis is open to some criticism.
With this in mind a simple statement anent the incidence
of serious farm injuries in this locality, treated at this
hospital, will suffice. During the decade embraced by
this study there were 1,329 patients with injuries of
comparable severity from all types of trauma; 310
of these, or 23.3 per cent, were related to the hazards of
farming.

Of the farm accidents 70.3 per cent were due to care-
lessness of the person injured and 9.4 per cent to the
carelessness of some one else, 1 5.5 per cent were unpre-

Table 2.— Etiologic Agents in 310 Farm

Accidents

Agent

Number Per Cent

Tool or implement

Animal

18.1

Machine

Vehicle

Falling tree

Pleat or Cold

a. a

Others or none

Total .

100.0

economic status of the family, the season of the year,
the condition of the roads, the distance to be traversed,
the severity of the injury, and the attitude of both the
family and the physician all exercise a selective effect
on statistics of hospital morbidity in a rural area. Hence

Table 1 . — Etiologic Analysis of 310 Farm Accidents

fields and pastures, 8.4 per cent in the hayfield and only
6.8 per cent in the house and shed. A few occurred on
the highway but were not due to motor vehicles.

3. Etiology. — At least two factors participate in
the causation of most farm accidents, a motivating
activity and a causative agent. Of the former, routine
chores accounted for nearly one third of the accidents,
logging for one fifth and haying for one sixth (table 1).
Ten per cent of the accidents were sustained by children

while at play on buildings or vehicles, in trees or near
men at work with machinery. Assault or suicide was
responsible for 4.2 per cent of the injuries, a rather
unexpected hazard but one which may be explained by
the lonely life of poverty and solitude which many
farmers lead in distinctly rural areas.

1. Powers. John H. : Rural Medicine: Emergency Surgery in a Rural
Hospital, Springfield, III., Charles C. Thomas, 3939, p. 51.

Volume 113
Number 15

FARM ACCIDENTS— POWERS

1377

The etiologic agents arc recorded in order of fre-
quency in table 2. Eighteen per cent of the accidents
were caused by farm tools or implements, 16.5 per cent
by animals, 12.9 per cent by machinery, 11.6 per cent
by vehicles, 5.5 per cent by falling trees or rolling logs
and 2.2 per cent by heat or cold. Under “others” are
included barbed wire fences, rusty nails, splinters,
thorns, hooks, chains and firearms. When a fall
occurred with no obvious causative agent responsible,
none was recorded ; tiic numerous falls on slippery, icy
ground account for the high percentage of accidents
included in this category.

4. Distribution by Age ami Sex . — In central New
York state all rural accidents were found to be most
common between the ages of 15 and 24; males were
injured twice as frequently as females. 1 Farm accidents
show no such definite peak but occur with little sig-
nificant variation from the beginning of the second
decade throughout the active working life of man.
Males are involved with ten times the frequency of
females (chart 3).

5. Analysis of Interval Between Accident and Admis-
sion . — One phase of this study has been of particular
interest, namely the disclosure of the length of time
required for injured farmers in the surrounding country-

hip and lower extremity, the bones of these parts were
fractured with almost equal frequency.

7. Period of Hospitalization . — As a result of these
farm accidents 4,855 days were spent in the hospital
by 266 inpatients and 1,333 visits were made to the
ambulatory surgical clinic by 232 outpatients (chart 7).

summer

CU?tm.ATIVE SCALE 310 CASES

admitted viithin
admitted within
admitted viithin
admitted within
admitted viithin
admitted v/lthin
admitted viithin
admitted after

per cent Interval not kno'itn

day

days

days

days

days

days

week

week

Chart 4. — Analysis of interval between accident and admission.

Chart 3. — Distribution of farm accidents by age and sex.

side to reach the hospital after an accident has occurred.
The data are presented in chart 4; 30 per cent of the
patients arrived within one hour, 46 per cent within
two hours, 56 per cent within four hours and 63 per
cent within six hours. The percentages for subsequent
intervals up to one week are tabulated in the chart.

6. Classification of Injuries and Topographic Dis-
tribution of Injuries and Fractures . — There were 289
fractures, of which eighty-five were compound, com-
prising 33.7 per cent of the 864 recorded injuries,
classified according to the second edition of the Standard
Classified Nomenclature of Disease. Lacerations were
next in frequency. Division of nerves, blood vessels
and tendons and partial or complete amputations of
fingers, hands or forearms are common among farm
injuries and are due to contact with rotary saws, mow-
ing machines, ensilage cutters, scythes and axes. Eleven
per cent of the patients sustained concussion of the
brain, and approximately 6 per cent were in shock on
arrival at the hospital. Many patients received multiple
lesions of bones and soft tissues in combination. All
the injuries are classified by number and percentage in
chart 5.

Actually of more interest in a study of the hazards
of farming is the topographic distribution of the injuries
and fractures thereby sustained. These are presented
in chart 6, which shows that, although the shoulder
and upper extremity were injured much more often
(in approximately 30 per cent of the cases) than the

These figures represent botli time which the farmer can
ill afford to lose and money which he can even less well
afford to pay for hired help. The average period of
hospitalization was 18.3 days and the average number
of outpatient visits was 5.7, yet neither figure is an
accurate representation of the total period of disability.

8. Fiscal Analysis . — The actual cost of a serious
injury is to most farmers a major financial catastrophe.

Chart 5. — Classification of 864 injuries sustained in 310 farm accidents.

Twenty per cent in this series were able to pay nothing
for their professional care and hospitalization, 18 per
cent paid in part and 62 per cent paid in full. Most of
the last mentioned required many months and even
years for the complete discharge of their financial
obligation. The hospital was forced to accept a financial

FARM ACCIDENTS— POWERS

Jour. A. ir. A.
Oct. 7, 1939

loss of about S 10,000, or 30 per cent of the total charges Routine chores were the ffln t i

made for hospitalization, outpatient visits and orofes- mnrivatina net' \ , e . most dan gerous single

sional care incidental to the hazards of farming order of frequencv. FarmTmlf n6Xt in

F ata ^ t ’ cs - Sixteen of the patients did mals, machinery and vehicles all comributedThdfshare"

survive 1 hree were moribund on admission and of injuries in about equal proportions. Falls were

died from the immediate effects of trauma within a few numerous.

lioui s. Three lived less than one day, and five survived
from two to four days. The remaining five died from

Table 3. — Analysis of Fatalities

Cause of Death No.

Fracture-dislocation of

cervical spine 4

Compound depressed
fracture of skull ... 3

Extensive burns 3

Multiple injuries and

shock 2

Tetanus 1

Peritonitis .......... 1

Bacteremia due to
Staphylococcus

aureus 1

Coronary thrombosis.. 1

Total 16

Contributing

Activity

Logging 4

Haying 3

Playing of children 2
Repair of buildings 1
Suicide \

Contributing

Agent No.

Animal 3

Heat (fire) 3

Vehicle 2

Falling tree 2

Machine 1

Firearm )

Others or none. . .

Males were involved with ten times the frequency
of females. J

Nearly 50 per cent of the patients reached the hos-
pital within two hours.

Fractures comprised one third of all injuries; division
of nerves and tendons and partial or complete amputa-

12 13 14 is L® 4 .P SO 60 70 B0 flo 100

. f _ r ,fl 59 89 79 69 9*9 +

TOTAL NUMBER OF HOSPITAL DAYS
’* IW-pATIENTS

AVERAGE PERIOD OF HOSPITALIZATION

4835 = 133 YEARS
266

18 3 DAYS

■\OTA\_ miWBETt ©? CVT-pATIEWT VISITS 1333
CUT PATIENTS 232

AVERAGE > OUT-PATIENT VISITS 5.7

Mortality, 5.1 per cent

ten to fifty-three days after admission because of com-
plications associated with the late effects of trauma or
from intercurrent disease. Fourteen of the deaths were
of adults, with an average age of 55 years, and two were
of children.

Chart 7.- — Data relative to period of hospitalization and number of out-
patient visits.

The contributing activities and agents are given in
order of frequency in table 3. The mortality for the
entire group of 310 patients was 5.1 per cent.

SUMMARY

Agricultural accidents were responsible for nearly one
fourth of all the serious injuries treated at a medium
sized rural hospital in the central part of New York

Chart 6. — Topographic distribution of injuries and fractures due to the
hazards of farming. All injuries of each anatomic subdivision are
recorded above the horizontal line and in the black columns; all frac-
tures of the bones of the same subdivision are recorded below this line
and in the shaded columns.

State during the years 1929-1938 inclusive. Such acci-
dents showed a definite seasonal variation with a peak
during July and August, for which haying, the playing
of children and other unclassified activities were largely
responsible.

Fifty 7 per cent of all farm accidents occurred either in
the ban: or in the barnyard.

tions of fingers and hands were common. The shoulder
and upper extremity were injured more frequently, than
the hip and lower extremity.

The average period of hospitalization was 18.3 days
and the average number of outpatient visits was 5.7.

The monetary loss incidental to a serious injury was
for most fanners a major financial catastrophe. Twenty
per cent were unable to pay anything for their hospital-
ization and professional care.

The mortality was 5.1 per cent.

CONCLUSION

Farming is an exceedingly dangerous occupation, the
hazards of which are not universally appreciated.

ABSTRACT OF DISCUSSION

Dr. Fred P. Helm, Topeka, ICan. : It is fitting that a physi-
cian devoted to the conservation of human life has made this
study. Farming is the occupation in which more accidents occur
than in any other line of industry, and it is the occupation in
which the least accident prevention effort has been made.
Education is the chief weapon by which we may combat farm
accidents, and a study of the causes is essential as the basis of
a safety program. The causes of farm accidents, as stated by
Dr. Powers, include machinery, animals, vehicles and falls.
These causes tally with the experience of the Kansas State
Board of Health. There is some variation in Dr. Powers'
analysis, as compared to the data assembled in our office, which
may be accounted for by the fact that (I) Dr. Powers’ study
includes nonfatal as well as fatal injuries, whereas our figures
deal only with fatal accidents; (2) Dr. Powers has included
all persons dwelling on the farm, whereas the health depart-
ment classification includes only those engaged in agriculture;
(3) Dr. Powers has included under "farm” accidents injuries
which, in our records, fall under four classifications, namely
"home,” "motor vehicle,” "public” and "occupational,” and (4)
homidical or suicidal injuries are not classified as accidental by
vital statistics bureaus. Obviously, restricting farm injuries to
those incurred in agriculture would change the picture as to
cause, age and sex. It is characteristic of all accident injuries,

Volume 1 13
Number -15

FARM. ACCIDENTS— POWERS

1379

however, that far more occur in males than in females. The
reports coincide in that summer is the season of greatest fre-
quency. Deaths due to Kansas farm accidents, by cause, during
1930-1938 inclusive, were machinery 244, animal 171, excessive
heat eighty-nine, vehicular eighty-one, falls eighty, lightning
forty-three, puncture and incised wounds and abrasions forty-
two, injury by falling trees cut for firewood or posts thirty-
eight, burns twenty-one, falling objects (other than trees) eight,
excessive cold seven, electric shock five and "other" twenty-
five, a total of 854. Although the leading cause is machinery,
as one would expect in this “mechanized" age, the animal
injuries, plus those caused by horse-drawn vehicles, exceed the
machinery fatalities. Dr. Powers stated that “70 per cent of
farm accidents arc due to carelessness.” Our reports also prove
carelessness to he the leading cause. These accidents therefore
arc largely preventable.

Dr. A. G. Cranch, New York: Dr. Powers has emphasized
certain hazards well worth considering. One is accustomed to
overlook the hazards in farming and agriculture. I spent prac-
tically five years in a rural community without hospital facilities
or improved roads or automobiles, and I have a little different
point of view from the men in the hospitals. Such a hazardous
situation exists in farming because of the primitive, makeshift
tools usually employed for the work on the farm, because of
the improper use made of ill adapted tools and because the
machinery on the farm is almost completely unguarded. The
safety movement as we know it in industry is practically unheard
of in farm circles, and you can’t tell them ; they know 1 Their
fathers did it that way before them, and their grandfathers did
it that way even before them, and why should they change
their methods? The missionary work I accomplished in five
years was practically nil. The accidents went on and from the
same sources, because of primitive instruments and unguarded
tools. There arc two other features in connection with rural
hazards. One is the presence of infections, the other infectious
diseases. Tuberculosis I found far more prevalent than one
would expect in the rural community. Other conditions peculiar
to farming, especially around the threshing season, are respira-
tory infections, fungous infections, allergic conditions and the like.
Another thing rather noticeably frequent in rural areas was the
presence of psychiatric conditions resulting possibly from isola-
tion and monotony more than anything else. The mental con-
ditions seemed out of proportion to the population.

Dr. Leopold Brahdv, New York: In New York we have
long been considering the advisability of extending compensa-
tion laws to the farming community and it is only with the
data in such papers as we have just heard that one can deal
with that question intelligently. There are several things I
would like to hear more about. One of them is brought up by
the surprisingly small, 2 per cent, number of injuries due to
cold. When we have a snowstorm in the city and put thousands
of men to shoveling snow, we have scores of serious frostbites,
largely because these men are not used to working in the cold.
How many of these farm accidents do you estimate occur to
the hired help, who are incompetent because they are not used
to farm life, and how many occur among the farmers them-
selves? The effect on the farmer’s economic status when he
has a serious accident must be given a great deal of considera-
tion from a social and public health point of view, from the
standpoint of the individual who is injured, and from the point
of view of our own profession. On this important subject there
are so little data that this* excellent paper marks, I hope, the
beginning of a great deal of study along this line.

Dr. Joseph W. Mountin, Washington, D. C. : The section
is deeply indebted to Dr. Powers for this splendid paper. There
are at least three reasons why accidents constitute a public
health problem: Accidents are a major cause of death and of
disability; they are preventable in large part; health agencies
are equipped for organizing measures in accident control. Acci-
dents of the type described by Dr. Powers come within the
province of health departments. No other agency is so well
prepared by reason of its interest and the technics represented
m its staff as an organized county health department for
resolving the causative factors associated with farm and home
accidents. In the way of specific procedure, I make these sug-
gestions : The health department should endeavor to secure

reports on accidents — those of a minor character as well as the
ones that have come to medical attention. The circumstances
associated with each accident should be investigated by the health
officer, the nurse or the sanitation officer. Moreover, routine
inspection of premises may disclose hazards that have not as
yet given rise to accidents. ' Many hazards about the farm
could be corrected by rather simple alterations of building and
grounds. Improvement in the design of farm machines offers
another possibility. Perhaps the largest achievements will come
as a result of education. Habits of safety need to be inculcated.
Most of all, farmers should be impressed with the fact that they
live and work in a dangerous environment. I urge that the
health authorities become active workers in the safety movement
and most especially in that part of it which is concerned with
prevention of farm and home accidents.

Dr. J. N. Baker, Montgomery, Ala. : I too should like to
commend Dr. Powers for the lucid and painstaking manner in
which he has presented his personal observations and study on
the hazards of farming. To an administrative health official of
Alabama, which is still predominantly rural, the questions dis-
cussed have an added importance. Because of the necessity for
concentration in onr state on certain major health problems
arising from environmental conditions such as malaria, hook-
worm and pellagra, and which, through an organized health
machinery, arc being brought under control, the hazards of the
farm worker, as contrasted with the industrial worker, have as
yet claimed small attention. The educative implications of this
study seem clear; agricultural states, under the leadership of
their health departments, must seek to bring to their rural
population every possible safeguard against hazards, just as our
industrial hygiene units arc striving to protect the employee in
the factory. The “safety first” doctrine, so valuable to industry,
must be made to permeate our rural workers. Here is a com-
paratively new “preventive field” opening up which challenges
the resourcefulness alike of physicians and of health workers.
Because of the economic factors which figure in the proper
medical and hospital care of farm workers after the accident has
happened, I should like to have Dr. Powers outline the economic
status of this group ; that is, how many may have been on relief
or were clients of the Farm Security Administration or, through
any source whatever, may have had protection through accident
or indemnity insurance.

Dr. John H. Powers, Cooperstown, N. Y. : With regard to
Dr. Helm’s comment about assault and suicide, I appreciate the
fact that these are not accidents but, nevertheless, I do regard
them as definite hazards of farming in a distinctly rural area
and for that reason they were included. Women are involved
in agricultural accidents more frequently in central New York
State than in Kansas, primarily because of the difference in the
type of farming. Where every member of the family must do
some form of agricultural labor, carelessness and inefficiency
are common ; individuals of both sexes and all- ages are prone
to injury. Dr. Cranch has certainly lived in a rural com-
munity. The fact that farming has been done in the same way
for generations is undoubtedly responsible for many of these
accidents. It is difficult to educate the farmer along progressive
lines. Dr. Brahdy’s comment regarding the small number of
injuries or accidents due to cold can be explained by the fact
that the farmer dresses properly for cold weather and the urban
citizen does not. With reference to Dr. Mountin’s remarks,
much, I am happy to say, has been done in a general way
regarding the prevention of farm accidents, particularly by two
great organizations, the American Red Cross and the National
Safety Council. For three years the Red Cross has been inter-
ested in this problem and through its local chapters has been
directing a program to promote greater safety on the farm and
in the home. With regard to Dr. Baker’s remarks, I did
analyze these statistics from a fiscal standpoint. Sixty per cent
of the patients were able to pay in full for their period of
hospitalization, professional care and outpatient visits; 20 per
cent were able to pay in part, frequently a very small part, and
20 per cent paid nothing. A serious injury is to most farmers
a major financial catastrophe; months and even years are
required for the complete discharge of the debt thus incurred.
Certainly less than 10 per cent of farmers carry accident insur-
ance or any other type of protection, and, even when carried,
the amount is usually very small.'

1380

HEART DISEASE-BLAND. AND JONES

Jour. A. M. A.
Oct. 7, 1939

THE DELAYED APPEARANCE OF HEART
DISEASE AFTER RHEUMATIC
FEVER

EDWARD F. BLAND, M.D.

AND

T. DUCKETT JONES, M.D.

BOSTON •

Involvement of the heart can be recognized in approx-
imately 70 per cent of patients during the course of
rheumatic fever in childhood 1 (table 1). It is generally
believed that the remaining 30 per cent also have at the
same time minimal cardiac damage too slight to be
evident by present methods Of clinical study. The later
appearance during subsequent years of characteristic
signs of permanent valvular deformity in a considerable
number of the latter group lends support to this con-
ception. This delayed appearance of heart disease is
responsible, however, for one of the chief elements of
uncertainty with which these patients with so-called
potential rheumatic heart disease must contemplate the
future. This uncertainty is due in part, we believe, to

Table 1 . — Incidence of Heart Disease Following Rheumatic
Fever

Observer 1 Total Cases R. H. D. P. R. H. D

Wilson, Lingg and Croxford

(New York, 1928) 41(5 79.5% 20,5%

Findlay (Glasgow, 1932) 644 66.4% 33.6%

Kaiser (Rochester, N. Y.,

1934) 1,240 64.0% 36.0%

Ash (Philadelphia, 1936) 445 66.1% 33.9%

Schlesinger (London, 1938).. 1,000 74.27o 25.8%

Bland and Jones (Boston,

1938) 1,000 68.6% 31.4%

Average 4,745 70.8% 29.2%

R. H. D. : Demonstrable rheumatic heart disease; P. R. H. D. : Poten-
tial rheumatic heart disease.

In the majority it represented the initial attack, and the
aveiage age at the time of the original illness was
approximately 8 years. The average period of hospital-
ization has been from three to four months, and not
infrequently as long as from one to two years. A
further and an important aspect of this study has been
the subsequent observation at frequent intervals of the
majority of this group. We ourselves have done the
greatest portion of this follow-up study.

From this group of 1,700 patients, only those on
whom we have complete data for a full ten years (or
more) have been considered suitable for our present
purpose. They constitute a special group, 1,000 in num-
bei , which will serve as the basis for a comprehensive
ten year report now in preparation. Among this group
of 1,000 young patients there were 314 (31 per cent)
who on recovery from their initial rheumatic infection
were left without demonstrable damage to the heart.
The subsequent course of these 314 patients with poten-
tial rheumatic heart disease serves as the basis of this
report.

The Delayed Appearance of Rheumatic Heart Dis-
ease . — In table 2 we have indicated the subsequent
cardiac status to date for these 314 patients. It is to
be noted in this table that the data are complete on the
entire group for the first two five year periods after
the onset of their rheumatic fever. A considerable num-
ber (153) 2 have also been followed into the second
decade. Our present observations must necessarily be
confined to the completed decade. There are, however,
certain trends already evident in the second ten year
period suggestive of the future course of events and,
hence, important for our present consideration.

The completed decade covers for the maj'ority of these
patients the years from S to 18, This in turn embraces
the most unstable period in the natural course of their '
disease — represented on the one hand by the high
incidence of recrudescences and fatalities during these

a lack of information concerning the actual incidence and
the extent of this later, and often insidious, crippling of
the heart.

Continuity of observation based on the entire life span
of a large number of patients with potential rheumatic
heart disease in different sections of the country will be
necessary for conclusive data. It is evident, however,
that studies of such duration lie in large measure out-
side the scope of contemporary medical experience;
nevertheless, we believe that it may be helpful to pre-
sent at this time certain interval data relevant to this
difficult clinical problem.

CLINICAL OBSERVATIONS

The source of our material has been described briefly
in previous communications. Since 1920 (a period
of nineteen years) approximately l,/00 children and
adolescents with rheumatic fever or chorea have received
prolonged care and intensive study at the House of the
Good Samaritan during an active stage of their disease.

From the House of the Good Samaritan.

The expenses of this study have been defrayed by a grant from the

Commonwealth Fund. . __ . . , T . ....

Read before the Section on Practice of Medicine at the Ninetieth
Annual Session of the American Medical Association, St. Louis, May 18,

92 Wilson, M. G-; Lmgg, C., and Croxford, G: Statistical Studies
Bearing on Problems in the Classification of Heart Disease, Am. Heart J.
4-164 (Dec.) lP^S. Findlay, Leonard: Rheumatic Infection in Child-
hood. New York WillL-irn Wood & Co 1932. Koiser. A. D. : Factors
That Influence Rheumatic Disease m Children, J. A. M. A. 103.886
fSent •>’) 1934 Ash, Rachel: Prognosis of Rheumatic Infection in
Childhood Am. T. Dis. Child. 52 : 280 (Aug.) 1936. Schlesinger,
Bernard: Public 'Health Aspect of Heart Disease in Childhood. Lancet
1: 593 (March 12) 1938. Bland, E. F., and Jones, T. Duckett: Unpub-
lished observations, 193S.

early years 3 and on the other by the regression of
physical signs of cardiac involvement (enlargement and
murmurs) in many instances, and complete disappear-
ance in others. 4

Signs of permanent valvular deformity have appeared
to date in seventy-nine patients (25 per cent of the
original 314). In approximately two thirds of these
seventy-nine patients (fifty-five in number) a recrudes-
cence of rheumatic fever or of chorea was recognized
at the time of this later appearance of heart disease. In
the remaining one third ‘(twenty-four patients) signs
of valvular deformity appeared insidiously without other
clinical evidence of coexisting rheumatic activity.

The importance of the first ten years in the natural
course of rheumatic fever and rheumatic heart disease
already noted is further emphasized by the after-history
of this special group. In only five patients have the
signs of heart disease appeared, to date after this first
ten year interval ; in two instances with coexisting signs
of rheumatic activity, and in three instances without
such being recognized. This represents a striking con-
trast to the number (seventy-four patients) in which
the delayed signs of heart disease appeared during the
first decade. It seems unlikely that this considerable
difference is to be entirely accounted for by the fact that

2. This group of 153 patients shown in table 2 is composed of thirty-
eight in whom heart disease had appeared during the preceding decade,
four in whom heart disease appeared from ten to fifteen years after the
onset of rheumatic fever, and 111 still without signs of heart disease.*

3. Bland, E. F., and Jones, T. Duckett; Fatal Rheumatic Fever,

Arch. Int. Med. 66:161 (Feb.) 1938 n . . .

4. Bland, E. F„ and Jones, T. Duckett: Disappearance of the Physical
Signs of Rheumatic Heart Disease, J. A. M- A. 107; 569-572 (Aug. 22)
1936.

Volume 113
Number 15

HEART DISEASE— BLAND AND JONES

1381

the data arc as yet complete on only one half of the
original 314 patients for the third five year period.

The twenty-four patients in whom heart disease
became evident without evident coexisting clinical signs
of rheumatic activity arc of special interest. The
appearance of valvular deformity in twenty-one of these
twenty-four patients during the first ten year period
when rheumatic fever is known to he most active
strongly suggests that in this “rheumatically” silent
group the insidious appearance of valvular disease also
coincides with subclinical activity of the rheumatic
process. The later occurrence of clearly evident rheu-
matic fever in eleven of the twenty-four patients lends
further support to this interpretation.

Manifestations of Rheumatic fever. — The manifesta-
tions of rheumatic fever in this special group of seventy-
nine patients has followed the general pattern of
rheumatic fever in our larger series of 1,000 patients. In
the majority, however, it has been mild. The initial
attack was considered severe in only seven instances.
In four additional patients, although the antecedent
rheumatic fever had been mild, the later appearance of
heart disease coincided with a severe recrudescence. In
fourteen additional patients rheumatic fever was of
average intensity, but in the remaining fifty-four it was
of a decidedly mild order.

Chorea has been a prominent clinical manifestation.
It occurred in sixty-four patients (81 per cent), which
is a significantly higher incidence than in our larger
series of 1,000 patients (50 per cent). In the majority
(thirty-eight instances) it was clearly' associated with
other clinical or laboratory signs of coexisting rheumatic
infection; in four patients other evidence of rheumatic
activity in addition to chorea occurred after the signs
of heart disease had been noted. In the remaining
twenty-two instances no indication of rheumatic activity
other than chorea could be identified either before or
after the appearance of heart disease.

In a previous communication we presented evidence
which led us to believe that chorea more often than
not occurred as a manifestation of a relatively mild form

Table 2. — Potential Rheumatic Heart Disease: Subsequent
Course

With Without
Recog* Recog-

Duration of Number of nized nized

Follow-Up Patients Number R. F. R. F. P. R. H. D.

First Decade: 314 Patients in Whom R. H. D. Developed

First five years 314 37 32 5 277

Second five years 314 37 21 16 240

Total first ten years.. 314 74 53 21 240

Second Decade: Data Available on 153 Patients

Third 5 years 153 4 2 2 111

Fourth five years 91 1 . . 1 65

Total for group ... 79 55 24

R. F.: Rheumatic fever; R. H. D.: Rheumatic heart disease; P. R.
H. D.: Potential rheumatic heart disease.

of rheumatic fever. 5 This conception was based in
part on the lower incidence of heart disease in those
patients whose rheumatic fever was manifested, among
other signs, by chorea than in those with rheumatic
fever not associated with chorea. This lower incidence
of cardiac involvement was especially striking in the
so-called pure chorea group. The late appearance of
permanent valvular deformity in a few additional mem-
bers of this uncomplicated chorea group strengthens

the opinion, previously expressed, that although “pure”
chorea is still considered by us a manifestation of rheu-
matic fever it represents as far as the heart is con-
cerned a relatively mild form of the disease.

A further indication of the relative mildness of
the preceding rheumatic fever in this special group is
the absence of significant cardiac enlargement in the
majority. In sixty patients (76 per cent) there remains
either none or, at most, only slight residual enlargement

Table 3. — Effect oj Recurring Rheumatic Fever on the Later
Appearance oj Heart Disease

Number

Still

Now

Patients

P. R. II. D.

R. H. D.

Single Attacks

Uncomplicated chorea

71

66 (93%)

5 ( 7%)

Rheumatic fever

24

22 (91%)

2 ( 9%)

Rheumatic fever -f- chorea. .

37

36 (97%)

1 ( 3%)

Totals

132

124 (94%)

8 ( 6%)

Multiple Attacks

Uncomplicated chorea

65

48 (75%)

17 (25%)

Rheumatic fever

31

19 (61%)

12 (39%)

Rheumatic fever -f- chorea. .

86

44 (51%)

42 (49%)

Totals

182

111 (61%)

71 (39%)

P. R. II. D.: Potential rheumatic heart disease; R. H. D.: Rheumatic
heart disease.

of the heart. Auscultatory evidence, however, of deform-
ity of the mitral valve is present in seventy patients, in
forty of whom aortic regurgitation is also present. The
involvement of the aortic valve is of slight degree in the
majority, but peripheral evidence of free regurgitation
is present in six instances. In the remaining nine
patients aortic regurgitation of slight degree has
occurred without definite signs of coexisting involve-
ment of the mitral valve. Aortic stenosis has not yet
appeared in this group. In general, the structural
alterations in the heart to date have been slight and the
impairment of cardiac function minimal. Eleven
patients have died. A recrudescence of rheumatic fever
was responsible for congestive heart failure and death
in ten instances. The remaining patient died suddenly
and unexpectedly.

Recurrent Rheumatic Fever and the Later Appear-
ance of Heart Disease. — The unfavorable effect on
the heart of recurring rheumatic activity is well shown
in table 3. Of the 132 patients who survived their
original illness with no demonstrable cardiac involve-
ment and have continued without subsequent rheumatic
fever or chorea, only eight (6 per cent) have had signs
of valvular disease appear, whereas, in the remaining
182 patients who have experienced recurring episodes
of rheumatic activity, signs of valvular deformity have
appeared in seventy-one (39 per cent).

COMMENT

The incidence of heart disease appearing later in our
series of 314 patients is notably higher than that recently
recorded by Boone and Levine. 0 These observers found
that among 166 patients with potential rheumatic heart
disease only 4.8 per cent subsequently developed signs
of valvular deformity. Their period of observation
averaged 9.6 years for the group. This compares with
an incidence of 25 per cent in our patients, all of whom
have been followed for ten (or more) years. We are
of the opinion that this considerable difference in the
incidence of heart disease in the two series is to be
accounted for by certain important differences in the
material studied. It must be remembered that the
majority of our patients at the onset of their rheumatic

5. Jones, T. Duckett, and Bland, E. F. : Clinical Significance of
c“. or ® a 1 as a Manifestation of Rheumatic Fever, J. A. M. A. 105 1 571-
577 (Aug. 24) 1935.

6. Boone, J. A., and Levine, S. A.: Prognosis in “Potential Rheu-
M Sc U95 r (June) 1938 d Eheuraat,c Mitral Insufficiency,” Am. J.

1382

Jour. A. M. A.
Oct. 7 , 1939

HEART DISEASE

fever were approximately 8 years of age, whereas the
average of the group studied by Boone and Levine was
13.8 years when first seen by them and hence already
well along in the decade in which rheumatic fever is
known to be most damaging to the heart (namely, from
5 to 15 years of age). We are inclined to accept this
apparent discrepancy in these two well studied groups
as important additional evidence bearing on the natural
course of rheumatic fever in young people. It empha-
sizes again the already well recognized significance of
the events in the earliest years after the onset as most
important in determining the subsequent extent of
residual cardiac damage.

It remains to be seen how many of those who at
present continue without evident heart disease will in
later decades develop signs of stenosis of the mitral or
aortic valve. The experience of Boone and Levine with
the intermediate age group, as well as our own observa-
tions on the younger patients already followed into the
second decade, are encouraging. A sharply diminish-
ing incidence in the later appearance of valvular disease
is to be expected. This prediction is in accord with
other recognized features of the natural course of
rheumatic fever and of rheumatic heart disease.

It should be emphasized that, although the data here
presented concern an unfavorable development in the
course of rheumatic heart disease from childhood
through adolescence, one must not lose sight of the more
favorable course of others. From the broader perspec-
tive of the after-histories in our ten year group of 1,000
patients, those in whom heart disease has later devel-
oped have been more than balanced by an equal number
in whom the signs of heart disease have regressed and
ultimately disappeared.

CONCLUSIONS

From a ten year follow-up study of 314 children and
adolescents with potential rheumatic heart disease it has
been shown that :

1. Characteristic signs of permanent valvular deform-
ity not present at the time of the original illness have
appeared later in seventy-nine patients (25 per cent).

2. This so-called delayed appearance of heart disease
was clearly associated with coexisting signs of recur-
rent rheumatic fever in two thirds of the group.

3. In the remaining one third it appeared insidiously.
Certain evidence suggests that here also the appearance
of the signs of heart disease coincides at this age with
persistent subclinical rheumatic activity.

4. Further observation into the second decade indi-
cates that a sharply diminishing incidence in the later
appearance of heart disease is to be expected in the
remainder.

25 Binney Street.

ABSTRACT OF DISCUSSION

Dr. Helen B. Taussig, Baltimore: This paper has empha-
sized the late manifestations of rheumatic heart disease. The
important feature, it seems to me, is not the number who
develop heart disease but the number who escape without car-
diac damage. The authors’ figures show that only 25 per cent
of patients who give no evidence of cardiac damage after their
first attack have subsequently developed rheumatic heart dis-
ease; of those 25 per cent in only one third did heart disease
develop insidiously. I should like to ask Drs. Bland and Jones
whether they do not believe that the development of rheumatic
heart disease is an indication that these patients are suffering
from persistent active infection; in other words, that rheu-
matic heart disease is not the late result of a former attack
but that it is, in itself, an indication of a subclinical attack.

3 LAND AND JONES

In our clinic we have been impressed by two groups: First
the group who do not report to clinic with the mild illnesses.’
the second those who report to the clinic with no complaints
but who show a low grade fever and change in quality of
heart sounds or in the type of murmur. I believe that such
manifestations are indicative of an active infection; in the vast
majority of these cases the sedimentation rate has been found
to be accelerated. I believe that changing endocardial mur-
murs indicate an active rheumatic infection. The authors’
analysis of single and multiple attacks seems to me highly
significant in that the number who have developed chronic
rheumatic hearts following a single attack is only about 8 per
cent, whereas among those who had multiple attacks it was
39 per cent. This indicates that those who do not have obvious
clinical manifestations are much less liable to have subclinical
manifestations of disease. I should like to ask about the group
of four cases in which signs of heart disease developed ten or
more years after the original attack. Did these patients have
single or multiple attacks? Did the authors think these cases
of heart disease represented the end picture of the early infec-
tions or were they reinfections? I concur with the idea that
these patients who had little or no cardiac enlargement suf-
fered from mild rheumatic infections. In my opinion, cardiac
enlargement is not a late result of previous valvular lesions
but is primarily due to myocardial damage.

Dr. T. Duckett Jones, Boston ; I should like to stress one
or two general features which Dr. Bland referred to in the
series which he reported. The incidence of the late develop-
ment of rheumatic heart disease is 7,9 per cent of a group of
1,000 patients, followed for a period of ten years. There was
a regression or disappearance of the signs of heart disease in
about the same percentage of those patients who developed
rheumatic heart disease early in the course of their rheumatic
fever. The two groups roughly balance each other. Improve-
ment is chiefly due to a lack of recurrences of rheumatic fever.
The question of active rheumatic fever is the most pertinent
and important feature in determining the outcome in a given
rheumatic subject. . I know of no more difficult problem than
the evaluation of therapy in a disease the cause of which is
unknown, and one for which there is no specific diagnostic
test. The disease can be diagnosed only hy the presence of
a more or less clearcut clinical picture or by the resultant
rheumatic disease. It is comparable to tuberculosis. I know
of no series in which has been proved with adequate controls
that long rest and sanatorium care have been the controlling
factor in the tuberculosis situation. It seems rational that in
caring for patients who have a chronic disease lasting for
months, and sometimes years, punctuated by repetitive acute
illnesses, usually precipitated by acute respiratory infection, we
should give the patient the benefit of perhaps one of the most
important laws of nature, namely, rest. I know of no other
real reason why we should keep these patients down other
than the fact that by taking them out of circulation it removes
them from contact with those factors or agents that frequently
cause their disease to increase in severity. From the results
of our ten years of observation it has been found that 60 per
cent of the rheumatic patients who have been given long bed
care during active infection are leading normal Jives today.
About half of these have slight rheumatic heart disease and
the other half have no clinical evidence of heart disease. Of
the remaining 40 per cent, about 25 per cent die. The remain-
ing 15 per cent enter adult life with moderate to severe rheu-
matic heart disease and have either moderate or considerable
restriction of their physical activities. This 15 per cent repre-
sent rheumatic heart disease as it is seen in the adult cardiac
clinics and in the wards of the general hospitals.

Dr. Edward F. Bland, Boston: We believe, although not
yet able to prove it, that the rhcumatically “silent” group of
patients who develop signs of heart disease represent sub-
clinical rheumatic activity. We have had occasion to follow
closely patients who were developing signs of mitral disease
without other signs of rheumatic activity at the time. In
some instances we were not able to establish clearly an active
process by our usual criteria, and yet we felt certain that the
rheumatic process was active in the heart. As to the second

Y01.ll.MK 113

Number 15

OTITIC INDUCTIONS— CONVERSE

1383

question concerning the small group of five patients who, after
a latent period of ten or more years, developed signs of heart
disease; they were all patients who had in the interim recur-
ring episodes of rheumatic activity. I should like to add one
word concerning the effects of pregnancy. Dr. B. J. Walsh
has recently reviewed our data in this connection, and he
agrees that the majority of these patients, with hut few excep-
tions, go through pregnancy later on without difficulty.

RECURRENCE OF OTITIC INFECTIONS
DUE TO THE. BETA-HEMOLYTIC
STREPTOCOCCUS

FOLLOWING INADEQUATE SUI.PAXII.AM IDE THERAPY

JOHN' MARQUIS CONVERSE. M.D.

xr.w YORK

The extraordinary success of sulfanilamide in the
treatment of streptococccic otogenic meningitis has led
to the widespread use of the drug in all cases of otitic
infection in which the beta-hemolytic streptococcus can
be identified. Such enthusiasm for specific chemo-
therapy is readily understood but is open to considerable
criticism. .The patient with meningitis is under hospital
observation, and treatment is continued until the spinal
fluid has returned to normal. The patient with acute
otitis media or mastoiditis receives sulfanilamide only as
long as there is persistent pain or discharge, and treat-
ment is usually stopped on clinical instead of laboratory
evidence.

It has been shown that the sulfanilamide treated ani-
mal survivors of hemolytic streptococcus infection fail
to acquire protective antibodies as a result of their
experience. 1 Lyons * has demonstrated that sulfanil-
amide induces an attenuation of the virulence of hemo-
lytic streptococci and that the organisms regain their
virulence on subcultivation in the absence of sulfanil-
amide. He has further shown that antibacterial antibody
is an important adjunct to sulfanilamide therapy. These
facts are important because they demonstrate that inade-
quate sulfanilamide therapy or premature discontinu-
ance of the drug may permit the infecting streptococci
to become fully virulent again in a patient who has no
immunity to his infection.

My purpose in this report is to present a series of
cases in which it appears likely that the premature
cessation of sulfanilamide therapy was followed by
recurrence and extension of the original infection.

BACTERIOLOGIC ANALYSIS OF ACUTE SUPPURATIVE
OTITIS MEDIA AND SUBSEQUENT MASTOIDITIS

Table 1 demonstrates that only a small percentage of
patients with acute suppurative otitis media progressed
to mastoiditis, but it is also apparent that the beta-
hemolytic streptococcus was present in approximately

This work was undertaken in the Mosher Laboratory and the Massa-
chusetts Eye and Ear Infirmary, Boston.

Dr. Champ Lyons revised this paper. The antibody and sulfanilamide
determinations were done in his laboratory at the Massachusetts General
Hospital.

Head before the Section on Laryngology, Otology and Rhinology at
the Ninetieth Annual Session of the American Medical Association.
St. Louis, May IS. 1939.

1. Seastone, C. V.: The Effect of Sulfanilamide (Para-Aminobenzenc-
sulfonamide) on Group C Ilemolvtic Streptococcus Infection, J. Immunol.
33: (Nov.) 1937.

2. Lyons, Champ, and Ward. II. K. : Studies on Hemolytic Strepto-
coccus of Human Origin: I. Observations on the Virulent, Attenuated,
and A virulent Variants, J. Exper. Med. 61: 515 (April) 1935: II.
Observations on the Protective Mechanism Against the Virulent Variants,
ibid. 61:531 (April) 1935. Lyons, Champ, and Mangiaraccine, A. B.:
The Effect of Sulfanilamide on Human Virulent Hemolytic Streptococci,
unpublished data. * Lyons, Champ, in Symposium on Sulfanilamide read
at n Wednesday meeting at the Massachusetts Eye and Ear Infirmary.

half of the cases. The high incidence of streptococci in
cases of otitic infection is adequate reason to attempt
a clinical evaluation of the usefulness of sulfanilamide
in such cases.

RECURRENCE OF ACUTE SUPPURATIVE OTITIS MEDIA
AFTER TREATMENT WITH SULFANILAMIDE

In a number of cases of acute streptococcic otitis
media, treatment consisted of paracentesis followed by
the administration of 16 Gin. of sulfanilamide in divided
doses over a three day period. In some of these cases a
recurrence of the acute infection was observed on with-
drawal of the drug.

The following four cases are reported from the Baby
Clinic of the Massachusetts Eye and Ear Infirmary:

Cash 1. — R. S., aged 26 months, who weighed 35N pounds
(16 Kg.), Nov. 15, 1937, had a rectal temperature of 101.2 F.
and a paracentesis was performed for suppurative otitis media
on tlie right side. November 17 the rectal temperature was
100 E. and the right ear was draining well. The left drum
was red and bulging : paracentesis yielded pus. November 19
a culture of material from the left car showed hemolytic strep-
tococci. Both cars were draining well. Sulfanilamide was
given, 20 grains (1.3 Gm.) the first day, 15 grains (1 Gm.)
the second day and 10 grains (0.6 Gm.) the third day. Novem-
ber 24, the condition in both ears was definitely resolving. .The
discharge had practically ceased.

November 27 the rectal temperature was 104.4 F. The night
before, five days after cessation of sulfanilamide therapy, the
discharge had reappeared in great abundance from the right car.
Pain was noted in the left ear. Examination, disclosed that
the right car was discharging abundant thick yellow pus through

Taiux. 1 . — Bacteria Involved in Acute Otitis Media and
Incidence of Complicating Mastoiditis * ' •

Oct., Not., .Tim"., Fob.,
Dec. 103T March 19SS

So. olea'cs ot acute otitis media 100 100

Unln-liciiiolytic streptococci 4.1 40

No. of cnFcs of lmisloiclitD 4 5

Itotn-hoinolytle streptococci 2 .0

* Statistics lor October-December 1937 collected by author: statistics
lor .Taniiary-Mnreh 10 1st collected by Dr. J. C. Drunker.

the paracentesis opening. The left drum was red and bulging,
with closure of the paracentesis incision ; paracentesis was per-
formed. December 1 the rectal temperature was 99.4 F. The
right ear showed no evidence of resolution and no definite
postaural signs, but roentgenograms, interpreted by Dr. A. S.
MacMillan, revealed “early decalcification” of the mastoid. The
condition in the left ear appeared to be resolving quickly, and
the landmarks were returning. Sulfanilamide was administered.
15 grains the first day, 10 grains the second day and 7'/z grains
(0.5 Gm.) the third and fourth days. December 6 the landmarks
were returning on both drums. December 10 there was con-
tinued improvement.

December 15, nine days after the cessation of sulfanilamide
therapy, the right ear began to discharge abundantly through
an anterior-inferior perforation. Beginning December 20 sulf-
anilamide was administered, 30 grains (2 Gm.) the first day,
20 grains the second day, 15 grains the third day and 10 grains
the fourth day. The discharge was still abundant. December 23
there was a marked decrease in the discharge, which was becom-
ing mucoid. December 31 there was complete resolution. All
landmarks returned.

Case 2.— L. L„ aged 2 years, who weighed 36 pounds (16
Kg.), Dec. 13, 1937, had bilateral paracentesis for acute sup-
purative otitis media. December 16 the child was brought hack
to the hospital, the cultures showing hemolytic streptococci.
Sulfanilamide, 25 grains (1.6 Gm.), was given. December 17
a marked decrease in the aural discharge was noticed. The

1 3S4

administration of sulfanilamide was continued, 20 grains being
given the first day, 15 grains the second day and 10 grains the
third day. December 20 the left ear showed a small amount
of pus exuding through a small posterior-inferior perforation.
December 23 the condition of the left ear appeared to be resolved
and the right ear began to show a return of the landmarks.

December 27, seven days after cessation of sulfanilamide
therapy, both ears presented an abundant purulent discharge.
December 30 the discharge was increasing. Sulfanilamide was
again administered, 25 grains the first day, 20 grains the second
day, 15 grains the third day and 5 grains (0.3 Gm.) the fourth
day. J an. 3, 1938, the condition in both ears was resolving.
January 6 resolution was complete.

Case 3.— R. C, aged 6 years, who weighed 54 pounds (24
Kg-), Jan. 17, 1938, had a rectal temperature of 100.8 F. and
paracentesis was done for suppurative otitis media on the right
side. The child presented acute rhinitis and pharyngitis. Jan-
uary 20 he was brought back complaining of pain in the right
ear. The culture in the meantime had been reported to show
hemolytic streptococci. The paracentesis incision was open.
Sulfanilamide was given, 45 grains (3 Gm.) the first day and
30 grains the second day. January 22 the rectal temperature
was 99.4 F. The ear had stopped discharging the previous
day, the acute rhinitis and pharyngitis had cleared up and for
the first time the child slept throughout the night without
complaining of pain. The condition in the right ear appeared
to be resolving. Sulfanilamide, 20 grains a day, was admin-
istered for two days. January 24 resolution appeared complete.

February 14, twenty-one days after cessation of the sulfanil-
amide therapy, the child had a rectal temperature of 100.2 F.
and again complained of pain in the right ear. The drum
appeared thickened, with injection of the malleus handle. Feb-
ruary 17 the rectal temperature was 100.2 F. and the patient
complained of pain in the left ear and increased pain in the
right ear. Examination revealed slight fulness and diffuse
injection of the left drum ; on the right drum the landmarks
could hardly be determined. Instead of a paracentesis, sulf-
anilamide was prescribed; 45 grains was given the first day
and 30 grains the second day. February 19 the temperature
was 99 F. The child was much improved, and all landmarks
could be made out. There was slight thickening in both drums.
Sulfanilamide, 20 grains, was given for three days. February
23 the condition in both cars was resolved.

Case 4. — J. B., aged 5, who weighed 36-kf pounds (16.7 Kg.),
Jan. 31, 1938, had a rectal temperature of 100.4 F. and para-
centesis was performed for suppurative otitis media on the right
side. February 4 the rectal temperature was 99.8 F. and
there was a pulsating discharge from the paracentesis incision.
Culture showed hemolytic streptococci. February 9 the rectal
temperature was 99.4 F. The condition appeared about the
same in the right ear. For the past two days the child had
complained of pain in the left ear. The left drum appeared
injected and thickened, with a slight bulging of the posterior
quadrants. Sulfanilamide, 30 grains, was prescribed. February
10 the temperature was 99.6 F. and the condition unchanged.
Sulfanilamide, 15 grains, was given. February 11 there was
great improvement. The child had had no symptoms, and the
condition of both drums was resolving. Sulfanilamide was
administered, 10 grains the first day and 5 grains the second
and third days.

February 16, three days after the cessation of sulfanilamide
therapy, the rectal temperature was 100.4 F., and that night
pain began in the right ear. The next day a discharge appeared
and the right drum was bulging and injected. The condition
in the left drum was resolved. Paracentesis of the right drum
yielded pus. February 17 the rectal temperature was 99 F.,
and there was a pulsating discharge from the paracentesis
incision in the right ear. Sulfanilamide, 20 grains, was admin-
istered. February 18 the rectal temperature was 99.2 F. and
the child felt better. There was a pulsating discharge, with
tenderness over the antrum on the right side. Roentgenograms,
interpreted by Dr. A. S. MacMillan, showed "decalcification
throughout the right mastoid.” March 4 simple mastoidectomy
on the right side showed that all the cells were broken down.
Recovery was uneventful.

Joes. A. M.'A.
Oct. 7, !93')

Table 2 summarizes the pertinent data with regard to
these recurrences following sulfanilamide therapy. It is
felt that the patients received too little of the drug for
too short a time. Attention is called to the fact that
these doses of sulfanilamide were given in the clinical
belief that a small amount of the drug would aid the
patient in his attempt to overcome the infecting organ-
isms, but it is obvious that apparent recovery was not
maintained after omission of sulfanilamide.

THE LATE OCCURRENCE OF MENINGITIS IN PATIENTS
TREATED WITH SMALL DOSES OF SULFANIL-
AMIDE AFTER MASTOIDECTOMY

1 he three patients in this series were all admitted to
the hospital during July 1938.

Case 5. — -B. K., a girl aged 6 years, admitted to the hospital
May 19, )938, with suppurative otitis media on the left side
of four and a half weeks’ duration, had a rectal temperature
of 99.6 F., a pulse rate of 100, a respiratory rate of 24 and
a white cell count of 8,300, with 58 per cent polymorphonuclears.
A history was obtained that the ear had begun to discharge
spontaneously after an attack of influenza. The child had no
other complaints.

Table 2. — Recurrence of Acute Streptococcic Otitis Media
in Children Following Small Doses of Sulfanilamide

Final

SllIfODll-

Suiiaml-

amide

amide

'

„ '

©

S

o

2

° c

0

3 tn

e: S

>» •

•rl|

Case Diagnosis

5

Q Z

-sa

1 Acute suppurative otitis

media

2G mo.

;{

2.8

3

1 4.S

47

2 Acute suppurative otitis

media

:t Acute suppurative otitis

24 mo.

3

4.3

7

1 4.3

2.1

media

C yr.

4

r.4

21

s.fi

3S

4 Acute suppurative otitis

media ;

r> yr.

3.4

31+

* TJio miijibrr of days clap-dug after cessation of the sulfanilamide
therapy.

The drum of the left ear was thick, with an anterior-inferior
perforation ; there was a pulsating mucopurulent discharge, and
the canal wall appeared to be sagging slightly, but no postaural
signs were found. The roentgenograms, interpreted by Dr.
A. S. MacMillan, showed "decalcification throughout” the left
mastoid. The tonsils had been removed, and palpation revealed
a .small mass of adenoids in the nasopharynx.

May 21 a report was obtained that the culture of the pus
from the left middle ear showed beta-hemolytic streptococci.
May 23 sulfanilamide therapy was started ; 50 grains (3.2 Gm.)
was given the first day, 30 grains the second day and 15 grains
each day thereafter. May 25, two days after the sulfanilamide
therapy was begun, a simple mastoidectomy was performed
on the left side. The mastoid was found to he broken down,
especially around the antrum, and to contain pus throughout.
No dura or sinus was exposed. Culture showed no growth.
June 6 the child was discharged to the outpatient department
for dressings, the middle ear being dry and the postaural wound
healing well. The sulfanilamide therapy was discontinued.

June 27 the rectal temperature was 103.6 F., the pulse rate
88 and the respiratory rate 30 and the child was readmitted
to the hospital. Two days previously she had complained of
frontotemporal headache on the left side, which had recurred
persistently, increasing in severity; it had kept her awake at
night and had made her scream with pain. That day she had
presented nausea and vomiting. On admission she was semi-
comatose. The right middle ear was normal, the left middle
ear was drv and the postaural wound on the left was discharging

OTITIC INFECTIONS— CONVERSE

VOLUMI. U.l
Num her 15

O 77 TIC INFECTIONS— CON VERSE

1385

thick pits. Moderate injection of the throat was found. The
eves, including the fundi, appeared normal. The neck was stiff,
Kernig's sign was present and Hahinski's sign was absent.
Lumbar puncture showed an initial pressure of 700 nun., nor-
mal dynamics, ground glass fluid, and 16,248 cells, with 99
per cent polymorphonuclcars. A blood count revealed 32,000
white cells, with 89 per cent polymorphonuclcars, and 3,6-10,000
red cells.

June 2S, at 3 a. nt„ a revision of the left mastoid and decom-
pression were done. Infected granulations were removed; the
tegmen was soft and necrotic, there was wide decompression
and the dura was injected and covered with a fibrinous exudate.
The sinus was exposed in its full length : the wall was gray and
covered with a fibrinous exudate. A culture of material from
the mastoid showed hemolytic streptococci, as did a culture
of the spinal fluid; culture of the blood was negative. Sulf-
anilamide therapy was started immediately after the operation.
The patient was seen in consultation with Dr. Lyons, who
advised the securing of a blood level of sulfanilamide of IS mg.
per hundred cubic centimeters. An antibody determination was
performed by Dr. Lyons, who found the phagocytic activity
to be 12-28 per cent (twelve cocci phagocytcd by 28 per cent
of twenty-five cells counted). The child was therefore con-
sidered as having practically no bacterial antibody. The blood
sulfanilamide level was therefore put up to 25 mg. per hundred
cubic centimeters (July 1). The patient’s condition improved
rapidly.

July 2 the first negative report from culture of the spinal
fluid was received. The number of cells in the fluid had dropped
from 16,2-48 to 440, with 56 per cent polymorphonuclcars. The
white blood cell count had dropped from 32,000, with 89 per
cent polymorphonuclcars, to 21,000, with 92 per cent iiolv-
morphonuclears. The rectal temperature was 101 F. July 6
the reports from culture of the spinal fluid had been continually
negative, the blood sulfanilamide level had been maintained
around 25 mg. per hundred cubic centimeters and the child had
improved remarkably. All meningeal signs had disappeared,
but she showed signs of anemia ; there were 3,200.000 red blood
cells and 167 cells in the spinal fluid, with 40 per cent poly-
morphonuclears. It was decided to stop the sulfanilamide
therapy and do a transfusion (300 cc.). During the ensuing
period of convalescence, a number of cultures were made of
material from the mastoid, and these showed a total absence
of hemolytic streptococci. The evolution was toward an
uneventful recovery. Dr. Lyons found that there was no
increase in the antibody level at this time.

Case 6 . — First Admission. — L. S., a girl aged 9 years, entered
the hospital April 15, 1938, with suppurative otitis media on
the right side of two weeks’ duration, which had followed spon-
taneous rupture of the drum. The otitis had been preceded by
a cold. Three days before entry the patient had presented
dizziness, nausea and vomiting, chills and sweats, and headaches
on the right side. Two years previously she had had a discharge
from the left ear for three weeks. She was thin and pale and
complained of pain in the right ear and of right hemicrania.
Examination of the right middle ear showed an anterior-inferior
perforation through a thickened drum, an abundant purulent
discharge and postaural thickening and tenderness. The left
middle ear appeared normal. The nose, throat and eyes were
normal. Roentgenograms, interpreted by Dr. A. S. MacMillan,
showed “decalcification with destruction in the right mastoid.”
The temperature was 100.8 F., the pulse rate 120, the respiratory
rate 27 and the white blood cell count 14,000, with 96 per cent
polymorphonuclcars.

_ April 16 a simple mastoidectomy was performed on the right
side. Destruction was found about the antrum and also in
the tip. A perisinus abscess was found; the sinus was widely
uncovered. No dura was exposed. The culture showed hemo-
lytic streptococci. The day after operation sulfanilamide
therapy was started ; 45 grains was given the first day, 30
grains the second day and 15 grains each day thereafter.

April 18, two days after the operation, the rectal temperature
rose to 102 F. The left ear drum became injected and soon
began to discharge spontaneously. April 20, four days after
the operation, the rectal temperature rose to 105.6 F. There

was no chill. Flood cultures were reported negative. Neuro-
logic examination and examination of the nose, throat and chest
gave negative results.

April 21 a roentgenogram was reported by Dr. MacMillan as
disclosing “decalcification in the left mastoid.” On account
of the history of disease in the left ear two years before and
the severity of the clinical signs, a simple mastoidectomy on
the left and revision of the right mastoid were advised. These
operations were done April 21. In the left mastoid destruction
was found around the antrum. The rest of the mastoid
appeared normal. No dura was exposed. The right mastoid
was revised and found filled With granulations. A small area
of dura was exposed. The sinus was covered by a pad of
healthy granulations in*the area previously exposed. The color
appeared normal, and the sinus filled well. The temperature
curve was irregular, reaching 103 F. during the five days fol-
lowing the operations, and then became flat.

May 8, seventeen days after the operations, both middle ears
being dry and both postaural wounds healing, the patient was
discharged to the outpatient department. The sulfanilamide
therapy was discontinued on discharge.

Second Admission . — The patient was readmitted June 5,
twenty-eight days after discharge and cessation of sulfanilamide
therapy, with a history of increase of the discharge through
the left postaural wound, of vertigo and frontotemporal head-
ache one day before admission and of a chill. The morning
of admission she had presented nausea and vomiting and had
begun to complain of pain in her left hip. She did not appear
particularly ill. Examination of the right ear revealed a
dry middle ear and a nearly healed right postaural wound.
The left car showed a purulent discharge from the middle ear
and from the postaural wound. The nose and throat were
not remarkable. The eyes showed no nystagmus ; the fields
and fundi were normal. Neurologic examination gave negative
results, and lumbar puncture yielded a clear fluid, with an initial
pressure of 100 mm., 2 lymphocytes and a normal reaction to
the compression test. The temperature was 102.5 F., the pulse
rate 116, the respiratory rate 24, the white blood cell count
10.200, with 90 per cent polymorphonuclears, the red blood cell
count 4,220,000 and the hemoglobin content 85 per cent. Blood
for culture was taken. Roentgenograms disclosed a normal
petrous bone and a postoperative mastoid. There were no
chills.

June 7 a revision of the left mastoid was done. The sinus
appeared thickened in the area previously exposed. June 7,
blood cultures showed a growth of hemolytic streptococci.
Sulfanilamide was given, 60 grains (3.8 Gm.) the first day,
30 grains the second day, 20 grains the third day and then
15 grains daily. After the operation the temperature became
normal and remained so. The blood culture was positive on
the day- of the operation and negative thereafter. The involve-
ment of the hip rapidly cleared up. The patient’s general
condition improved rapidly, her only complaint being a fleeting
but recurring frontotemporal headache on the right side.
Repeated lumbar punctures yielded normal fluid. June 30 the
patient was discharged from the hospital and the sulfanilamide
therapy was discontinued.

Third Admission . — The patient was readmitted, semicomatose,
to the hospital July 6 after what appeared from the family's
description to be a generalized convulsion. This was six days
after discharge and cessation of the sulfanilamide therapy. The
child had complained frequently of frontotemporal headache
on the right and had presented nausea and vomiting. There
had been no injury to the tongue during the convulsion. She
emerged from her semicomatose condition a half hour after
admission. The neurologic examination showed a suggestion
of rigidity of the neck. Examination of the eyes, nose and
throat was unproductive. The right ear showed a" completely
healed postaural incision and a healed anterior-inferior perfora-
tion, and all the landmarks could be made out on the tym-
panum. Examination of the left ear showed a slight muco-
purulent discharge from the lower portion of the postaural
incision and from the middle ear through an anterior-inferior
perforation. The rectal temperature was 100- F., the pulse
rate 130, the respiratory rate 28, the white cell count 21,000,

1386

with 92 per cent polymorphonuclears, the red cell count
3,950,000 and the hemoglobin content S3 per cent (Sahli).
Chemical analysis showed protein 22 mg. and sugar 70 mg.
The lumbar puncture showed a cloudy fluid with a pressure
of 220 and 285 cells, of which 28 per cent were polymorpho-
nuclears, and a positive Tobey-Ayer reaction on the right side.
Blood for culture was taken. Dr. Lyons saw the patient in
consultation. In view of the previous treatment with sulfanil-
amide, it was decided to carry the sulfanilamide blood level up
to from 20 to 25 mg. per hundred cubic centimeters. Sulfanil-
amide therapy was started; 150 grains (10 Gra.) in divided
doses every four hours was given the first day and 180 grains
( 1 1 Gm.) the second day.

July 7, the day after admission, the laboratory reported that
the cultures of the blood and the spinal fluid showed beta-
hemolytic streptococci. The rectal temperature had not gone
over 101 F. There was no chill. The patient was perfectly
rational and presented a slightly stiff neck and a suggestion
of Kernig’s sign. Lumbar puncture yielded a slightly hemor-
rhagic fluid with a pressure of 350 and 202 cells, 64 per cent
of which were polymorphonuclears. Compression tests could
not be performed, the patient not cooperating. The eyegrounds
were normal.

July 8, on account of the presence of a discharging postaural
wound, the left mastoid was reentered and the lateral sinus,
which appeared normal, was uncovered from the knee to the
bulb. The dura was widely decompressed and appeared nor-
mal. A cisternal puncture was then done and yielded hemor-
rhagic spinal fluid like that obtained by spinal puncture. It
was then decided to explore the right mastoid if the headache
on the right side persisted. A bacterial antibody test by Dr.
Lyons showed 56 per cent of the cells phagocyting. It was
decided that, in view of the relatively high antibody level, the
sulfanilamide level could be brought down to 15 mg. per hundred
cubic centimeters.

During the next two days the child complained constantly
of temporofrontal headache on the right. She had a slightly
stiff neck, Kernig’s sign was present and there was marked
drowsiness. Exploration of the right mastoid was postponed
one day. These signs disappeared on the third day. Neurologic
signs of localization could be found, and the blood cultures
were negative, the spinal fluid cell count was rapidly dropping
and all cultures of the spinal fluid were negative. Clinically the
patient was improving rapidly.

July 18 all the signs and symptoms had disappeared and the
spinal fluid cell count, which had been dropping steadily, reached
1 1, with 3 polymorphonuclears. All cultures of the blood and
spinal fluid were negative. The white blood cell count reached
10,200, with 68 per cent polymorphonuclears. Two transfusions
of 250 cc. of blood had been given July 9 and 11. The mastoid
wound, which had been left wide open, was filling in with
healthy granulations, and the middle ear was dry. The sulf-
anilamide blood level had been maintained at about 15 mg.
per hundred cubic centimeters, during the entire pc riod the
highest level reached being 24 mg. and the lowest 10.8 mg.
per hundred cubic centimeters.

August 2, in view of sustained improvement and a complete
absence of the previous signs, and after three successive cul-
tures of material taken from the mastoid wound showed an
absence of hemolytic streptococci, sulfanilamide therapy was
stopped. A transfusion of 500 cc, of blood was given; after
the cessation of the sulfanilamide therapy and the transfusion,
an improvement in the patient's general condition was noted.

August 13 a plastic closure of the left postaural wound was
performed, and the patient left the hospital August 20.

C AS f. 7.— First Admission. — R. S., a boy aged 8 years, was
admitted to "the hospital May 20, 1938, with suppurative otitis
media of five weeks’ duration on the right side and three weeks’
duration on the left side. Three weeks before admission he
had had measles, after which the left ear began to discharge.
For three days lie had a swelling in the left zygomatic area.
There were no chills and no headaches. Examination of the
right ear showed thick pus draining abundantly through a
high anterior perforation. There were no postaural signs. The

Jour. A.

Oct. 7, 1939

left ear showed a thick red drum with a posterior-inferior
perforation, thick pus draining, the canal wall sagging, post-
aural swelling extending into the zygoma and tenderness.

Roentgenograms revealed destruction of the right mastoid
and in the left mastoid cells in the tip and over the knee of
the sinus. Pus was present. The rectal temperature was
I01 ; 2 F., the pulse rate 112, the respiratory rate 28 and the
white blood cell count 18,200, with 90 per cent polymorpho-
nuclears. Lumbar puncture disclosed a pressure of 125 mm„
clear fluid and no cells. Compression tests suggested a block-
on the right side.

May 21 a simple mastoidectomy was performed on each side.
The right mastoid was completely broken down and contained
pus; no dura or sinus was exposed. In the left mastoid the
cells were completely broken down and pus was present under
pressure. A small area of sinus was exposed and appeared
normal. A large zygomatic development was cleaned out and
a subperiosteal abscess drained through an anterior counter
incision. No dura was exposed. Cultures showed hemolytic
streptococci.

May 23, the day after the operation, the rectal temperature
rose to 105 F. There was no chill, and a blood culture was
reported negative. There were no neurologic signs. Signs
of consolidation were found in the left side of the chest and
were confirmed by x-ray examination. May 24 sulfanilamide
therapy was begun, 60 grains being given the first day, 40
grains (2.6 Gm.) the second day, 30 grains the third day and
15 grains the following days. May 28 evidence of fluid in the
pleural cavity was found. A thoracentesis yielded clear fluid.
Cultures of the sputum showed hemolytic streptococci. A
culture of the fluid removed by thoracentesis showed no growth.

May 31, the eighth day after operation, the temperature,
which had been between 104 and 105 F., came down to 97.5 F.

A crisis occurred. The pleural fluid resorbed slowly during the
following days. Both mastoids healed rapidly, the middle ears
stopped running and June 30 the patient was discharged to the
outpatient department. Sulfanilamide therapy was stopped.

Second Admission . — July 9, nine days after discharge and
interruption of the sulfanilamide therapy, the patient was read-
mitted with a history that the day before swelling had
appeared in the left zygomatic area. No other symptoms were
noted. On admission the right middle ear was dry and there
was a small amount of mucopus discharging from the mastoid
wound; the left ear showed a discharge of mucopus through
a posterior-inferior perforation and through the postaural
wound. A diffuse tender swelling was noted in the left zygo-
matic area. The rectal temperature was 101.5 F., the pulse
rate 10S, the respiratory rate 24 and the white blood cell
count 23,000, with 94 per cent polymorphonuclears. Roentgeno-
grams revealed an absence of cells in both mastoids. It was
decided to employ conservative treatment with hot poultices
before revising the left mastoid. The rectal temperature reached
103 F. Two days after admission the temperature was down
to 100.5 F. and the zygomatic swelling had disappeared.

July 13, four days after admission, the patient had acute
tonsillitis and a culture of material from the throat showed
hemolytic streptococci. The temperature rose to 104 F. Sulf-
anilamide was not administered, but irrigation of the throat
was started. Three days later (July 16) the pharynx had
cleared up and the temperature was normal.

July 17, seventeen days after cessation of sulfanilamide
therapy, the temperature rose suddenly to 102 F. at 3 a. in.
The patient began to complain of frontal headache and showed
slight stiffness of the neck but no Kcrnig or Babinski sign.
While being examined he presented projectile vomiting. Lum-
bar puncture showed a pressure of 210 mm. and cloudy fluid
with 2,500 cells, 95 per cent of which were polymorphonuclears.

On account of the recent zygomatic involvement on the left
side, it was decided to operate immediately on that side. The
tegmen was found to he soft and the dura to he injected,
granular and covered with a fibrinous exudate. On further
decompression the injection of the dura was found to be limited
to an area of approximately 2 by 3 cm. All the soft bone of
the tegmen was removed. The sinus was widely exposed
and appeared normal.

OTITIC INFECTIONS— CONVERSE

Vo lit* M K IM
•Number 15

O TITIC INFECTIONS— CONVERSE

1387

Sulfanilamide therapy was immediately started, ISO grains
being given the first twenty-four hours and a blood level of
7.2 mg. being reached within seventeen hours. The next morn-
ing the neck was definitely stiff and there was a Kernig sign
but no Babinski sign. No other neurologic signs could be
found. The spinal fluid taken for culture the previous day
was reported in twenty-four hours to show hemolytic strepto-
cocci. Blood culture was negative. The level of sulfanilamide
in the blood reached IS mg. per hundred cubic centimeters
the second day, was maintained at this point and then was
gradually elevated, reaching 24 .4 mg. the eleventh day.
Improvement was continuous, the meningeal signs disappeared
within three days and cultures of the spinal fluid were all
negative after the first one.

Sulfanilamide therapy was stopped fourteen days after it
was begun, three successive cultures having shown an absence
of hemolytic streptococci in the wound. August 13 a plastic
closure of the wound was performed, and August 30 the patient
was discharged to the outpatient department.

Table 3. — Summary of Cases in Which Late Meningitis
Developed sifter Mastoidectomy and Sulfanilamide
Therapy

Sultnnll-

Sulfmiihniililo Unto nrnlclo

Cnso

Age,

Yr.

r * \ of Occur-

Pose, Gm. rrnce of
Day* Polly MenlnpItN*

Antibody

in Mood,
KlTeetlve Mir. P<*r
Pays 100 Cc.

r.

G

1.1 1 20 (lays

Very low

10 2.5

c

n

20 1 27 (lays

Present

27 i:»

7

8

7 1 17 days

Not determined 14 2.5

* Pnys olnp-ine Between the eos-utlou of siiltnnllninlile therapy amt
tlic onset of mrnlncitls.

These cases of late meningitis arc summarized in
table 3. All three patients recovered, but it required
large doses of sulfanilamide to sterilize effectively the
spinal fluid. The blood antibody in ease 5 was low
both before and after therapy. It is felt that in case 6
septic thrombophlebitis on the right side was probably
“masked’’ by the negative blood cultures obtained when
the patient was receiving small doses of sulfanilamide.
On the basis of this and similar evidence it seems likely
that sulfanilamide therapy may produce negative blood
cultures when the patient has a persistent septic endo-
phlebitis capable of exacerbation on withdrawal of the
drug.

COMMENT

It is believed that this evidence demonstrates that
the institution of sulfanilamide therapy creates an
obligation to continue it until there is bacteriologic as
'yell as clinical evidence of complete subsidence of infec-
tion. Premature cessation of the drug therapy on clin-
ical evidence alone permits exacerbation of the infection
in patients whose defensive mechanism is not prepared
to deal with residual living streptococci.

Bacteriologic sterility of the inflammatory process is
evidenced by :

1. Absence of streptococci and pus cells in smears
from the site of infection.

2. Absence of streptococci in cultures made by plant-
ing swabs in 10 cc. broth. (It is necessary to dilute the
exudate in broth to overcome the bacteriostatic effect
of the drug.) Cultures should be repeated from three
to five days after discontinuation of sulfanilamide
therapy and prior to discharge of the patient. A word
of caution is given as to the interpretation of blood
cultures from patients receiving sulfanilamide. Negative
cultures may be reported because the blood is planted
in a quantity of culture broth inadequate to dilute the

drug beyond the bacteriostatic concentration present in
the blood. This “masking” effect may lead to oversight
of a complicating endophlebitis that merits jugular
ligation or further surgical drainage.

The clinical experience with sulfanilamide at the Mas-
sachusetts Eye and Ear Infirmary has led to the
belief that sulfanilamide should be reserved for the
treatment of spreading or life-endangering infections
and that it should not be used as an adjunct to the
usual measures for the treatment of infections of minor
severity. There are three reasons for this belief: 1.
Premature initiation of drug therapy has made complete
clinical evaluation of the patient difficult, and progress
of the infection to a complicating endophlebitis has been
obscured during treatment. 2. There has been recur-
rence and further spread of the infection after omission
of sulfanilamide in patients who had clinically appeared
to be healed, so that it is clear that the use of sulfanil-
amide necessitates fairly extensive laboratory' studies to
confirm the clinical impression of subsidence of the
infection. 3. The amount of sulfanilamide required to
sterilize a focus of infection is so large that the danger
of toxic manifestations necessitates the hospitalization
of all patients receiving the drug.

SUMMARY

1. Inadequate sulfanilamide therapy has been fol-
lowed by recurrence of otitic infections with beta-
hemolytic streptococci.

2. The laboratory studies which are required for the
effective use of sulfanilamide necessitate hospitalization
of patients under treatment.

3. Sulfanilamide therapy' should be reserved for the
treatment of spreading or life-endangering streptococcic
infections.

121 Hast Sixtieth Street.

ABSTRACT OF DISCUSSION
Du. Bernard J. McMahon, St. Louis : Dr. Converse has
mentioned the importance of hemotherapy or serotherapy when
the response to sulfanilamide therapy is inadequate, since with-
out the timely mobilization of the phagocytic cells at the area
of infection chemotherapy will be unavailing. Sulfanilamide can
exert a bacteriostatic effect for only a certain length of time
before toxic signs may develop; consequently, the adjunct treat-
ments should be resorted to within the first forty-eight to
seventy-two hours. Sulfanilamide should not be administered
unless the patient is kept in bed and under the careful and con-
stant observation of his physician. It is the duty of the physician
to warn patients of the dangers of ill advised and uncontrolled
administration of this drug, and one may hopefully look forward
to the enactment of legislation in every state prohibiting the
sale of sulfanilamide, sulfapyridine and their allied products by
the druggist without a physician’s prescription.

Lister Was His Own Bacteriologist. — The cause of
human disease never has been, and never can be, found purely
within the walls of a laboratory; there must be at least some
association, direct or indirect, with patients. This association
has grown, especially in the case of bacteriology, to be too loose;
it is quite necessary to the proper study of many diseases that
the association should develop the intimacy which has proved
so successful in investigation of tropical disease. Let us remem-
ber that Lister was his own bacteriologist. The solution is not
usually to be found in what has been termed team work. Can
it not be hoped that skilled clinicians will be found in this
country who will devote their lives in studying the origin of
disease, and who will fit themselves by special and appropriate
training for this particular task?— Lewis, Sir Thomas : Research
in Medicine and Other Addresses, London, H. K Lewis & Co
Ltd., 1939.

1388

GENITAL TUBERCULOSIS— MILLER AND LUSTOK

Jour, A. M. A.
Oct. 7, 1939

GENITAL TUBERCULOSIS

ELI A. MILLER, M.D.

DENVER

AND

MISCHA J. LUSTOK, M.D.

SPIVAK, COI-O.

In this discussion we are primarily interested in
genital tuberculosis in the male. Much progress has
been made in this field in the past few years.

tXCIDENCE

The incidence of genital tuberculosis will of course
vary with different authors, depending on the type of
material under observation. The average figures given
in the literature vary between 2 and 8 per cent of male
tuberculous patients. At the Sanatorium of the Jewish
Consumptives' Relief Society in the eleven year period
of observation (January 1928 to January 1939 ) sixty-
one of a total of 1,316 male patients admitted had
genital tuberculosis, an incidence of 4.7 per cent.

Clinical evidence of tuberculosis in the male genital
tract occurs during the age of greatest sexual activity,
and the vast majority of patients range from 20 to 40
years. In our series the mean age of incidence of genital

Tabu-: 1, — Incidence of Genital Tuberculosis

Period of Observation — January 1928 to January 1939
Total number of patients admitted to the sanatorium 1,890
Total number of male patients 1,316, or 69.9%

Total number of male patients with genital, renal or combined urogenital
tuberculosis 84, or 6.4%

Total number of male patients with genital tuberculosis 61, or 4.7%

Of the 61 patients with genital tuberculosis

15, or 24.5%, had associated proved renal tuberculosis
46, or 75.47c , had no definite evidence of renal tuberculosis
Of the 61 patients with genital tuberculosis

58, or 95.0%, had associated far advanced pulmonary tuberculosis
2, or 3.2%, had associated moderately advanced pulmonary tuber-
culosis

1, or 1.6%, had no associated pulmonary tuberculosis
Of the 61 patients with genital tuberculosis

53, or 86.8%, had sputum containing tubercle bacilli
8, or 13.1%, had normal sputum

tuberculosis was 30 years. That genital tuberculosis
may occur at any age is evident by the report of the
Greenbergers and Alexander, 1 whose series showed
patients ranging from 2 to 67 years of age. It is well
recognized that the younger the patient the more viru-
lent the. infection. In a greater sense this is also true
of pulmonary tuberculosis.

PATHOGENESIS

Genital tuberculosis is accepted as secondary to some
other tuberculous focus in the body, the focus being
most commonly found in the respiratory system,
whether clinically apparent or not. It is agreed that
the infection may reach the genital tract directly by
way of the blood stream from a focus elsewhere in the
body, by way of the lymphatics and, secondarily, by
continuity of tissue.

Young’s studies bring out the fact that whereas the
epididymis attracts more attention and gives more pro-
nounced symptoms, especially at the onset of the dis-
ease. the seminal vesicles and the prostate are in fact

Owing to lack of space, this article is. abbreviated in The Journal.
The complete article appears in the authors’ reprints.

Read lief ore the Section on. Urology at the Ninetieth Annual Session
of the American Medical Association, St. Louis, May 19, 1939.

From the Urological and Medical Services of the Sanatorium of the
Te wisli Consumptives’ Relief Society, Spivak, Colo. Apparatus from the
'Max Straus Physiotherapy Department. , r „ . .. , TT

1 Greenbercer, A. J.; Greenberger, M. E.. and Alexander. H.:
Tuberculosis of the Male Genital Tract. Quart. Cull- Sea \ lew Hosp.
1 : 425*441 (July) 1936.

the primary seat of the genital tuberculous infection. 2
The prostate and seminal vesicles are not only the pri-
mary focus from which the epididymis is involved but
also the focus from which the bladder and the kidneys
m many cases are affected. Menville, 0 Braasch, 4 Bum-
pus and Thompson " and the Greenbergers and Alex-
ander 1 have expressed the same opinion. Barney,
\\ atsen and Elliott n and Caulk 7 have said, on the
contrary, that the epididymis is the seat of primary
genital involvement and that the infection is hematog-
enous in origin.

In the opinion of Campbell, 8 genital tuberculosis
without renal involvement is a hematogenous infection
and starts in the epididymis, whereas with renal tuber-
culosis the infection reaches the genital tract by way of
the urinary passages. The tuberculous urine bathing
the prostatic portion of the urethra causes the prostate
and seminal vesicles to be involved first. He further
stressed the role as a focus of the avascular vas deferens,
which keeps the vesicles and prostate constantly rein-
fected, most probably by' extension along the lumen
or possibly by extension along the lymphatics.

Moore 0 presented histologic and correlative evidence
that the bacilli in most eases reach the prostate and
seminal vesicles through the blood stream and that the
prostatic lesion is secondary to other urogenital lesions
in less than 20 per cent of the cases.

There are then two general theories concerning the
pathogenesis of tuberculosis of the male genital tract:

1. That the prostate ancl seminal vesicles are involved
primarily in the genital system and that the disease may remain
localized or spread as descending genital or ascending renal
tuberculosis.

2. That the prostate and seminal vesicles are involved
secondarily from other urogenital organs by dissemination
through the lumens or walls of hollow viscera connecting them,
ascending genital or descending renal tuberculosis.

It must be borne in mind that the presence of genital
tuberculosis does not preclude the presence of renal
tuberculosis, and vic^e versa. While the two conditions
do commonly occur together, each will occur inde-
pendently of the other in sufficient frequency to war-
rant individual consideration. In the eleven year period
of our observation there were twenty-three cases of
renal tuberculosis without genital involvement, fifteen
cases of combined renal and genital tuberculosis and
forty-six cases of genital tuberculosis without renal
involvement. Furthermore, the presence of urine show-
ing tubercle bacilli on direct smear or guinea pig inocu-
lation is not pathognomonic of renal tuberculosis, since
the urine can be infected from a genital tuberculous
lesion alone by means of the discharge into the posterior
portion of the urethra. In our series of sixty-one cases
there were forty-six cases of genital tuberculosis with-
out proved renal involvement, in thirteen of which the
urine contained tubercle bacilli.

2. Young, H. H.: (a) Practice of Urology, Philadelphia, VLB-

aunders Company, 1 926, vol. 1 p. 326; (*) Tuberculosis of the Genital
Fact, J. A. M. A. 104 : 722 (March 2) 1935; (c) Tubercidosis of the
Irogenital Tract: Early Diagnosis and Treatment, S. Clin. A or
merica 16: 1239-1256 (Oct.) 1936. ^ t , T . rnc _: {

3. Menville, J. G.: Tuberculosis of Mate Genital Tract: Microscopic

tttdy of Post Mortem Material, Proc. Staff Meet,, Mayo CJm. 16. -
fan. 16) 1935. .

4. Braasch, XV. F., in discussion on Menville. . .

5. Bumpus, H. C- Jr., and Thompson. G. J. : Tuberculosis of the
enital Tract, Sun?., Gvnec. & Obst. 4T:/91-/99 (Dec.) 19-8.

6. Barney, J. D.; Watsen, J. L. and Elliott. S.: The Diagnosis and
rcatment of Tuberculosis of the Genital Tract, Am, J. Surg. 1 ...

,J ?.' Caulk, J. R., in discussion, Tr. Am. A. Gcnito-Urin. Surgeons
3* °72-°7Z 1920. . _ . .

S: Campbell, H. E.: The Rationale of Epididymovasectomy in Cemtr .1
uberculosis, J. Urol. S4: 135-141, 1935. . ^ {

9. Moore. H.: Some Problems in Diagnosis and TreatntJJt or
rnito-Crinary TuT*rcti)o«i<. M- J. Australia Is 13/- 143 (Feb.) 19^^.

VOU’.ML 115
Number 15

GENITAL tuberculosis— miller and lustok

1389

It is our belief, based on our clinicopathologic obser-
vations. that the disease most frequently starts in the
vesicles and prostate but may occasionally start in the
epididymis. The mode of infection is primarily hematog-
enous.

Genital tuberculosis is principally a disease of the
structures apart from the testis, the latter remaining
intact in the presence of extensive long standing dis-

T.\nr.r. 2 . — Relation nj Onset of Genital Tuberculosis to That
of Pulmonary Tuberculosis in Sixly-Onc Cases

Mean ape of cm^ct of pulmonary tubcrculoM*-. about 27 years
Mean age of onset of genital tuberculosis about 50 years

Of the 61 cases of genital tuberculosis
Genital tuberculosis developed, in 47 from 1 to 20 years after pul-
monary tuberculosis, but in the majority within 3 to 10 years
In 5 cases genital tuberculosis developed from 1 to 5 years before
the onset of pulmonary tuberculosis
In 7 the patient was unaware of fits genital tuberculosis, winch was
diagnosed on admission
In 1 tlic onset was not known

In 1 pulmonary tuberculosis has not jet developed

ease of the epididymis, only becoming involved by con-
tiguity very late. In tlic large majority of cases, both
epididymides eventually show clinical evidence of tuber-
culosis, though there may lie a long interval before this
is observed.

DIAGNOSIS

The difficulty in accurate diagnosis of the scrotal and
prostatic masses lias been emphasized frequently, yet
the chief underlying cause is incomplete investigation.

The only method available for the examination of
the prostate and seminal vesicles is palpation with the
finger in the rectum. In the early stages of the dis-
ease no change may be demonstrable by this means of
examination, but in the vast majority of cases definite
signs are present. Irregular, firm but not stony hard
nodules in the prostate recognized by means of touch
indicate extensive involvement of this organ. Like-
wise when the seminal vesicles arc felt as pencil-like
bands, extending in an upward and outward direction

Table 3. — Classification of Genital Tuberculosis

1. Catarrhal

A lesion clinically characterized by predominant evidence of tissue
breakdown; this lesion is soft or even fluctuant and the masses are
ns a rule comparatively large; there is no evidence of sinus formation,
although it may seem imminent; the presence of a hydrocele (allergic
effusion) will place a lesion in this class

2. Ulcerative

A lesion clinically characterized by the presence of draining scrotal
sinuses, irrespective of the state of the scrotal mass

3. Fibroid

A lesion clinically characterized by predominant evidence of fibrosis or
calcification; there are no soft or fluctuant masses and no hydrocele
or sinus formation; a lesion with a hard fibrotic scrotal mass and
with old, healed, not active sinuses may be included in this class
Occurrence of the Types of Genital Tuberculosis

In the 61 cases there were

8 eases of catarrhal genital tuberculosis, in 8 of which there was no
evidence of renal tuberculosis

21 cases of ulcerative genital tuberculosis, in 5 of which there was
proved renal tuberculosis and in 16 of which there was no evidence
of renal tuberculosis

cases of fibroid genital tuberculosis, in 10 of which there was proved
renal tuberculosis and in 22 of which there was no evidence of renal
tuberculosis

from the upper margin of the prostate, extensive
involvement of these organs is indicated.

Examination of the external genitalia is best done
with the patient in a standing position facing the sur-
geon. Observations are made of alterations in the
normal rugose appearance of the skin of the scrotum,
die shape of the testicles and their relative position in
respect to each other. Changes in the scrotal skin arc

sometimes a valuable guide, as shown by a smoothing
out of the rugae and a wasting of the cellular tissue
immediately beneath the dermis. Adhesion of the skin
to the epididymis is a well known sign, as is also a
sinus discharging creamy pus. A comparison of the
mobility of the two testicles is sometimes helpful. A
normal organ can be moved freely within its covering,
particularly in the upward and downward direction.
This movement is often restricted when tuberculosis
of tlic genital organs is present. In the early stages a
soft or even fluctuant mass at the site of the epididymis
and involving it is present in a large percentage of cases.
If untreated, it will result in ulceration and formation
of a chronic sinus discharging pus or it will become a
hard, fibrotic or calcific mass. Late in the disease the
epididymis may entirely lose its identity or, if it can
he palpated, will be craggy and nodular. The vas
becomes thickened and has bead like prominences.

CLASSIFICATION

Genital tuberculosis has the same macroscopic and
microscopic characteristics as tuberculosis elsewhere in
the body, and its clinical-pathologic behavior simulates

Tabu; 4. — Other Extra pulmonary Tuberculous Lesions
Associated zeith Genital Tuberculosis (Exclusive
of Renal Tuberculosis)

Of the 61 cases of genital tuberculosis
In 27, or 44,2%, the condition was not associated with other extra-
pulmonary tuberculous lesions

In 34, or 55.7%, tlic condition was associated with other cxtrapul-
nionary tuberculous lesions

In 26 there was only one cxtrapulmonary tuberculous lesion
14, tuberculosis of the larynx
5, tuberculosis of the osseous system
3, tuberculous ischiorectal fistula
2 , tuberculous chronic otitis media
2, ileocecal tuberculosis

In 8 there was more than one cxtrapulmonary tuberculous lesion
3, tuberculosis of larynx and ileocecum

2, tuberculosis of larynx and osseous system

1, tuberculosis of ileocecum and osseous system

3, tuberculosis of larynx and ischiorectum
1. tuberculosis of skin and osseous system

Total

20 cases, associated tuberculosis of the larynx
9 cases, associated tuberculosis 4 of the osseous system
, j 4 cases, associated tuberculous ischiorectal fistula
' ' 6 cases, associated ileocecal tuberculosis’

2 cases, associated tuberculous otitis media

3 case, associated tuberculosis of the skin

that of pulmonary tuberculosis. The phthisiologist has
long been classifying pulmonary tuberculous lesions into
various types, depending on the predominant pathologic
process, and has based the necessity for a sanatorium
regimen, the indications for collapse therapy and the
prognosis on the clinical-pathologic classification.
Similar types of tuberculous lesions exist in the case of
genital involvement and show a parallel response to
treatment. A discussion on genital tuberculosis which
does not take into consideration the clinical-pathologic
type of tuberculosis hut merely includes all cases under
a blanket heading of genital tuberculosis is not justified.

We have divided the genital tuberculosis in our cases
into three main classes, as shown in table 3.

As is true of pulmonary tuberculosis, these types
represent various stages in the tuberculous pathologic-
process, the end result being fibrosis.

OTHER EXTRA PULMONARY LESIONS ASSOCIATED
WITH GENITAL TUBERCULOSIS
If the mode of infection in genital tuberculosis is
hematogenous, as stated, it would he logical to suppose
that other parts of the human anatom) 1 ' would become
seats of tuberculous infection at the same time as the

1390

Java. A. M. A,
Oct. 7, 1939

GENITAL TUBERCULOSIS— MILLER AND LUSTOK

genitalia, while the blood stream was laden with tuber-
culous bacillary emboli. This is indeed the fact. In
our series thirty-four patients, or 55.7 per cent, had
tuberculous lesions outside the lungs and kidneys.

The prevalence of other extrapulmonary tuberculous
lesions associated with genital tuberculosis strengthens
the theory of the hematogenous route of infection.

PROGNOSIS

The life expectancy of the patient with far advanced
cavernous pulmonary tuberculosis who has received no
form of active therapy was studied by Sclnvatt and
Rest 10 at our institution. The 267 patients had a
racial and sociologic background similar to that in our
series. They found that only 38 per cent of the
untreated patients with this type of tuberculosis were
a live at the end of the three to ten year period. In our

:»uaber of years after the onset of genital tuberculosis

Fig. 1. — Life expectancy of patients with genital tuberculosis (sixty -one
patients). Note that this is not parallel to that of patients with far
advanced pulmonary tuberculosis, as it is generally accepted to he.

series 95 per cent of the patients had far advanced
pulmonary tuberculosis and 27.8 per cent received
successful pulmonary collapse therapy. Our patients
therefore were in much better condition than those of
Sclnvatt aucl Rest, who did not receive collapse therapy,
and should have shown a much longer life span if the
prognosis of genital tuberculosis cases depends entirely
on the prognosis of the associated pulmonary lesion.
On the contrary, at the end of a one to eleven year
period of observation only 34.4 per cent of our patients
were alive. It becomes obvious then that the presence
of genital tuberculosis adds considerably to the gravity
of the general disease and shortens the life expectancy.

The cause of death was as a rule attributed to tuber-
culosis in general, although three patients died of tuber-
culous meningitis and three of uremia with a basis of
renal tuberculosis.

10 Schmitt H.. and Rest, A.: Prognosis of the Cavity Bearer, Am.
Rev.' Tulierc. 37: 65-70 (Jan.) 193S.

During the period of observation, of the patients with
the catarrhal type four, or 50 per cent, died ; of those
with the ulcerative type fifteen, or 71 per cent, died,
and of those with the fibroid type twenty-one, or 65
per cent, died.

TREATMENT

There are two distinct schools of thought with refer-
ence to therapy. The surgical treatment recommended
varies from a careful resection of the infected focus 11
to the complete removal of the seminal tract. 13 The
immediate mortality rate of radical surgical manage-
ment, the persistent draining sinuses that are frequent
sequelae of such intervention and the false rationale of
removing a single focus and leaving the primarily
infected prostate have placed this form of therapy in
general disrepute among phthisiologists and urologists
versed in the management of tuberculosis. 13

The beneficial effect of ultraviolet therapy in extra-
pulmonary tuberculosis lias been well known for many
years. Myl 14 reported most favorably on cases of
treatment with solar exposure at the Fitzsimons Gen-
eral Hospital in Denver. Other authors have reported
successful results in the treatment of genital tuberculosis
with ultraviolet therapy 15 and a sanatorium regimen. 10
It is logical to choose a form of therapy which will
lend itself to sharp localization to the desired areas,
that is the prostate, the seminal vesicles and the epi-
didymis, thus producing the maximum local effect
without doing any general harm. Irradiation of the
epididymis alone has been common practice among
the men who advocate this form of physical therapy
for genital tuberculosis. It is our belief that if radia-
tion was given with equal intensity to the prostate and
seminal vesicles, the most frequent primary seat of
tuberculous infection in the genital tract, the result
would be more certain and more rapid and reactiva-
tion would be less likely to occur.

GENERAL CONSIDERATIONS OR ULTRAVIOLET
RADIATION

The erythemagenic efficiency of a lamp as tested on
untanned skin is of importance in determining the indi-
vidual sensitivity of the patient to the raj' in order to
avoid serious burns, but it is not a measure of the
therapeutic action of the source of ultraviolet ray.
The popular use of the presence and extent of erythema
as an index of therapeutic efficiency of a lamp is
erroneously founded. Certain sources of radiation
capable of producing erythema in a comparatively short
time have little therapeutic effectiveness, and vice versa.
Other criteria for determining the therapeutic value of

H. Kretschmer, H. L.: Tuberculosis of the Epididymis: A Crtml
tevieiv Bused on the Study of Ninety-Four Cases, Surg., Gynec. & u>
17 : 652-659,1938. , . , , _ ,

12. Lowsley, O. S., and Duff, J.: Tuberculosis of the Prostate Glmm

inn. Snrg. 91:106-11+ (Jan.) 1930. Hinman, Frank: The Surge
Yeafment of J.ower Tract Tuberculosis, Genital and \ esical, J. Urol. -
21-5+0 (Nov.) 3928. Voting. 3 ' , . . T

13. White, E. W-, and Games, R. 1!.: Concerning Genital Tubercu

isis, Illinois 51. J. 70 : 78-82 (July) 1936. -

14 . Myl, N. A.: Heliotherapy in the Treatment of Genlto-Urinary

’nberculosis, j. A. M. A. 83: 1834 (Dec. 6) 1924. operative

15. Wang, S. L. : The Treatment of Inoperable and JPostoperau
nberculosis of the Urinary Tract, J. A. XL A, 8S: 1872-1875 (Jun .
927. Wang. S..L.: Quartz Light Therapy m Urogenital Tuterculo^.

. A. M. A. 104: 720-722 (March 2) 193a. Negley, J. C.. Cold <Ju
Utraviolet Light Therapy in Urology, Cahfornia S: U c, ir . 1 Indirect
26-229 (Oct.) 1933. Caulk, J. R., and Eiverhardt. F. H.:

Vernal Irradiation of Ultraviolet to Bladder, Arch. 1 'T'-fTM Ouarlr"
25-327 (June) 1932. Behneman, H. M. F.: Use of Co W Quan _
igbt in General Practice, ibid. 14:/2-/8 (Feb.) 1933. - r - ' .

rradiation Treatment of Genital Tuberculosis, Urol. & Cutan M -
207, 1936. Miller, E. A.: Present Day Conception of Tuwreuiojis
le Male Genital Tract, Dis. of Chest 3 : 120-131 (Ucc.) 1937.

16. Thomas, G. J., and Kinsella, T. J.: Factors Favoring

on of Certain Tuberculous Lesions of the Gemto-Lnnarj Tract, 1 -
. Genito-Urin. Surgeons 29:441-452, 1936. Thrr-mv J. A.

17 Coblentz, W. IV.: Physical Aspects of Ultraviolet Therapy, J-
[. A. 111: 419-423 (July 30) 1938: footnote 18.

1392

GENITAL TUBERCULOSIS-MILLER AND LUSTOK a. m. a.

Oct. 7, 1979

a commercial lamp must then be employed. The
rational means of evaluation of the therapeutic efficiency
of the commercial sources of the ultraviolet ray are
based on the quantitative and qualitative characteristics
of the spectrum emission. After careful study we
have chosen the so-called cold quartz lamp as the source
of ultraviolet ray in the treatment of genital tuberculosis.

Fijf. 2. — Treatment of the epididymis with topical applicator of the
so-called cold quartz ultraviolet lamp . Note' that the burner is at contact
to the scrotal skin and that the epididymis is held against the burner by
the operator s hand.

This has essentially a low vapor pressure, a low
amperage (0.015 amperes), a high potential (5,000
volts, open circuit) and a glow discharge similar to the
well known Geissler tube. The power consumed is
small and consequently there is no great rise in the
temperature of the burner. 18 The advantages of this
commercial source of ultraviolet rays lie in its effective
administration and its characteristic spectrum emission.
The burner is “cold,” exceeding room temperature only
after about an hour of continuous operation, and thus
the actual source of radiation can be placed directly on
and in contact with the target. This fact increases the
total quantitative output of the so-called generator
manyfold as compared with other commercial sources

Fig.

.—Treatment of prostate and seminal vesicles with the rectal

annlic'ator of the so-called cold quartz ultraviolet lamp. Xote that the
applicator .or me so K gf jts , ip t0 preven t exposure to the

,, r is covered to within 6 cm. of. its. tip to prevent exposure to me
anal sphincter and that the applicator is tipped so that the exposed end
lies directly on the prostate and seminal vesicles.

of ultraviolet rav. The latter, because of the heat gen-
erated at the burner, must be kept some distance from
the target (the air cooled machines at least 36 inches
and the water cooled machines from 3 to 6 inches,
depending on the type of quartz conduit used). Since
ultraviolet rays are essentially light rays, they are dis-

\V W • Source of Ultraviolet and Infra-Red Radiation
T-i S ; £°TW-,'nv I A ' M A. 10S : 1S3-1SS (July 21) 193-1; Sources of
Ultraviolet and In/ra-Red Radiation Used in Therapy, J. A. 31. A. 103 :
354-337 (July 2S) 1934.

seminated inversely to the square of the distance. When
the factor of air absorption is added to the loss by dis-
semination, it becomes obvious that the machine which
will permit application of the source in contact with
the target will deliver a greater quantity of ultraviolet
rays than a machine whose burner must be kept at a
distance from the area under irradiation.

The mechanical ease of manipulation and the imme-
diate maximum output (there is no “wanning, up”
period characteristic of other commercial sources) make
the so-called cold quartz apparatus very desirable. The
various applicators which emit radiation with equal
intensity at all points and angles and which are available
for topical, orificial, rectal and sinal irradiation at con-
tact to the tissues involved add further to the clinical
efficiency of administration. While the quantitative
appreciation of ultraviolet irradiation has been common-
place since its inception, the qualitative studies of the
ultraviolet spectrum and the characteristics of its com-
ponent wavelengths have been of recent origin in the
clinical literature. Most of the commercial sources of
ultraviolet rays produce radiation of mixed wavelengths,

predominantly between 2,537 and 3,130 angstroms, 18
while the so-called cold quartz lamp emits a spectrum
whose intensity along a wavelength of 2,537 angstroms
is within 95 per cent of its total spectrum emission,
to all practical purposes a monochromatic radiation. 19
The biologic effects of monochromatic ultraviolet
radiation in the wavelength of 2,537 angstroms have
been extensively studied. The bactericidal action
(Bacillus coli ) , =0 growth restriction of tissue culture,* 1
coagulation of albumin- 2 and hemolysis - 3 have their
peak effectiveness with radiation in the region of a
2,537 angstrom wavelength. The peak of the ergos-
terol activation curve (formation of vitamin D) has
been credited by some workers to wavelengths other
than 2,537 angstroms, 21 and Van Wijk and Reerink
have even claimed destruction of vitamin D by radiation
of this wavelength. A greater number of workers have.

19. Caulk.’ 1 Behncinaii. 15 Colilcnlz."

20. Elirisman. O., and XoctMinn, W. .- Uebcr die Bactcnculc W irUm.
Dnochromatischcn Lichtes, Ztschr. f. Hyg. u. Infekttonskr. llo . 29/

21. flayer, e! S ic Wirkunx von uttraviofcuen Strahfengrmisdicn cat

wcbeculturen, Strahlenthcrapie 30 : 348-193. 3930. , c

22. Lucfceish, 31. : Artificial Sunlight, Xeiv 3 ork, Dc Xostrand tom

23. ’ Sonne, C.: Die AMinengigkeit tier lichtbioloKisclicn Reaktionen %cn

r Wcllenlaence, Strahlenthcrapie 2S: 4J-51 1928. v.-.l-W,

24. Van Wijk. A., anil Reertnk. E. II.: Eme Methode zum

r tlierapeuti^clien Werte verschicdcner Lltrnviolcttstrahler, Strai) c
Topic 40 : 739-742, 1931. Col,lcntz.' :

Volume 113
Number 15

GENITAL TUBERCULOSIS— MILLER AND LUST OK

1393

however, found ultraviolet radiation of the wavelength
2,537 angstroms unusually active in the production of
vitamin D, both in vitro by activation of ergostcrol and
in vivo by cure of rickets in experimental animals.- 5

MODE OE TREATMENT

In our scries we employed the monochromatic ultra-
violet radiation of 2,537 angstroms emitted (95 per
cent) by the so-called cold quartz lamp as the sole
direct therapeutic agent. All irradiation was done with
the burner in direct contact with the tissues treated.
Treatment was given twice weekly. The initial dose of
fifteen seconds exposure was given to each epididymis
by scrotal contact and to the prostate and seminal vesi-
cles through the rectum. This was increased by fifteen
seconds weekly, until at tbe end of tbc first seven weeks
of treatment a full two minutes treatment was given

Table 6. — Summary of Results in the Treatment oj Genital
Tuberculosis By Means of Monochromatic Ultra-
violet Radiation with n ll'avclcngth of
2,5.?/ Anijslrouts

1. Fifteen patients with genital tuberculous were treated with ultraviolet

radiation of the wavelength 2,537 angstroms for from 1 to 19
months

2. Four patients with catarrhal genital tuberculosis were thus treated with
(o) Prevention of sinus formation in all 4

(fr) Absorption of the scrotal and prostate masses, with- small residuals,
in 2

(c) Reduction in the size of the masses in the scrotum and prostate
in 2

3. Five patients with ulcerative genital tuberculosis were thus treated with

(a) Complete closure of all sinuses in 2

(d) Closure of some* of the sinuses, with reduction in drainage from
the remaining sinuses, in 2

(c) Marked reduction in drainage from all sinuses in 1

(d) Marked reduction in the scrotal and prostate masses in 4
(c) No change in the masses in 1

4. Six patients with fibroid genital tuberculosis were thus treated with

(a) Reduction in the size of scrotal and prostate masses in 1

( b ) Slight reduction in the size of the scrotal mass in 1

(c) No remarkable change in 4

Conclusions

1. Ultraviolet radiation of wavelength 2,537 angstroms is of greatest value

.in the treatment of catarrhal and ulcerative genital tuberculosis
and of lesser value in the treatment of fibroid genital tuberculosis

2. The most distressing complication of genital tuberculosis, draining

sinuses, has been successfully prevented in cases of the catarrhal
type in which breakdown of the t issue ^ seemed imminent and suc-
cessfully eliminated in cases in which it was already present; the
patients with incomplete closure of the sinuses can be considered
as not yet adequately treated

3. This form of treatment has been less effective, if at all so, in the treat-

ment of fibroid genital tuberculosis; this condition^ like fibroid pul-
monary tuberculosis, presents the predominant picture of healing
by fibrosis and in all probability does not require any treatment

over each area treated. Treatment was continued semi-
weekly without interruption for from ten to twelve
months, after which there was a two months rest period.
Only patients who showed inadequate improvement
from the first course were given the second. Total
and differential white blood counts were made twice
monthly in anticipation of the leukopenia occasionally
seen as a result of heavy ultraviolet therapy, hut this
condition was never seen in our cases.

RESULTS OF TREATMENT OF GENITAL TUBERCULOSIS
WITH MONOCHROMATIC ULTRAVIOLET RADIA-
TION OF 2,537 ANGSTROMS

The period of observation in this group of cases was
from one half to two years. The majority of the patients
had had their genital tuberculosis for two years or
longer. With two exceptions the condition was asso-
ciated with far advanced pulmonary disease. Of the
twenty-one patients with genital tuberculosis (in our
series of sixty-one) who are alive at the present time,

25. Goldblatt, H. : Prevention and Cure of Rickets in Rats and Anti-
rachitic Activation of Ergosterol by Cold Quartz Mercury Lamp, Proc.
S 9 C. Exper. Biol. & Med. 30: 380-383 (Dec.) 1932. # Windaus, A.:
Lunge weitere Erfahrungen fiber das bestrahlte Ergostenn, Nachr. Ges.
V >ss. Gottingen 1: 36-37, 1930. Action of Monochromatic Actinic Radia-
tion, editorial, Arch. Phys. Therapy 14: 107-109 (Feb.) 1933.

fifteen received monochromatic ultraviolet radiation of
2,537 angstroms. While the greatest mortality for the
entire series with genital tuberculosis was for the first
two years of the illness, the majority of these fifteen
patients had their disease two years or longer, and none
of this group have died. The results appear striking in
spite of the brief period of observation.

Fig. 5 (ca^e 5). — Result of treatment of genital tuberculosis of tbe
ulcerative type. Note tbe healed scrotal sinuses and the restitution of
the normal rugose appearance of tbe scrotum. Reduction in the size of
tlic scrotal mass was marked, and the epididymis was no longer embedded
111 tbc mass and could be individually palpated. The prostate was
markedly reduced in size and was firm. The seminal vesicles were barely
palpable.

From the social and economic standpoint this form
of treatment is also very favorable. Of these patients
only five are undergoing absolute bed rest; four are
totally ambulant, two are ambulant and working in the
sanatorium and four are clinically well and living out-
side the sanatorium and working. The favorable effect
on the progress of the far advanced pulmonary tuber-

Fig. 6 (case 11). — Result of treatment of genital tuberculosis of the
fibroid type. Note only slight reduction in the size of the scrotal mass
and the absence of other demonstrable change.

culosis in these cases by the arrest of the genital
tuberculosis cannot be denied. This form of therapy
aptly lends itself to office practice.

In the analysis of the results obtained in the treatment
of genital tuberculosis by means of ultraviolet radiation
of 2,537 angstroms, the need for the aforementioned
classification of genital tuberculosis becomes apparent.
In the cases of the catarrhal type the results were the
most striking.

The ulcerative type of genital tuberculosis showed
the next best results.

1394

THORACIC SURGERY— ARBUCKLE AND STUTSMAN jo®«. a._
The third type of genital tuberculosis, that is the

SueX Pe ’ the i£aSt aPparait Change under THE BRONCHOSCOPIST AND THE

summary thoracic SURGERY TEAM

1. A statistical analysis of cases of genital tubercu-
losis observed in an eleven year period of 1,316 male
admissions to the Sanatorium of the Jewish Consump-
tives Relief Society was presented.

2. A classification for genital tuberculosis was pro-
posed, based on the clinicopathologic interpretation of
the lesions and their response to treatment.

3. Ultraviolet -ray therapy was advocated in pref-
erence to surgical treatment of genital tuberculosis, and
encouraging results in the treatment of the catarrhal
and ulcerative types was reported.

4. The consideration of the quantitative and quali-
tative spectrum output of a commercial source of
ultraviolet ray based on the individual biophysical
characteristics was stressed.

ABSTRACT OF DISCUSSION
Dr. Homer C. Hamer, Indianapolis: The authors present
a summary of the results of treatment of fifteen cases of genital
tuberculosis by ultraviolet radiation. Since no mention is made
as to what treatment was given in the remaining forty-six
cases of the series, it may be inferred that orthodox methods
were employed. If so, a comparison of results would he interest-

M. F. ARBUCKLE, M.D.

AXD

A. C. STUTSMAN, M.D.

ST. LOUIS

After several years’ experience as members of a
tnoiacic surgery team, we have become convinced of
the importance and value of teamwork in the diagnosis
and treatment of numerous types of pulmonary dis-
orders. Although there is not unanimous accord with
the following statement, we feel that thoracic surgery
has already become a highly specialized division of gen-
eral surgery and that special training for this type of
surgery is required.

1 he improved methods of diagnosis and treatment
now available make it possible to obtain results in the
treatment of certain varieties of pulmonary disorder
which are far better than have been achieved hereto-
fore. Treatment of some of these conditions may be
carried out by so-called medical care alone, this may he
combined with bronchoscopic treatment, or the two
methods may be combined with surgical intervention.
As an adjunct to medical treatment we find that
bronchoscopic treatment is much more efficacious in

ing and it is to be hoped that a later report may give data in
the other forty-six cases. In the five cases with sinuses, com-
plete closure had occurred in two. There was improvement in
two cases and no change in one case. Of the six cases of
fibroid tuberculosis, two were improved while four showed no
change. The results obtained in the scries by palliative treat-
ment may be as good as could be expected in a group of cases
of far advanced tuberculosis, in some of which possibly even
conservative surgery was contraindicated. Yet one may ques-
tion whether the prognosis was greatly improved. Spontaneous
arrest of the disease sometimes occurs, which tendency would
be enhanced by sanatorium treatment, but there is little justifica-
tion for nonoperative treatment in operable cases. Epididyroec-
tomy or castration is advocated by the majority of surgeons.
Good results are reported by Young and others who advocate
radical excision of the seminal vesicle, prostate, vas and epididy-
mis, together with the testicle if it is involved. The mortality
and operative results are about the same whichever site of pri-
mary focus is adhered to and whether conservative or radical
surgery is performed. From S3 to 80 per cent of clinical cures
are obtained by cpididymectomy. Local morbidity following
this operation is slight. Sinus formation following high excision
of the vas is uncommon. The observation of most observers
is that following epididvmectoniy the disease in the seminal
vesicles and prostate not only ceases but retrogresses to a point
of clinical cure. It is highly improbable that the operation,
conservative or radical, removes all the tuberculous tissue.
Arrest of the disease following operation depends on the ability
of the body defense to control the remaining infection. Pallia-
tive treatment preceding and following operation in the more
advanced cases should enhance the success of surgery. From
the results obtained by Drs. Miller and Lustok, it is fair to
predict that ultraviolet radiation may find a place as an adjuvant
to the surgical treatment of genital tuberculosis.

Dr. M. J. Lustok. Spivak, Colo. : I would stress the point
that we are dealing with persons who came to Denver primarily
for the treatment of pulmonary tuberculosis. These patients are
different in their behavior from the group which presents genital
tuberculosis alone without clinical pulmonary involvement. AYc
arc convinced that genital tuberculosis adds to the gravity of
the pulmonary disease and that the prognosis of the individual
j s not dependent on the progress of the pulmonary disease alone.
The successful management of tne genital tuberculosis is as
important as the management of the pulmonary tuberculosis in
the treatment of an individual so afflicted.

certain conditions, notably lung abscess, than we had
reason to believe only a short time ago. In some pul-
monary disorders it is true that relief is to be found
only through surgical intervention, an outstanding
example being endobronchial cancer. Either lobectoiny
or total pneumonectomy is at the present time the only
hope for curing this disease, which until five years
ago had a mortality rate of 100 per cent. As is well
known, in April 1933 the first successful total pneu-
monectomy as a means of treating cancer of the lung
was carried out by Dr. Evarts Graham. 1 The patient
is alive and carrying on with his profession as an
obstetrician without a sign of recurrence. The micro-
scopic diagnosis of cancer in this case was established
by study of a biopsy specimen obtained by us through
the bronchoscope. Dr. Graham informed us on Dec.
23, 193S, that in the last seven cases of total pneu-
monectomy for cancer of the lung there had been only
one operative death. Before the planning of treatment
for this or any other obscure pulmonary condition,
such as abscess, unexplained endobronchial stenosis or
unexplained variation in tuberculosis, a diagnosis is
essential, and an absolute diagnosis is particularly
important in the case of tumor of the lung. It is
obvious that the only method of making a definite diag-
nosis of a tumor is by study of a biopsy specimen,
which can he obtained on!} - with the bronchoscope.

As a result of our experience and from conversation
witft men from other centers we are convinced that the
most successful operations on the chest are accomplished
as a result of teamwork by a group of men, each a spe-
cialist in his own field, who collaborate in each case in
establishing the diagnosis and in outlining and admin-
istering treatment. Such a group properly consists oj
an internist who is especially interested in thoracic
disorders, a thoracic surgeon who is a specialist in this

From the Chest Service. Washington University Hospital Croup, an' 1
the Mallinckrodt Institute oi K.iriiolony.

Read before the joint meeting of the, Middle Section ot the i.n u*
gological, Rhinologicaf amt Otologicat Society and the Sioux »
and Ka r Academy. Sioux City. Iowa, Jan. 19, 1939, , * „„

1. Graham. E. A., and Smstr. J. U Sacec«ful Removal of an
Entire Lung for Carcinoma of the iSronchus. J- A. M.

1374 (Oct. 2S) 1933.

Voi.UMK 1 1
NvMpkk 15

THORACIC SURGERY— ARB UCKLE AND STUTSMAN

1395

field by reason of actual and thorough training, a
bronchoscopist similarly qualified, an expert radiologist,
a pathologist and a bacteriologist. It would seem that
special training on the part of the pathologist in the field
of tumors of the tracheobronchial tree increases his
usefulness as a member of a thoracic surgery team.
Tumors of all kinds arc difficult of classification in
some instances when a decision is wanted as to malig-
nancy, hut apparently tumors of the respiratory tract
possess this quality in a more marked degree than do
ordinary tumors. The difference of opinion and the
occasional inability to establish an opinion are based
on sound reasoning. One possible explanation is the
fact, often unrecognized, that a tumor may he made
up of more than one variety of cells. We have in our
laboratory a specimen of an endobronchial cancer in
which at least four grades (Brodcrs -) of cells have
been found. Many pathologists, radiologists and can-
cerologists feel that the degree of radiosensitivity of a
given tumor may he prophesied within limits by the
microscopic appearance of its cellular make-up. It is
well known that tumors frequently do not live up to this
prognostication. The presence of several varieties of

duction of the oil will he far more satisfactory if the
operating room is equipped with adequate x-ray
apparatus and if the tube is focused before the oil is
put in so that the exposure may he made before the
position of the oil is disturbed by coughing. Interpre-
tation of bronchograms presupposes an accurate knowl-
edge of the topographic anatomy of the tracheobronchial
tree. The bronchoscopist, furthermore, is a more valu-
able member of the team if he is also a trained oto-
laryngologist, because of the fact that many pulmonary
disorders are secondary to those of the upper respira-
tory tract.

Bronchoscopic examination entails much more than
the mere introduction of the bronchoscope, but it is
very important that the instrument be passed into the
trachea without injury to the lips, teeth, tongue, gums,
pharynx or larynx and without mental hazard to the
patient. Careful inspection will reveal notable depar-
tures from the normal, if they are present, in the visible
portion of the tracheobronchial tree, namely' the larynx,
trachea and the larger bronchi and even the opening of
the bronchus to the various lobes. With instruments
especially designed for this purpose, we are at times

Fig. 1 (case 1). — A plain anteroposterior
film showed a tumor in the right lung near
the border of the heart. The patient was a
woman aged 65.

Fig. 2 (case 1). — A localizing antero-
posterior brotichogram showed blocking of
the bronchus to the middle lobe of the right
lung.

Fig. 3 (case 1). — A localizing lateral
brunchogram showed blocking of the bronchus
to the middle lobe of the right lung with
atelectasis. In view of this information the

cells within the tumor, unrecognized because of failure
to study the entire tumor, may he the basis for this
disappointment.

Most pulmonary disorders may be discovered and
recognized by means of x-ray and physical study, hut
they may he much more accurately localized and their
exact nature may he more definitely established by'
visual examination through the bronchoscope and the
study of specimens obtained during the examination.
The bronchoscopist will carry on more satisfactorily
when and if he is competent to make a physical exam-
ination of the chest and to interpret films for himself.
Bronchograms may he made as a rule by the house
officer working with the team, according to the simple
method suggested by Singer , 3 whereby the oil is intro-
duced directly into the larynx with the patient in front
of the fluoroscope. In an occasional case this is impos-
sible, and then the oil is introduced through the
bronchoscope and a film made while the patient is on
the table. Bronchograms made by bronchoscopic intro-

2. Brokers, A. C. : Grading of Cancer: Its Relationship to Metastasis
ami Prognosis, Texas State J. Med. 89: 520-525 (Dec.) 1933.

3. Singer, J. J.: A Simple Method of Introducing Iodized Oil into
the Lungs, J. A. M. A. S7: 1298-1299 (Oct. 10) 1926.

enabled to see
lesions well up
within a branch
bronchus. Some
of the changes to
be found are alter-

bronchoscope was introduced directly into the
bronchus of the middle lobe after the neces-
sary dilation had been carried out. The
tumor was then visualized and a biopsy speci-
men recovered. A diagnosis of benign
adenoma was made by microscopic examina-
tion, and roentgen treatment was recom-
mended.

ations in the position, shape and size of the tubes ; the
presence of blood or pus in the tubes; changes in the
appearance of the mucosa, including its color, and
the presence of ulcer, scar tissue, tumor masses and, of
course, foreign body. Thus, for example, changes in the
position, shape and size of the tubes may he caused by
pressure on their walls by a tumor mass which is located
outside the tubes. Similar changes may be caused by the
pressure accompanying pneumothorax, by a mass of
enlarged glands or by adhesions. Inflammatory changes
in the mucosa itself will encroach on the lumen hut
usually do not change the actual shape of the tube or
its position. As is true with inflammation elsewhere
in -the body, there is usually redness as well as swelling.
When one finds blood or pus or both one must localize
the lesion by tracing these secretions to their source.
This is best accomplished by the use of suction and
lepeated inspection at the same sitting. We are presup- ~

1396

THORACIC SURGERY— ARBUCKLE AND STUTSMAN

posing, of course, careful physical and x-ray examina-
tions. including the making of bronchograms, before
bronchoscopic examination is carried out.

When scar tissue is found as a basis for endo-
bronchial stenosis the stricture must be dilated, secre-
tions carefully collected for bacteriologic study and
evidence of recent inflammatory reaction noted. In
such cases tuberculosis and syphilis must be ruled out.
Indeed it should be routine practice to secure a speci-
men of secretions whenever possible, for laboratory
study, including, when indicated, guinea pig injections.
The rather unusual disorder, such as actinomycosis or
other fungous disease, will be detected in this way,
while otherwise the diagnosis might be missed. We
have observed an occasional case in which tubercle
bacilli in the pulmonary secretions were demonstrated
in a specimen obtained by bronchoscopic suction when
the patient did not have sufficient sputum to cough up a
specimen in the amount required for examination. We
have one patient who had localized tuberculosis in the
upper lobe of the left lung with blocking of one of the

At all times the bronchoscopist must be prepared to
deal with hemorrhage. This is of comparatively rare
occurrence, but when it does happen it is a most serious
matter and requires immediate and exact management
“ one IS t0 avoid asphyxiation as soon as the blood
clots, which it does promptly, or possible exsanguination
or postoperative complications such as pneumonia.

Avoidance of mental hazard to the patient is an
important feature always, but particularly when the
patient is suspected of having tumor or other disorder
for the relief of which surgical intervention will be
required later. We find that we have much less diffi-
culty in arranging for such treatment if the patient has
been shielded at the time of the bronchoscopic exatnina-
tion, and also we are certain that if the patient is
asleep the bronchoscopic examination can be carried out
in a much more satisfactory manner. For these reasons
we have employed avertin with amylene hydrate for
all our bronchoscopic examinations for several years,
and we see no reason to alter this practice.

An occasional case is observed in which by broncho-
graphic examination one may establish that tire obstruc-

Fig. 4 (case 1). — This view anti others Fig. 5 (case 2). — Puddling denotes the

showed a decrease in the size of the tumor area of granulation tissue which was treated

and in the area of atelectasis. by actual cautery. The patient was a woman

aged 36.

branches of the bronchus of this lobe by granulation tive lesion is with-
tissue and subsequent atelectasis. The differential diag- in one of the
nosis between cancer and tuberculosis was made by smaller bronchi at

Fig. 6 (case 3), — A filling defect in the
trachea extends from the level of the second
rib posteriorly down into the lower lobe of
the right lung, where extensive bronchiec-
tasis is seen. The tuberculous granulations
in the trachea and at the opening of the
right bronchus were removed with the biting
forceps and the actual cautery. The patient
was a woman aged 37.

studying secretions obtained with a curved suction tube
which at the same time traumatized the granulation tis-
sue so that it bled. The application of suction and the
bleeding were followed promptly by ventilation and
drainage of the atelectatic lung. Tin's patient was
treated locally and by general medical care three years
ago. She was away from her employment for the period
of about a year but has been back at work for two
years.

When a tumor mass is found, its position must be
definitely established by actual measurement and a
biopsy specimen taken. Some time ago one of us
pi. F. A.) described a method of measuring the dis-
tance between the proximal portion of a tumor and the
carina. This method is highly important to the thoracic
surgeon when lie is contemplating surgical removal of a
lobe or a lung. Tumors in the vicinity of the carina
have a tendency to grow by direct extension across the
dividing line and obstruct the bronchus of tile other
side, temporary relief of obstructive symptoms may
be afforded by removal of the tumor with the forceps
and the actual cautery.

sufficient depth to

place it beyond the range of ordinary bronchoscopic
visibility, or it may be in a bronchus which is
placed at such an angle as to prevent introduction
of the bronchoscope (figs. 1, 2, 3 and 4, case 1). In
the former instance it occasionally is possible to dilate
tile bronchus sufficiently to introduce the broncho-
scope and permit visualization and recovery of a biopsy
specimen under visual guidance ; or it may be necessary
to take the biopsy specimen without actually seeing the
tumor by simply introducing the forceps to the point
indicated on the bronchogram. This method is obviously
unsatisfactory for numerous reasons and of course is
employed only of necessity. The results are conclusive
only when positive. We have had one case of car-
cinoma of the upper lobe of the right lung in which the
tumor was around the comer to such an extent that it
was impossible to see it or get the forceps up to it. W
inducing artificial pneumothorax with the patient supine
and then placing him in a semiprone position, it was
first demonstrated that there were no adhesions between
the lung and the parietal pleura in the apical region.

Volume 113
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THORACIC SURGERY— ARB UCKLE AND STUTSMAN

1397

Later the bronchoscope was introduced, and again
the air was allowed to float up, as docs the bubble in the
carpenter’s level, under fluoroscopic guidance with the
bronchoscope in position and with the pneumothorax
needle in position. More air was then introduced, and
the tumor was forced down under fluoroscopic visualiza-
tion until the lumen of the bronchus containing the
tumor was on an axis parallel with that of the broncho-
scope. The bronchoscope was then pushed into the
bronchus containing the tumor, the tumor visualized and
a specimen taken. The results of biopsy in this instance
were negative for cancer, hut transthoracic exploration
confirmed the inferential diagnosis of endobronchial
carcinoma. The method of taking biopsy specimens
from endobronchial tumors, or from other tumors, for
that matter, is a subject worthy of considerable discus-
sion, hut for lack of space we will merely say that more
than once we have had negative results from a biopsy
when we felt certain that the correct diagnosis was
cancer. In some instances it was discovered that the
reason for the failure to demonstrate cancer cells was
that the specimen was not cut deeply enough through

lene hydrate and local anesthesia. The lesions have
entirely disappeared and the sputum has become free
from tubercle bacilli. The patient had no untoward
constitutional reaction from any of the several applica-
tions of the cautery.

The second patient (fig. 6, case 3) was a young mar-
ried woman who had had pulmonary tuberculosis for
some time and who finally came to us because of con-
tinued difficulty with breathing. She had a high degree
of tracheal stenosis with stridor and cyanosis. The
tracheal obstruction was readily demonstrable with
films made after injection of iodized oil. Inspection
revealed the fact that her trachea was filled, except for
a narrow slit, with granulation tissue from a point about
midway between the cricoid cartilage and the bifurca-
tion down to and into the right main bronchus. She
also had a severe bronchiectasis in the lower lobe of
the right lung, which was the affected side. We have
been able with the biopsy forceps and the cautery to
relieve her respirator}’ difficult}' and with the suction
to relieve the signs of absorption which she was getting
from the bronchiectasis. We realize of course that this

Fig. 7 (case •}). — A filling defect in the
lower lobe of the left lung behind the heart
and close to the midline shows the location
of a bronchiectatic lesion at this point. This
observation was confirmed by endobronchial
inspection and by examination of the speci-
men after' lobectomy. The patient was a
boy aged 10 years.

Fig. 8 (ca*e 5). — A filling defect in the
right main bronchus denotes the point of
lodgment of a foreign body, removed
through the bronchoscope. This body prob-
ably caused the bronchiectasis. The nature
of the bronchial obstruction could not be
established except by direct inspection. A
diagnosis of tumor had been made and was
not untenable. The patient was a woman
aged 42.

Fig. 9 (case 6). — A post-tonsillectoniy
lung abscess of three years’ duration in a
woman aged 38. The plain roentgenogram
showed a shadow in the lower lobe of the
right lung which at first glance appeared to
be in the upper lobe (a mistake which is
commonly made). After detailed study for
localization the abscess was demonstrated to
be in the apical division of the lower lobe.

the surrounding layer of fibrous tissue to include the
cancer cells. This is exactly what happened in this
case. In other cases the specimen was taken from the
immediate vicinity of the tumor rather than from the
tumor itself. . ,

For years we have been on the lookout for localized
lesions of the tracheobronchial tree in tuberculous
patients, but not until comparatively recently was it our
fortune to see one that could be identified as such, and
then came three in rapid succession in Dr. Graham’s
service.

The first patient (fig. 5, case 2) had had a successful
pneumothorax but the sputum had continued to show
tubercle bacilli, which the internist and the thoracic sur-
geon were at a loss to explain. Bronchoscopic exam-
ination revealed the fact that she had an ulcer on the
surface of the carina on the side of the affected lung
and an ulcer and granuloma in the bronchus to the
upper lobe on the affected side. These were treated by
repeated applications of the actual cautery through the
bronchoscope with the patient under avertin with amy-

is almost a hopeless situation, but we are trying to free
the trachea of its involvement in the hope that we may
later be able to recommend a lobectomy or a pneu-
monectomy for the tuberculosis and bronchiectasis.

The third patient was a physician’s wife who also
had long standing tuberculosis on the right side and
pneumothorax. When it was decided to let the lung
expand by releasing the pneumothorax, the lung failed
to expand. When she came to Barnes Hospital she had
severe respiratory difficulty with marked stridor and
cyanosis. Bronchoscopic examination revealed a high
degree of obstruction at the lower end of the trachea
caused by external pressure and displacement into the
lumen of the wall on the left side. There was also pres-
ent a mass of granulation tissue which completely
obstructed the right main bronchus at the carina. It
was necessary to apply some force in passing a 9 mm.
bronchoscope through the obstruction in order to dis-
place outward the tracheal wall. Then the granulomas
were visualized and touched with the actual cautery.
Y\ ith the first treatment the patient had immediate relief

1398

THORACIC SURGERY— ARBUCKLE AND STUTSMAN

from dyspnea and cyanosis, and she has continued to
improve with subsequent treatments. The lung has
expanded somewhat.

Bronchiectasis is a disease of frequent occurrence
and may be found at any age. It occasionally is com-
plicated by hemorrhage due to ulceration into a sizable
blood vessel. The hemorrhage may be severe enough
to necessitate lobectomy as an emergency measure.
Such a condition was found in a 10 year old boy (fig. 7,
case 4), who had had pneumonia six months prior to
admission to the St. Louis Children’s Hospital in the
service of Dr. Evarts Graham in the summer of 1938.
When admitted he was having pulmonary hemorrhage
several times a day, and he had required numerous
blood transfusions before coming to St. Louis. On
his arrival it was found that his red cells numbered
3,200,000 and his white cells 8,600 and that his hemo-
globin content was 70 per cent. He continued to spit
up blood in the amount of 150 to 250 cc. once or twice
a day. A plain film showed evidence of disorder in the
lower lobe of the left lung behind the heart. A broncho-
gram made immediately by the direct method showed a
filling defect in the same region. On bronchoscopic
examination we found the tracheobronchial tree more

is well known, was done years ago, but this method of
treatment was more or less abandoned because of the
terrific mortality rate. With the methods of today a
well trained thoracic surgeon has no hesitation in recom-
mending a lobectomy in a suitable case. Our own opera-
tive mortality is now less than 5 per cent. 4

Abscess of the lung is an important and serious dis-
ease of rather frequent occurrence, in the diagnosis and
treatment of which the bronchoscopist may play a most
important part. First of all, abscess of the lung in
adults not infrequently is caused by a foreign body or
by failure of resolution of a disease such as pneumonia,
and not infrequently it is the result of bronchial obstruc-
tion by an endobronchial cancer. We as laryngologists
are especially' interested in the condition, since in a high
percentage of cases it follows tonsillectomy'. Inspection
of the tracheobronchial tree in search of the cause as
well as for the purpose of localization is important in
diagnosis and treatment. We have found that a fairly
good percentage of the patients will make complete
recovery' by' bronchoscopic treatment combined with
medical care, which consists chiefly of rest in bed and
postural drainage. This is contrary to the opinion
which we held a few y'ears ago. Bronchoscopic treat-

ing. 10 (case 6). — Iodized oil was injected
into the abscess cavity after removal of
granulation tissue from the fistulous opening
and evacuation of inspissated pus.

or less blood stained throughout. With the application
of suction it was found that the source of this blood
was in the mesial division of the bronchus to the lower
lobe of the left lung. A diagnosis of bronchiectasis
with ulcer localized to the lower lobe of the left lung
was made and immediate lobectomy recommended. This
was done on the following morning, two transfusions
having been required in the meantime. The diagnosis
was confirmed at operation, and the accompanying
illustration (fig. 7) shows the involvement of the lobe
itself. The boy made an uncomplicated recovery and
has had no hemorrhage since the operation.

Every patient with bronchiectasis should have at least
one bronchoscopic examination because of the possible
presence of an unsuspected foreign body (fig. 8, case 5)
or bronchial stenosis caused by scar tissue or granula-
tion tissue. If a foreign body is found, removal will
promote drainage and ventilation and help to improve
the patient's general condition. Bronchoscopic therapy
alone will not cure bronchiectasis, but it does make life
more livable for the patient and improves his chances
for recoverv if lobectomy is to be done later. v\ e are
convinced that once bronchiectasis is well established
the only hope of cure is surgical removal of the affected
portion of the lung. Lobectomy for bronchiectasis, as

Fig. 12 (case 6).— Remarkable clearing in
keeping with the patient’s general condition,
which, as far as one can make out from her
statement, is normal.

ment of abscess of the lung as we apply' it consists n>
the removal of granulation tissue if present from around
the fistula leading into the abscess by' the use of the
sponge curet, the biting forceps or sometimes the cau-
tery', dilation of the fistula, the use of special suction
tubes and the introduction of remedies which we think
help to reduce the virulence of the infection. These
consist of 1 per cent guaiacol in oil of sweet almond and
iodized poppy'seed oil in spite of discussion pro and con-
It is our feeling that iodized poppyseed oil introduced
into these cavities, even for bronchographic examina-
tion, often has a very salutary effect on the infection
present. Coupled with such treatment we always carry
on with postural drainage. Careful study' of properly
made localizing films before bronchoscopic treatment
facilitates entering the cavity'. The study' of lamina-
grams helps us in deciding whether or not the abscess
cavity is single or multiple.

We have had made several special flexible metallic
suction tubes with which we have been able to enter
and drain abscess cavities which we could not otherwise
reach through the bronchoscope. We have one patient
who had had an ab scess for three years following

4. Graham, E. A.; Singer, J. }., and Ballon. Harr*- C.: Surgical
Diseases of the Chest. Philadelphia, Lea & Febiger, 193a.

Fig. 11 (case 6). — The important
lateral view demonstrates beyond
doubt that the abscess is in the
apical division of the lower lobe.

Volume 113
Number IS

THORACIC SURGERY— ARBUCKLE AND STUTSMAN

1399

tonsillectomy. According to her own statement, the
bronchscope had been used twenty-seven times before
she came into Dr. Graham’s service (figs. 9, 10 11 and
12, case 6). At the first sitting we found granulation
tissue obstructing the fistula leading into the abscess.
After removal of this granulation tissue the stench was
so terrific that the assistants and nurses in the room
were sickened by it. With one of the special flexible
tubes we were able to enter the cavity, which was
very large and which was filled with inspissated pus.
In this case, as in another case which we are here-
with reporting (figs. 13. 14 and 13, case 7), there
was momentarily free bleeding apparently from granu-
lation tissue. According to our experience such bleed-
ing apparently diminishes the granulation tissue and
improves drainage. The chronic unilocular abscess with
exuberant granulation tissue which bleeds when suction
or sponging is done and which has a very foul odor
offers a good prognosis for recovery with bronchoscopic
treatment alone. The bleeding is usually readily con-
trollable by the application of epinephrine and cocaine
on a sponge. Sometimes even this is not required.

When one considers the difference in the hazard
between bronchoscopic treatment of lung abscess and

considerably increased. One reason for the increase
in the number of positive diagnoses almost certainly is
the fact that more accurate diagnostic methods are being
employed. There are authorities who think that there
is an actual increase, and while this may be true we are
inclined to think that the increase is more apparent than
real. Until well within our time the diagnosis of endo-
bronchial cancer was made by inference, until the patient
came to the autopsy table, or until the cancer filled the
pleural cavity, or until occasionally a piece was broken
off and coughed up or until metastasis to a superficial
location permitted biopsy. Now in a large percentage
of cases it is possible actually to secure a biopsy speci-
men from endobronchial tumors, and, as we remarked
earlier in this paper, actually to localize the tumor.
Tuttle and Womack 5 from a study of our cases found
that as a rule there is a much greater life expectancy
for the patient whose endobronchial cancer is in the
larger tubes than for the one whose cancer arises in the
smaller tubes. It is also possible at times for the bron-
choscopist to obtain by palpation with the end of the
bronchoscope some idea as to the presence or absence of
fixation of the hilar portion of the lung by pleural
adhesions or by pressure from a peribronchial tumor.

Fig. 13 (ca^e 7). — Involvement of the lung
early in tlie course of the disease in a man
aged 21 referred to u« f»y Dr. John R. Dc
Veiling, RosicI are, III., Aug. 25, 1938.

Plate shows area of infiltration of tlie right
hilar region, which was again the apical
division of the loner lohc. There is no
cavitation at this time.

external drainage through the temperature for aboi

chest wall, one realizes how foUowmg n '<ia'\ to'”*

important is the fact that a

respectable percentage of patients home, and a commm

will get well with this compara- weir 193S ’ stalc

tively simple method of treat-
ment. We have been looking over our case records
in an effort to discover if possible some method of
telling beforehand which patients will and which will
not get well with bronchoscopic treatment. To date
our only means of answering the question is to institute
treatment.

It is recognized of course that a large percentage
of all patients with lung abscess recover spontaneously,
some without any medical care and many with so little
medical care that it amounts to the same thing, while
others will recover with rest and postural drainage.
But there remain a group who do not recover with this
method of treatment, and it is with these that we as
bronchoscopists are concerned.

The diagnosis of cancer of the lung is being made
much more frequently than it was only a very few years
ago, so much more frequently in fact that the incidence
in comparison with that of all types of cancer has been

Fig. 14 (case 7). — Plate made four months
later for comparison shows increased dis-
tribution of infiltration with cavitation in the
center of the shadow. Aug. 25, 1938, with
bronchoscopic visualization granulation tissue
was removed from the fistula leading to the
abscess in the apical division of the lower
lobe of the right lung and a large quantity
of inspissated and extremely foul -smelling
pus was evacuated with the special suction
tip. Although the patient had had a septic
temperature for about a year, his tempera-
ture promptly fell to normal, and on the
following day, to use his own expression, he
had “an appetite like a horse.” After three
bronchoscopic treatments he returned to his
home, and a communication from him dated
Nov. 3, 1938, stated that he was entirely
well.

Fig. 15 (case 7). — The improvement in the
appearance of the chest, visible even at an
early date.

iuii Ki.iuuiauun usbue . • t t

fistula leading to the When operations on the lung

arid 'a* 1 large 'quantity through the chest wall are to be

tremeiy foul-smelling carried out, we find that for sev-

cm had had a septic eral reasons it is important for

normal’, ami'^'n'The the brouchoscopist to be on hand

is own expression, he in the operating room and ready

ts h h r e e returaed r to h his t0 work. The type of anesthesia

at'on from him dated which is best wlieil the Chest Wall

tliat he was entirely . . . t .

is opened is endotracheal anes-

thesia administered by an endo-
tracheal tube connected with apparatus for accurate con-
trol of the intrapulmonary pressure. The anesthetist
occasional!}' has difficulty in introducing the endo-
tracheal tube, and the brouchoscopist can help with this.
In all types of lung suppuration it has been demon-
strated by numerous other workers as well as by our-
selves that bronchoscopic suction immediately before
and after operation almost surely prevents not only
respiratory difficulty during the operation but also the
development of postoperative pneumonia.

By the prompt introduction of the bronchoscope and
the application of suction, we have been able on several
occasions to save the life of a patient who, because of
complete tracheal obstruction by pus and blood, had
stopped breathing on the table. In each instance after

. .. s - Tuttle, W. M. , and Womack, X. A.: Bronchogenic Carcinoma:
Uassification in Relation to Treatment and Prognosis, J. Thoracic Sure.
4: 125-146 (Dec.) 1934.

1400

PYOCYANEUS MENINGITIS — SLUTSKY AND MAT LIN

Jour. A. M. A.
Oct. 7, 1939

the trachea had been cleared the patient breathed again,
the operation on the lung was completed and the patient
is now alive and well. One interesting example is that
of a small child with a lung abscess possibly caused by
a foreign body.^ Her condition was so precarious that
a pieliminary introduction of the bronchoscope was
postponed because we felt that immediate drainage of
the lung abscess was her most urgent need. After the
incision had been made, pleural adhesions had been
found, an abscess had been located with a needle and
the surgeon, Dr. Brian Blades, had begun to apply the
actual cautery to uncap the abscess, the child suddenly
quit breathing. She was said to have died of an
embolus. Since one of us (M. F. A.) was standing
by the head of the table and the bronchoscope was ready
for use, immediate inspection of the trachea was under-
taken. This showed that its lower end was entirely
filled with a blood clot, which came away rapidly in
one piece with the suction. With cleaning up of the
pus which filled the bronchus and with artificial respira-
tion the child resumed breathing and the operation on
the abscess was finished. We had a letter from her
mother at Christmas 1938 reporting that siic was in
perfect health.

Another patient with bronchiectasis, an adolescent
who had had preoperativc bronchoscopic suction, became
cyanotic and quit breathing in the midst of the operation
for lobectomy. This operation was abandoned for the
moment while bronchoscopic suction was immediately
applied by one of us (A. C. S.), who was on hand and
ready to work. As soon as the airway was cleared the
patient began to breathe, the operation on the lung was
completed and the patient made an uneventful recovery.

by bronchoscopic treatment in cases of lung abscess
demonstrates the necessity for keeping in mind this
method when outlining treatment in such cases. It is
of course the accepted method for removal of a foreign
body and is the only approach for applying direct treat-
ment to localized tuberculous lesions.

In establishing the cause and location of unexplained
pulmonary bleeding, direct inspection (bronchoscopic)
lias been found most helpful. We have had no unfavor-
able reaction as a result of the necessary manipulations,
and it is our feeling that the propitious time for such
examination is while bleeding is active.

539 North Grand Avenue.

Clinical Notes , Suggestions and
New Instruments

PVOCVA i\'£US MEXIXGITIS

REVIEW OF THE LITERATURE AM) RETORT OF AS ORIGISAL CASS

Nathan Slutsky, M.D., axd Pm Matuk, M.D., Brooklyn

We arc taking this opportunity of reviewing the literature
and presenting a case report of a comparatively frequent
saprophyte which on occasion attains moderate virulence and
invades the blood stream and nervous system with fatal sequelae.

The general surgeon, while not often troubled by the invasion
of Bacillus pyocyaneus, encounters it frequently enough to
recognize the greenish discoloration over a heretofore healthy
granulating surface and may even anticipate it by the charac-
teristic odor suggestive of wet musty hay arising from the
dressings. A few applications of boric acid rapidly eradicate
the invasion and hence cause no undue concern.

CONCLUSIONS

Because of' improved diagnostic and therapeutic
methods, the outlook for persons suffering from a rather
wide variety of pulmonary disorders has improved
tremendously during the past decade. Of importance
in the application of these methods of study and treat-
ment is the realization that this is a special field in
which, in order to obtain the best results, the work
must be carried out by a group each member of which
has been,thoroughly trained for his particular job. In
our service some of the members of this group find it
necessary to have their own individual teams in ordei
to carry on more satisfactorily with their phase of the
work.

The epoch making developments in thoracic surgery
of the past five or ten years have depended not only on
improved surgical technic, anesthesia and postoperative
as well as preoperative care, all of which are of first
importance, but also on better x-ray and pathologic
studies Probably the greatest single step forward has
been early and actual diagnosis by direct inspection of

the lesion. ...

The presence of pulmonary disorder ot almost any
type may be demonstrated by the usual methods of
study, namely physical and x-ray, but unfortunately such
studies do not reveal in many cases the exact nature of
the disease nor do they demonstrate its endobronchial
distribution. These usually may be established by direct
endobronchial inspection and by the study of specimens
obtained during the course of this inspection.

The same approach is extremely valuable m the treat-
ment of certain varieties of pulmonary disorder, promi-
nent among which are lung abscess and localized
tuberculous" lesions. The percentage of cures obtained

The genitourinary surgeon meets this organism with more
frequency, for the urine appears to be an excellent culture
medium. Weiss 1 claims an incidence of 25 per cent following
pyelotomy.

Scott 2 in 1929, while investigating the rigors attendant on
instrumentation of the genito-urinarv tract, took blood cultures
on patients suffering chills and fever above 102 F. Over a
period of two years he was able to obtain eiglitv-two positive
cultures, recovering Bacillus pyocyaneus three times. This
bacteremia was transitory with no sequelae. Hyman and
Edelman s in 1932, repeating this procedure, obtained sixty-
three positive cultures and one case of pyocyaneus bacteremia
following cystoscopy in a case of renal neoplasm. Barrington
and Wright 1 report twelve positive cultures in a series of
eighty-eight cases, with one case of Bacillus pyocyaneus.
Powers, 5 in a series of thirty cases, recovered this organism
from the blood on one occasion. Ewell 0 reports a case of
pyocyaneus bacteremia following pyelonephritis and prostatic
abscess with subsequent death. Fish and his associates • report
a case of acute bacterial endocarditis in a man aged 71 after
repeated catheterization and suprapubic prostatectomy. He also
mentions four similar cases from the German literature.

In 1936 Florence Evans 8 reviewed the literature on menin-
gitis due to Bacillus pyocyaneus and reported a total of forty -
two cases, including three of her own. This series included six
cases in which there were meningeal symptoms, but no organ-
isms could be recovered from the spinal canal. There were
fourteen cases due to direct trauma (spinal tap, injury and
the like), four cases of otitic origin and eighteen cases of
pyocyaneus meningitis following systemic infection. Of these

2 Weiss: Personal communication to the authors.

£ Scott, W. \V.: J. Urol- 81:527 (May) 3929.

3. Hyman, A., and Edelman, L-: J> Ur°K 28: 2/3

4. Barrington, F. J. F., and Wright, H. D.: J. Path. & Bact.

1 5 C °Pmvers!' 5 j: H.t New York State J. Med. SC: 3 123 (Mad, 1) 1936.
6 Ewell. G. H.t Urol. & Cutan. Rev. 40: 69. - (Oct.) 1W6. ,

7. Fisb. G W.; Hand, M. M„ and Keint. W. F., Jr.: Am. J. Pa*"-

! S. 1 Evi£ n Flo 1 ren«: M. Rec. 144: ill (A tig. 5) 1936-

VOU’.NU 113
Numufr 15

PILONIDAL SIN US11S— GOLDBERG AND BL 0 OM ENT I1AL

1401

eighteen cases fifteen terminated fatally, a mortality of 8 3 per
cent. Since then, Shrewsbury 11 lias reported a ease following
spinal tap with recovery after repeated drainage. Roberts and
Belsey 10 report a case of tuberculous empyema with secondary
invasion by Bacillus pvocyaneus. Surgical drainage was insti-
tuted and on this there followed a meningitis from which the
pvocyaneus could he recovered. There was recovery after
symptomatic treatment.

111. 1’OUT OK CASH

B. B., a woman aged 49, white, admitted to the Belli Moses
Hospital Jan. 8, 1937, complained chiefly of pain in the right
lumbar region and right upper (piadrant for the past three
years. The pain was colicky and radiated to both shoulders
and downward toward the symphysis. The patient had repeated
attacks of this nature and noticed frank blood in the urine on
each occasion, accompanied hv dvsuria. There were no chills
or fever. The past personal and familj histories were irrele-
vant.

The patient was examined with a cwoscope and x-rays by
one of us prior to admission to the hospital. A large calculus
occupying the pelvis and lower calix of the right kidney was
visualized. The urine obtained from this side by ureteral
catheterization revealed many leukocytes in clumps. Kidney
function (by the indigo carmine test) was normal on both sides.

On admission the patient was acutely ill. The only gross
abnormalities were spasm in the right upper (piadrant and the
presence of the Murphy sign on the right side. The blood
pressure was 130 nun. of mercury systolic and 80 diastolic.
The temperature, pulse and respiratory rates were normal.
There were 7,200 white blood cells with 05 per cent polymorpho-
nuclear leukocytes. The urine was cloudy and acid, had a
specific gravity of 1.015 and contained no albumin or sugar.
There were many erythrocytes and leukocytes present, the
latter in clumps.

On January 9 a pyelolithotomy was performed under cyclo-
propane anesthesia. The stone was removed from the pelvis
and two small catheters were inserted into the opening. The
following day the temperature rose to 104.2 F., the pulse to 104
per minute and the respiratory rate to 26 per minute. January
11 the temperature was 104.8 F. and the pulse 96. With this
discrepancy between pulse and temperature, meningitis was of
course suspected. The sensorium was clear but there was evi-
dence of some nuchal rigidity. Inspection of the wound showed
a slight greenish discoloration at the drainage tubes with a
definite odor of musty hay. Bacillus pvocyaneus was obtained
on culture. On the third day after operation there was no
improvement. The temperature was 104.6 F. and the pulse 90.
Blood culture taken revealed Bacillus pvocyaneus in the broth;
there was no growth on the plates. The urine showed 2 plus
albumin with an occasional white cell. The patient’s condition
remained essentially the same until the sixth day, when a
herpetic eruption of the buttocks became evident. On the
seventh day the patient became irrational and incontinent and
there was moderate distention. Nuchal rigidity was marked
and Kernig's sign was present. The patient was given a trans-
fusion. A spinal tap yielded 12 cc. of a light green cloudy fluid
under increased tension. There were 4,300 mononuclear cells
present and the culture revealed Bacillus pvocyaneus in pure
growth. January 18, eight days after the operation, there was
evidence of a right hemiplegia, speech defect, ankle clonus on
the right side and the already noted nuchal rigidity and Kernig
sign. The temperature was 102.5 F., the pulse 112 and the
respiratory rate 32. Another spinal tap was performed ; 10 cc.
of a green cloudy fluid under increased pressure was with-
drawn. The same organisms were recovered. The patient
suffered an attack of pulmonary edema with marked dyspnea.
Fifty cc. of 50 per cent dextrose was given intravenously with
marked beneficial effect. Bacteriophage was obtained and a
course of intravenous therapy instituted. At 4:20 a. m., after
jb cc. of the bacteriophage had been given in graduated
increasing doses, the patient suffered a severe chill lasting eight
minutes (the desired reaction). The temperature was 104 F.,
the pulse 120 and the respiratory rate 52.

Another spinal tap was performed, and after withdrawal of
15 cc. of green cloudy fluid 2 cc. of bacteriophage in 8 cc. of
saline solution was injected. The patient died on the tenth day
after the operation with a complete right hemiplegia present
at the time of death.

SUMMARY

In the original case here presented Bacillus pvocyaneus was
obtained from the wound following a pyelolithotomy for
calculus ; bacteremia ensued and this organism was recovered
from the blood stream ; meningitis followed and the same
organism was again recovered. From the clinical picture one
might justifiably conclude that a solitary cortical abscess had
developed with a complete right hemiplegia and motor aphasia
as focalizing signs.

1602 Avenue IT.

PII.OXIDAL SIXL'SES IX IDENTICAL TtYIXS

Sutiu. I.. (ioi.iuiKitc. M.D., and Ernest D. JIi.oomfntiial, M.D.
Chicago

Search of the literature reveals only one instance of the
occurrence of pilonidal cysts and sinuses in identical twins. 1
The following report of such an occurrence is interesting also
because of the appearance of the symptoms at approximately
the same time in the two twins :

I. K. and J. K., identical twins, aged 23, in December 1935,
within a period of a few days, each noticed a symptom free
lump at the end of the spine. One year later, again within a

Pilonidal sinuses removed from identical twins.

few days, both lumps began to drain very slightly. The drainage
was serous and in one patient remained so. The other patient
had a mild inflammatory .reaction in March 1937 with some
soreness for several days.

Examination revealed in each case two small openings in the
midline over the coccyx into which probes could be inserted
about 2 cm. and from which there escaped a small amount of
serous drainage.

Both cysts were removed May 3, 1937. They were rather
small but typical. The ensuing cavities were closed primarily.
One healed by primary union; the other, which previously had
been inflamed, drained some serum for a few days but was
completely healed within three weeks.

The significance of the occurrence of this developmental defect
in identical twins is a question. Whether it is purely coinci-
dental or whether the “anlage” for the defective development
is present in the ovum before it splits to form twins, we do
not know.

104 South Michigan Avenue.

Shrewsbury, J. F. D.: Brit. M. J. 1: 2S0 (Feb. 17) 1934.
in Ro ! ,erts ' J. E. II., ami Belsev, It. II. R. : Brit. M. J. 3:1276
(Dec. 25) 1937.

From the Surgical Service of Michael Reese Hospital.

M. A 102: n 367 C (Feb : . Pr0C,0 ' 0sic Defects 1,1 T 'vius, 3- A.

1402

SEROTHERAPY OF PNEUMONIA— BULLOW A

Jove. A. M. A.
Oct. 7, 1939

Special Clinical Articles

SEROTHERAPY OF THE PNEUMONIAS

CLINICAL LECTURE AT ST. LOUIS SESSION

JESSE G. M. BULLOWA, M.D,

NEW YORK

The article by Dr. Biillowa and the articles by Drs. MacLeod.
Blaitkcitliont and Lee. which follow, constitute a symposium on
Pneumonia.

Serum therapy of the pneimiococcic pneumonias rests
on the firm basis of our knowledge of their pathogenesis
and mechanism of healing and on experience in practice.
In response to infection with pneumococci, antibodies of
various kinds are produced by the patient, and as part
of the healing mechanism they unite with the antigen
or capsular carbohydrate. T.hese antibodies arc specific
for each type of pneumococcus. United with antibody,

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circulating carbohydrate is inactive. The blood usually
i inhospitable to pneumococci when free antibody »
present. Antibodies sensitize pneumococci so that the>
nre either lysed or phagocyted and destroyed. Freecai-
bohydrSe makes tile leukocytes antiphagocytic. Recov-
ery Occurs when more specific antibodies aie present
than the antigen or carbohydrate which induced then
‘ranee By the administration of serum, a favor able
condition of the blood in respect to antibody is produced
a shortened time and healing is accelerated.

For therapeutic use, antibodies are produced in horses
po.i " T: the serum is injected intravenously m
and m rabbits , the set ^ } q-j ie an tibodies

adults and intramuscular y ]vance the moment

aug »«t .IK »»“SX”ie„ ( ?£ ^ Covcry ili be present.
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euglobulin fraction ms pc 0 f t i ie remaining

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”**4^ S—l- of the American

Medi^A^^ Meaidn r e^n|m°|e

Tbe.ce studies ****“ University College ol d >r Barucli.

^ Mrs - "•

>Ir. Bernard M- naruen j
Samstag.

and refined rabbit serum has the albumin and some
globulin removed and the antibodies in very great con-
centration. often as much as 10,000 or more units per
cubic centimeter. The method of refining rabbit serum
is shown in figure 1. Thermal reactions are rare with
most preparations. Allergic reactions, immediate and
delayed, occur with no greater frequency than with the
best horse serums. The antibody molecule of rabbit
serum is smaller than that of horse serum and it probably
penetrates more readily into tissues and through mem-
branes. It is desirable to have available serum from
two kinds of animals because, if a patient is allergic
to one, the other may be used. Occasionally after the
given antibody is excreted the patient becomes vulnerable
again and is invaded by either the same pneumococcus
or a different one. In this event, if the patient has
become allergic to the serum used in the first admin-
istration, serum from a different animal is useful.

When adequate amounts of specific serum are
promptly administered, the death rate from pneumo-
coccic pneumonias is reduced ; the clinical picture is
modified. However, administered serum may be with-
out apparent benefit and death may occur. Unless the
antibody matches the organism, results cannot be
expected. The action of serum is specific. Errors
in typing may arise either in the laboratory or at the
bedside. Improperly collected sputum may be msuth-
ciently studied ; improper typing methods or materia s
may be employed, or reliance may be placed on direct
study without mouse inoculation. Secretions from tnc
upper respiratory passages, rather than from the lung,
may have been used for typing. Sometimes two orga
isms are found and the incorrect one is chosen tor
treatment. Blood for culture may not have been taken
frequently enough; the blood may be invaded without
the usual signs of sepsis, such as peteclnae.

Enough serum must be given to inactivate complete )
the circulating carbohydrate and sensitize all the organ
isms. To give less than this amount will not produce
a successful therapeutic effect unless the Jficins^ ^
tip by the patient. On this account it is
give insufficient serum. The serum may
leisurely, so that no instant occurs when aU the s «
hydrate is neutralized and the oigamsins a

DS« ffASUSnBSlONOfORGAUSUSCAPT JOOJOOO -MSOOCOOj ftUCCTCD .MT 0 CKH SERUU

UNKNOWN SERUM 90 Kout i

, „ _ _ $1 isf !j! X Y£jurw*'

.

os..Xojw crT T.gpjaaia

Marne prolection test.

for phagocytosis and lysis^ 5” „ar en t C ben eff t because
o-iven first has been without app requires

ibohytate to. teen lJS.1

neutralization. Such ‘ ^ ou id have been necessar)
require more serum than i m ^ ^ Qutset . Serum
had a sufficient dose hce g nHmber of organisms
may be given too late after^ , JC introduced

changes have been pro-

Volume 11.1
Number 15

SEROTHERAPY OP PNEUMONIA— BULLOW A

1403

duced. Scrum may be given in the presence of purulent
complications; then it is impossible to neutralize the
antigen present and the collections of purulent material
keep pneumococci inaccessible to the antibodies so that
the pneumococci continue to multiply. Surgical evacua-
tion is then required in addition. Serum therapy and
other specific therapy fail when the pncumococcic infec-
tion places an insupportable load on an already weak-
ened mechanism, so that the breaking point is reached
and death occurs, as with degeneration of heart, liver
or kidney. The exudate which collects in response to
the pneumococcus may exert fatal pressure, as in menin-
gitis. Finally, death may he due to reduction of
functioning pulmonary tissue, to dehydration or
azotemia from loss of chlorides, to other infections and
to a number of other circumstances.

Antibody can he measured. The amount of antibody
required for neutralization of a given amount of antigen
or soluble carbohydrate is measurable, so that the rela-
tive strengths of serums can he compared, either outside
the body or in an animal. The protection of mice

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l'jg. 3. — Type I pneumonia treated with 49 cc., 147,000 units, of refined
and concentrated antipneumococcus horse serum in three doses iti four
hours. On the third day, agglutinins which were negative became positive.

against organisms is the accepted value, and for com-
mercial serums its use is required by the National
Institute of Health. The titration of serum against a
control is shown in figure 2. Antibodies may he
measured by the nitrogen united with a known amount
of soluble carbohydrate. Antibodies may also he gaged
by the amount of capsule swelling they cause under
standard conditions. Serums should be clinically tested
for reactions under controlled conditions before they
are released to practitioners.

The variables present in any given case make an
exact estimate of the required dose difficult. The
organisms may be few or many, and they may differ
m virulence and in capacity to produce soluble carbo-
hydrate. The ability of patients to respond with anti-
body and the amount of antigen invading organisms
liberate are variable. The lung blood harrier produced
by local defenses may he ineffectual.

Because it has been observed that there are from 10
to 20 units of antibody in many spontaneously recover-
ing patients, it is probable that 100,000 units in an adult
is the amount required to induce a cure in most cases

of early and not too severe involvement in which the
organisms are not too virulent. This amount is inferred
from the fact that there are, in an average person,
approximately 10 liters of blood. If 100,000 units of
antibody is diluted in 10,000 cc. of blood, there will be
10 units to each cubic centimeter. Some patients will

Fig. 4. — Type IV pneumonia treated with 20 cc., 200,000 units, of
refined and concentrated rabbit serum in a single dose.

require much more than this. This is especially true
of patients who have bacteremia, who suffer from infect
tion due to pneumococci of type II, III or VII or who
have several lobes involved and are seen late in the
course of the disease, when much antigen or carbo-
hydrate is present. Because the maximum concentra-
tion of antibody is required immediately, it is necessary
to give serum in-
travenously in the
shortest possible
time consistent with
the avoidance of
chills and other re-
actions. Two thirds
of the last eighty
patients treated
with serum at Har-
lem Hospital re-
ceived between
100,000 and 300,000
units of antibody,
but more was re-
quired by the
others.

It is well to give
a probative dose to
determine the reac-
tion of the patient
to serum and thus
avoid severe reac-
tions, and then to give the remaining serum as quickly
as possible. I recommend injection of the serum at
intervals of one or two hours into the tube of a
running infusion of saline solution and 5 per cent dex-
trose in progressively increasing doses as illustrated
in figure 3. Only with infants is it advisable to give
serum intramuscularly. Ihis is an extravagant method,

Fig. 5. —The effect of serum therapy on
the mortality rate; contrast between hospital
and home treatment in the years 1937 and
1938, in the department of public health,
Pittsburgh.

SEROTHERAPY OF PNEUMONIA— BULLOWA

because an infant must receive, through the muscle
approximately the same dose as would be adequate
lor an adult. Figure 4 shows the results of a single
dose of refined and concentrated rabbit serum.

At the present time, serums are available for all the
types of pneumococci established by Cooper and her
co-workers. Scrum will have to be prepared for sev-
eral strains which were not differentiated at the time of
her report and for some which cross with the strains
segregated and numbered by her. There arc undoubt-
edly types of organisms and possibly conditions of
soluble specific substance with which union with anti-
body is less ready than usual and for which extremely
large amount of antibody may be required. The condi-
tions which make for prompt union of antibody and
soluble carbohydrate are still not entirely known. With

Serotherapy l 'ersns Chemotherapy

ri\u,u m UiM i /i — a U LLOWA Jo™, a. u. a.

Oct. 7, 1919

temperature may occur in patients without specific
tieiapy, it is necessary to present proof of benefit.
1 emunation of pneumonia occurs even in cases of early
involvement m direct time relation with the administra-
tion of the serum instead of at the times expected from
observation of the disease unmodified bv specific
therapy.

With all the variables in patients and in invading
oiganisms, how shall one determine whether lives are
saved by using serum? Comparing the results in
patients treated with serum and those from whom it
is withheld seems an appropriate method. One must,
however, compare only those patients in each series
who had the same chances of recovery. This involves
comparing similar age group, similar types of pneu-
monia, illnesses of similar duration and illnesses of
similar severity as measured by bacteremia. If one
applies these standards, one must have sufficient patients
in each group so that the difference in death rate will

Serotherapy !•'
Advantages
Xmitrii llzi's cnpsiilnr
KpjwUfzes pneumococci for piuiuo
cytoffc nnii JysN
Hertunx vinilMioc

Ciieinolliernpy be}
Advantages

Is eflVctlvp for both pneumococci
am\ ftreptoeooci
May bo used orally
Is olTeetivp lor moninKUS
Vo*t low

Combination
Knhaticov oflVetiveiio.e* of both

IdU'b the Patient

Disadvantages
Is type specific
There are resistant typo
.Must he used intravenously
May cause reactions:

Anaphylactic
Thermal
Scrum fteknes-.

Cost is high
(•'-M'S the Organisms
D/t-ad van In

Then* are resistant Mrjiin*
Organisms survive
There is Irregular absorption and
concentration
Toxicity may develop
There way develop symptoms refer -
able to the

Gastrointestinal tract
Liver

Central nervous system
Skin

Urinary tract
There may develop:

Hemoiyiic anemia
Agranulocytosis
Sulfapj'ridine sicklier
f Drug and Serum

gents: supplement drug with serum

patients who have large amounts of soluble carbohydrate
already in the blood or in whom the pneumococci have
invaded the blood and are in a rapidly multiplying phase,
serum will fail unless huge amounts of serum are

lie of such a magnitude that it can be said , wit!) reason-
able certainty, that the lowered death rate is due to the
difference in therapy and not to a chance difference in
the groups of patients selected for comparison. This
evidence lias been provided in the case of many types
of pneumonia and for man)- age groups.

Such figures from various sources show what lias
been accomplished with serum therapy. In Massachu-
setts, according to Dr. Arthur P. Long of the Anti-
toxin and Vaccine Laboratory of the Massachusetts
Department of Public Health, from July 1, 193S, to
April 4, 1939, there were 199 patients tinder 60 years
of age, with fourteen deaths, or a mortality of 7 per
cent. In the Boston City Hospital, Dr. Maxwell Fin-
land, using both horse and rabbit serum, lost no patients
under 40 years of age. There were thirteen patients
with bacteremia, with three deaths, a mortality of 23
per cent. The excellent results achieved in Pittsburgh,
reported by Dr. I. Hope Alexander, in which the death
rate was halved by the use of serum, are shown in
figure 5.

Because at the present time chemotherapy, repre-
sented by sulfapyridine, offers assistance in the therapy
of the pneumonias, it is important to contrast the
advantages and disadvantages of the two types of
therapy, as in the accompanying tabulation.

Serotherapy, which primarily fortifies the patient,

promptly given; such patients are benefited by the
administration of serum. With these patients other
methods, such as a chemotherapeutic attack on the
pneumococci, by depressing the production of soluble
specific substance, may be an important adjuvant.

The clinical results of the administration of serum
have been amply demonstrated not only in patients
treated promptly in the first few days of the disease
but also in those for whom treatment has been delayed.
It has been shown that intensity of therapy is a greater
factor in securing recovery than the time when serum

s administered.

The influence of serum on the course of pneumococcic
meumonia is seen in the regular fall of pulse rate and
>f temperature as soon as a sufficient amount of anti-
erum has been injected. The patient is unpoisoned
,nd frequently is reading the paper on the day after an
njection. Bacteremia can no longer be demonstrated,
veil in cases of heavy invasion. A crisis has been
nduced. The temperature became normal m twenty-
our hours in sixty-eight of the last eighty patients
reated with serum." Patients with bacteremia usuaffv
equired forty-eight hours. But. since a critical fall of

has these advantages :

Antibody neutralizes capsullar substance which either is
already present in the body or develops during several days
when sufficient serum is given.

Pneumococci arc not dissolved or pbagocyted unless they ar
sensitized by antibody. This may be autogenous or mjcctci
when vicariously produced in horses or rabbits.

Pneumococci "have their virulence reduced when grown m
the presence of antibody.

The disadvantages are as follows:

Serum administered must be specific for t be infecting type.
Some types, especially those which produce a very large
amount of antibody, such as pneumococcus type III, are resistan

to serum. . .

Serum must be given intravenously and requires devotion on

the part of the physician. , •

Though unfavorable reactions may be forestalled, jner
always the possibility of anaphylaxis, thermal reactions ami

serum sickness.

Scrum therapy is expensive.

Determination of the ultimate places to be assigned
serum therapy and chemotherapy must wait on furtner
studies.

fil West Eighty-Seventh Street.

Vormtr 113
Nusihfr 15

CHEMOTHERAPY— MacLIiOD

1405

CHEMOTHERAPY OF PNEUMOCOCCIC

PNEUMONIA

CLINICAL LECTURE AT ST. LOUIS SESSION
COLIN M. MacLEOD, M.D.

XI'AV YORK

The ideal chemotherapeutic agent may he defined as
one which, 1>v inhibiting certain vital functions of the
invading micro-organism or neutralizing its products,
terminates the disease without causing any toxic effect
on the host. This definition presupposes that the point
of attack must he on a specific function or structure
unique to the micro-organism, so that the tissues and
organs of the host escape the toxic action.

Ethylhydrocupreinc (optochin) was introduced by
Morgcnroth and Levy 1 in 1911 for the treatment of
pneuinococcic infections, after study of numerous other
quinine derivatives. A good deal of enthusiasm followed
the early experimental results and cthvlhydrocupreine
was used in the treatment of human pneumonia. How-
ever, the observations of Moore and Chesney- led to
the conclusion that the use of ethylhydrocupreinc in the
treatment of pneumonia could not he recommended
since it was impossible to administer an amount suffi-
cient to achieve an effective concentration in the blood
stream without subjecting the patient to the danger of
toxic effects, of which amblyopia was the most fre-
quent. Other quinine derivatives have since been
recommended but up to the present time not one has
had widespread clinical use.

The report by Domagk 3 in 1935 of the therapeutic
action of a sulfonamide compound on infections due
to the hemolytic streptococcus led to the use of related
compounds in the treatment of pneuinococcic infections.
Sulfanilamide was the first of these derivatives to be
extensively used but its effect on experimental pneumo-
coccic infections was found to be relatively small.

The most promising sulfonamide derivative, sulfa-
pyridine, was introduced in England in 1938. The
first report by Whitby' 1 on the use of this drug in
experimental pneuinococcic infections of mice showed
such striking results that little time was lost in applying
the experimental results directly in the treatment of
pneuinococcic infectious of man. It is difficult to say
at present how much the early enthusiasms may have
to be tempered in the light of further experimental and
clinical observations. However, it seems quite certain
that the use of sulfapyridine is a distinct advance in
the therapy of pneuinococcic infections.

.MODE OF ACTION

The mode of action of the sulfonamide group of
drugs on different species of bacteria is poorly under-
stood. Sulfanilamide exerts a bacteriostatic effect on
susceptible micro-organisms, but its mode of action has
not been fully elucidated. It has been postulated that
sulfanilamide achieves its bacteriostatic effect by the

From the Hospital of Rockefeller Institute for Medical Research.

Read in the Panel Discussion on Pneumonia, Medical Division, General
Scientific Meetings, at the Ninetieth Annual Session of the American
Medical Association, St. Louis, May 16, 1939.

1. Morgenroth, J. f and Levy, R. : Chemotherapie der Pneumokoken-

mfektion, Perl. Win. Wchnschr. -IS: 1560 (Aug. 21) 1911; ibid. 48:
1979 (Oct. 30) 1911- ,

2. Moore, H. F. t and Chesney. A. M.: A Study of Ethyl hyclrocupreine
(Optochin) in the Treatment of Acute Lobar Pneumonia, Arch. Int. Med.
49:611 (April) 1917; A Further Study of Ethylhydrocupreinc (Opto-
c hin) in the Treatment of Lobar Pneumonia, ibid. 21: 659 (May) 1918.

3. Domagk, G. : Ein Beitrag zur Chemotherapie der Bakteriellen
•nfektionen, Deutsche med. Wchnschr. Gl: 250 (Feb. 15) 1935.

4. Whitby, L. E. H. : Chemotherapy of Pneumococcal and Other
Infections with 2(p-Amino-Benzenesulfonanmlo) Pyridine, Lancet 1:1210
Olay 28) 1938.

inhibition of certain enzyme systems of the bacterium,
thus interfering with cell nutrition. On the other hand,
it lias been suggested that the drug combines with some
essential growth substance, which then ceases to he
available to the micro-organism. A somewhat different
hypothesis has been advanced by Locke and his associ-
ates 0 based on the observation that sulfanilamide when
oxidized by ultraviolet rays exerts an anticatalase effect.
From this point of view the action of sulfanilamide is
indirect, depending on the accumulation of hydrogen
peroxide when catalase is inhibited. In the case of
micro-organisms such as the pneumococcus or the
hemolytic streptococcus, which do not possess demon-
strable catalase activity, the bacteriostatic effect would
then depend on the inhibition of catalase in the tissues
and fluids of the host or in the medium in which the
organisms are growing, thus permitting hydrogen
peroxide to accumulate and exert a bacteriostatic effect.
While this may he one of the systems affected by
sulfanilamide or sulfapyridine, it would not appear to
he the sole one so inhibited, since sulfapyridine will
restrain the growth of pneumococci in a medium which
does not contain demonstrable catalase.

DEVELOPMENT OF “SULFAPYRIDINE FASTNESS’’

IN VITRO

The action of sulfapyridine on the pneumococcus was
believed at first to he on the capsule." The theory was
advanced that in the presence of the drug the pneumo-
coccus became deprived of its capsule and; denuded of
this protective covering, became a ready prey for the
phagocytes. This view has now been generally aban-
doned. We have been unable to confirm the observa-
tion that pneumococci in the sputum of patients treated
with sulfapyridine lose their capsules and become
avirulent. Indeed, we ' have shown that pneumococcus
type I can be adapted to growth in increasing concentra-
tions of sulfapyridine until finally it will multiply
freely in concentrations of the drug which inhibit the
growth of organisms not so accustomed. Throughout
the procedure of adaptation the pneumococcus retains
not only its type-specific capsule but its virulence as
well. T his “drug-fast” strain, unlike the parent strain
from which it was derived, does not respond to the
therapeutic effect of sulfapyridine in experimental
infections. However, the “sulfapyridine- fast” strain
is fully susceptible to the therapeutic action of type-
specific antipneumococcus serum. In table 1 are shown
the results of treatment with sulfapyridine and specific
antiserum on the experimental infections of mice with
the "sulfapyridine- fast” and parent strains of pneumo-
coccus type I.

From the results shown in table 1 it can be seen
that, although mice are protected by type I serum
against fatal infection with both the parent and “drug-
fast” strains, sulfapyridine has no curative effect on
infections with a drug-fast strain. The acquisition of
“sulfapyridine fastness” by a strain of pneumococcus
type I takes place without alteration in the morphology,
type specificity or virulence of the organism. “Sulfa-
pyridine fastness” acquired by pneumococcus type I
under these circumstances is relatively permanent.

o. Locke, Arthur; Alain, E. R., and Mellon, R. R.: Science SS:620
(Dec. 30) 193S. Main, E. R.; Shinn, L> E.. and Mellon, R. R.: Proc.
Soc. Exper. Biol. & Med. 59: 272, 1938. Locke, Arthur; Main, E. R. f
and Me! Ion, K. R.: J. Immunol. 56: 183, 1939. Shinn, L. E.; Main,
1939 on ’ Troc. Soc. Exper, Biol. & Med. 40: 640,

~ Telling-, M., and Oliver, \V. A.: Ca^e of Massive Pneumonia,
Type IH, with Massive Collapse Treated with 2(p-Ammobe«zenesuIf-
on anu do) Pyridine, Lancet 1:1391 (June 18) 1938. Whitbv.*

/. MacLeod, C. M., and Dnddi, G.: A “SuIfapyrirline-FasV' Strain of
Pneumococcus Type I, Proc. Soc, Exper. Biol. & Med. 41:69, 1939.

1406

C H EM 0 THERAPY— MacLEO D

Aftei forty serial transfers in broth not containing the
drug, fastness” is retained. Similarly “fastness” is
still present after fifteen passages in untreated mice.

DEVELOPMENT OF SULFAPYRIDINE FASTNESS"

IN VIVO

More recently we have been able to demonstrate that
fastness to sulfapyridine may be acquired by pneumo-
coccus type I in the animal body as well’ as during
cultivation in the test tube. Mice were infected with
pneumococcus type I and treated with sulfapyridine in
dosage sufficient to prolong life but insufficient to bring
about recover)-. After three passages through mice
which were treated in this manner, the strain of
pneumococcus was found to be “sulfapyridine fast.”
Mice infected with the strain, rendered “drug fast"
in vivo, died despite treatment with sulfapyridine in
dosage sufficient to bring about recovery of all mice
in the control group infected with the parent strain of
pneumococcus type I.

Variations in susceptibility to the bacteriostatic action
of sulfapyridine have been noted by MacLean, Rogers
and Fleming. 8 These investigators were able to show
in addition that a strain of pneumococcus type VIII
which was relatively insensitive to the action of sulfa-
pyridine could be made even more insensitive to the
drug by repeated passage of the strain in mice treated
with sulfapyridine.

METABOLISM OF “SULFAPYRIDINE-FAST" A.YU
PARENT STRAINS OF PNEUMOCOCCUS
TYPE I

Studies of the metabolism of the “sulfapyridine- fast"
and parent strains of pneumococcus type I have revealed
certain differences. In aerobic cultures the parent strain
of pneumococcus produces large amounts of hydrogen
peroxide. 0 whereas the “sulfapyridine- fast” strain forms
little or no hydrogen peroxide under similar condi-

Table 1 . — Results of Treatment with Sulfapyridine or Type /
Serum of Mice Infected with Parent Strain and
" Sulfapyridiuc-Fast " Strain of Pneu-
mococcus Type I *

Jour. A. M. A.
Oct. 7, 1919

desciibed by Penfold . 11 Strains which produce large
amounts of peroxide form jet-black colonies, whereas
sti ains forming small amounts of peroxide cause much
less discoloration of the medium.

„ Moreover, we 10 have recently found that the
sulfapyridine- fast’ strain has lost in great part its
ability to dehydrogenate certain three-carbon com-

Ta,,,e Dehydrogenase Activity of Parent and "Sulfa-
Pyridinc-Fast Strains of Pneumococcus Type I*

Substrate

Finn] Concentration

Dextrose M/140

Glycerol M /80 **,

.Sodium pyruvate M/SO. . . .

Sodium lactate M/SO

Xo substrate

“Sulfa pyridine-Fast"
Parent Strain Strain

* A -

Without

Sulfa-

Without

Sulfa-

Sulfa-

pyridine

Sulfa-

pyridine

pyridine

1:8,0001

pyridine

1:8,000

++++t

+++-1*

++++

+ + + +

+

—

+ + + -F

+

—

+++

—

—

—

_

# Knell tube contained 0.5 cc. of 0.002 M methylene blue in M/20 phos-
phate buffer Ihi 7.G; 0.1 cc of plain broth as a source of coenzyines:
0..) cc of tiie appropriate substrate; 1.0 ce. of the suspension of pneumo-
coccus cells. The final volume was brought to 4.0 cc. in each case by
the addition of M/20 phosphate buffer pn 7.G. The tubes were sealed
with a layer of petrolatum and incubated at 37 C.

f + +++ indicates complete reduction of methylene blue after one
hour at 37 C. — Indicates no reduction of methylene blue.

♦ One cc. of a neutral solution of sulfapyridine 1:2,000 added as
indicated, making a final concentration of 1 : 8 , 000 .

pounds (glycerol, pyruvate, lactate). The ability to
utilize dextrose remains undiminished.

The technic used in demonstrating the differences in
the metabolism of the parent and “sulfapyridine-fast”
strains was the estimation of the reduction of methylene
blue by “resting” cell suspensions 12 of the micro-
organisms in the presence of the various substrates, as
shown in table 2.

In extension of these results we have observed that
sulfapyridine added directly to cell suspensions of the
parent strain of pneumococcus type I inhibits the
dehydrogenation of these same substances. Thus it
would appear that the bacteriostatic effect of sulfa-
pyridine on the pneumococcus may be due in part to
inhibition of an enzyme or enzymes concerned in the
utilization by the bacterial cells of these substrates—
glycerol, pyruvate and lactate.

Treatment

Type I antlpDcumococm*
rabbit serum unconcen-
trated 0.2 cc.

Sulfapyridine 4 clones of
30 mg. each

Result

infecting r

—

-A „

Dose,i

Parent.

“Sulfapyridine*

Ce. Culture

Strain

Fast” Strain

10-=

ssss;

ssss

10"»

SSSS

ssss

SSSS

ssss

io-=

sss

DDT)

SSS

DDD

sss

DDK

« All mice were infected intraperitoneally. Sulfapyridine was admin-
istered by stomach tube in 30 mg. doses. The first dose was given
immediately following infection, the second five hours later. Subsequent
f j 0 «cs of 30 zng. were given at daily intervals. The serum used was
tvpe I unconcentrated nntipnenmocoecus rabbit serum. Serum and cul-
ture were mixed in the syringe immediately before intraperitonenl injec-

f The virulence of both cultures was such that untreated mice infected
with 10~ 7 or 1Q~ S ec. died within forty-eight hours.

♦ S indicates survival; D indicates death.

tions. 10 The production of hydrogen peroxide by cul-
tures of pneumococcus may he determined readily by
cultivating the organisms on the surface of blood agar
which contains benzidine, according to the technic

S. MacLean, I. H.; Rogers, K. B„ and Fleming Alexander: 31. & B.
,9 V:' “ordon.l. o/ Hydrogen Peroxide

0 i? a Ma r cT.'eod.° C C. C ™'t.': ' Metabolism of “Sulfapyridinc-Fast" and Parent
Strains of Pneumococcus Type I, Proc. Soc. EXper. JJiol. & Med. 41.
'15, 1939.

EFFECT IN THE ANIMAL BODY
In the animal body sulfapyridine exerts a. bacterio-
static effect on the pneumococcus 13 — a reflection of the
effect which occurs in the test tube. If one considers
the course of events in recovery from pneumococcic
pneumonia it will be seen that in many cases bacterio-
stasis may lie all that is required for a favorable
outcome to occur. Spontaneous recovery from pneunio-
coccic pneumonia is usually associated with the develop-
ment by the host of specific antibodies. At the risk
of oversimplification it may be said that, if the pneumo-
coccus is able to multiply more rapidly than the paheji
is able to produce specific antibody, the patient will. die.
However, if a bacteriostatic agent is used, the organisms
multiply more slowly while the rate of antibody pro-
duction is undiminished ; hence the acute course of ie
disease may be shortened. There is no good evidence a
present that the body can rid itself of virulent pneumo
cocci by phagocytosis unless the organisms are first

11. Penfold, W. J.: The. Action of the Pneumococcus on Aromatic

mino Bodies, 31. J. Australia 2: 120 (July -S) 19--. Produced

12. Qtiastel, J. H„ and Whet ham, M D.: Dehjdrogjnation^ l^oa ^
Resting Bacteria. Btochem. J. 19 ; a20. 19.a. Co o . Fc rmenta-

enhenson, 31. D: The Aerobic Oxidation of Glucose and Its letmi
n Products in Its Relation to the Viability of the Organism, B

13 1 Wh’ithvM E’ H.: Chemotherapy of Bacterial Infections. Lancet
1095 (Nor. 12) J 93 S.

Volume 1 13
Number IS

CHEMO THERAP Y— Mac LEO D

1407

sensitized by specific antibody. Kvcn virulent pneumo-
cocci which" have been killed by heat are not phago-
cytozed unless they are first sensitized.

If a ])articular strain of pneumococcus happens to be
a good antigen in a certain host species, injection of
the organisms of such a strain will cause a good anti-
body response. On the other hand, if the strain is a
pool' antigen the antibody response will he poor. This
is illustrated by the antigenicity in the mouse of
pneumococci types I and III. Type 1 is a good antigen,
whereas type 111 is a relatively poor antigen. If groups
of mice are infected intraperitoneally with 10‘- cc. of
fully virulent broth culture of these strains and treated
with sulfapvvidine, the survival rate parallels in each
case the immune response elicited by a single intra-
peri toneal injection of the same amount of heat-killed
organisms of the respective strains in other groups of
mice. The results of a series of such experiments are
shown in table 3.

Mice injected with 10'- cc. of culture of pneumo-
coccus type I, and treated with six doses of 30 mg. each
of sulfapyridine over a five day period, show a survival
rate of from 95 to 100 per cent. Similarly, from 95
to 100 per cent of mice given a single intraperitoneal
injection of 10"- cc. of heat-killed organisms of the
same culture showed active immunity when tested five
days later by infecting intraperitoneally with 1.000
lethal doses of homologous culture.

In the case of pneumococcus type III a similar rela-
tionship was found to exist between the immune
response and the survival rate following sulfapyridine
therapy, although in this case both are very low. Ten
per cent or less of mice survived which were infected
with 10'- cc. of culture and treated with the drug.
The immunity induced in a comparable group of mice
by a single injection of the same amount of heat-killed
vaccine was of the same order.

It is also of great interest that, in this species of
animal, treatment with sulfapyridine is necessary only
for the period known to be required for the develop-
ment of antibodies. Thus there appears to be a corre-
lation not only between survival from infection and the
antigenicity of the strain of pneumococcus but also
between the time required for the host to develop anti-

Tabi.e 3. — Relation of Effectiveness of Sulfapyridine Therapy
to Inmnmi/y Induced in Mice by Infection
of Pneumococcus Vaccines

Infection with 10- 2 Cc. Immunized with 10~- Cc.
Culture; Treated with Heat-Killed Cultured

Sulfapyridine;* No Sulfa pyridine Given;
Piiewnoeoecu® Type per Cent Survival per Cent Immune

Type 1 93-100 93-100

Type III 0-10 0

* Hice were infected intraperitoneally. The virulence* of both cultures
was such that untreated mice infected with J0~ T or 10 - S ec. died within
forty-eight hours. Treatment with sulfapyridine was carried out for
five days, a total of ISO mg. of draff per mouse being given.

t Single immunizing dose of lieat-killed organisms Riven intrnperito-
twaYly. Immunity tested five days later by infect inn intraperitoneally
with 3,000 lethal doses of homologous culture.

bodies and the length of time necessary to continue
sulfapyridine treatment.

In his original communication Whitby 4 pointed out
that mice which recovered following infection with
pneumococcus type I and treatment with sulfapyridine
are immune to reinfection with the homologous organ-
ism, and we have confirmed this observation. Similarly
Larson and his co-workers 14 have observed the same

N. Larson, W\ P.; Bieter. R. N.» and Levine, Milton: Protective
Action of Sulfapyridine in Rabbits Infected with Pneumococci, Proc. Soc.
1’Aper. Biol. & Med. 40:70.3 (April) 1939.

phenomenon in rabbits which recovered following intra-
dermal infection with pneumococcus type II and treat-
ment with sulfapyridine. McIntosh and Whitby 15 have
extended Whitby's earlier observations and conclude
that administration of the drug to mice does not affect
“the quality, quantity or speed of production of recog-
nized specific antibodies.”

Tabix 4. — Synergistic Effect of Sulfapyridine and Anlipnnwio-
cocctts Scrum in Experimental Infection of Mice
with Pneumococcus Type 111 *

Infecting

Sulfa*

Dofc,

Amount

pyridine

Number of

Number of

Cc. o!

of

Number of

Mice

Mice

Percentage

Culture

Scrum, Cc.

Dose®

Infected

Survivlnc

Survlviil

Id* 2

0

2

20

1

5

io- 2

0.03

0

20

n

0

in- 2

0.03

o

20

32

GO

* Unconrrntratrd type III untf pneumococcus rabbit serum and culture
were mixed in the syringe immediately before intraperitoneal injection.
The administration of sulfapyridine was as described in tabic I.

SYNERGISM OF ANTIPNEUMOCOCCUS SERUM
AND SULFAPYRIDINE

Since the participation of the active immune mecha-
nism appears to play a considerable role in the success-
ful action of sulfapyridine on experimental infections
with the pneumococcus, it was of interest to determine
whether synergism exists between the drug and the
passive immunity conferred by the administration of
specific antiserum.

Groups of mice were infected with pneumococcus
type III and treated respectively with sulfapyridine
alone, serum alone and the same amount of the two
agents in combination. The dosage of serum and sulfa-
pyridine when used alone was such that little or no
protection was afforded against the infecting inoculum.
Tlie protocol of a typical experiment is shown in
table 4.

The results presented in table 4 make it clear that
type III antipneumococcus serum and sulfapyridine are
synergistic, since amounts of each agent which used
singly exert little or no protective action afforded pro-
tection to 60 per cent of mice when used in combination.
The demonstration of synergism of the two agents in
the treatment of infections due to pneumococcus
type III is of particular interest, since the protective
action of either agent alone in experimental infections
of mice is distinctly less than that which occurs in infec-
tion with pneumococci of other types.

CLINICAL USE OF SULFAPYRIDINE

The numerous reports concerning the therapeutic
effect of sulfapyridine in pneumococcic pneumonia have
been uniformly favorable. Mortality rates of from
2 to 10 per cent in series of cases reported from
various parts of the world indicate that the drug is
effective in reducing the mortality rate. However,
insufficient attention has been paid to the toxic effects
of this chemotherapeutic agent.

Nausea and vomiting are frequent accompaniments
of the administration of sulfapyridine. These reactions
are unrelated to the dosage of drug or to the blood level.
Since vomiting occurs in individuals to whom the drug
has been administered parenterally, the effect would
appear to be central, in addition to a possible local
action on the stomach. 10 Morbilliform skin rashes have

TMtl°9 f 39 ACti0n " f

J. A. ( J (prn n 29) L w?9. P - H ' : Sodil,m Su,fai ’ yri(,iM ’

1408

CHEM 0 Til II RAP Y—MacLE 0 D

Jour. A. 31. ,\.
Oct. 7, 193V

been leportcd, as well as numbness and tingling of tiie
extremities. 1 ' Cyanosis due to methemoglobinemia
oecins, particularly if high blood levels of the drug are
attained. &

IMoie serious toxic manifestations mav appear, how-
ever, involving parlicularlv the hemopoietic svstein and
the urinary tract.

EFFECT OF SULFAPYRIDINE OX 11 KMOPOIKTIU
SYSTEM

The occurrence of acute hemolytic anemia in patients
receiving sulfanilamide has been the subject of many
reports, but as yet there is little information available
concerning increased blood destruction in patients
receiving suliapyridine. During the routine administra-
tion of sulfapyridinc to patients with pneumonia, hemo-
lytic anemia occurred in two instances: consequently a
study of the effect of this drug on hemolysis was under-
taken. 1 ' Estimation of the total urinary and fecal
excretion of urobilinogen was used as an index of the
rate of hemolysis, since by this means increases in the
rate of blood destruction may be observed which might
escape detection if only routine clinical procedures
are used.

Of the twenty-six patients with pneumonia for whom
estimations of urobilinogen excretion were made, six
did not receive sulfapyridinc and in none of these was
there an increase in the excretion of urobilinogen.
Twenty patients received sulfapyridinc in total dosage
varying between 4.5 and 81 (lm„ and in eight of these
the excretion of urobilinogen in stools and urine was
increased from one and one-half to five times the nor-
mal amount. Acute hemolytic anemia occurred in three
of these patients. However, in the twelve other patients
who received sulfapyridinc. the urobilinogen excretion
was normal or only slightly increased. The total
dosage of drug administered to patients in the latter
group tended to be less than that given to patients who
showed increased urobilinogen excretion.

Increased blood destruction does not appear to be a
usual accompaniment of the acute infectious process
itself, since in eighteen of the twenty-six patients
studied the excretion of urobilinogen was within nor-
mal limits. The evidence indicates that hemolysis was
due to sulfapyridinc rather than to pneumonia itself
and that increased blood destruction occurs more fre-
quently following the administration of this drug than
would be suspected unless special methods for its
detection are used.

The occurrence of granulocytopenia in patients
receiving sulfapyridine has been reported.'” This toxic
effect occurs less frequently than hemolysis but is
additional reason for making repeated blood exami-
nations on patients who receive the drug.

also for irregularities in its excretion. Antopol and
Robinson J0 have described the occurrence of calculus-
formation in the urinary tract of monkeys fed sulfapyri-
dine. The same complication occurred also in rats and
1 abbils, although in the case of the last two species much
laiger dosage was required. Renal calculi have been
obseived likewise by Gross, Cooper and Lewis- 1 in
tuts that were led sulfapyridine. The calculi described
by both groups of investigators were found to be com-
posed chiefly of the acetyl derivative of sulfapyridine.

Hematuria, aside from that occurring during hemor-
rhagic Bright s disease, has been observed in only two
instances during the course of sulfapyridine therapy in
this hospital. One of these patients, a man aged 21,
suffered from typical renal colic with hematuria shortly
after discontinuing the drug. A calculus was not
visualized by x-ray examination and the symptoms
gradually disappeared. According to Antopol and
Robinson the concretions of sulfapyridine and its
acetylated derivative which occur in the urinary tract
of monkeys arc not usually seen in roentgenograms
although they may become radiopaque because of over-
layering with calcium salts.

Soutlnvorth and Cook have reported the occurrence
of azotemia in two of three patients who developed
hematuria during sulfapyridine administration. In
addition there was acute abdominal pain, which was
believed to he of renal and ureteral origin. On cessa-
tion of drug therapy and with thy forcing of fluids,
these signs and symptoms cleared rapidly.

Depression of renal function may occur, however, in
the absence of hematuria. In two patients treated with
sulfapyridine we have observed a temporary depression
of the urea clearance to critical levels associated with
azotemia, although hematuria was not present in either
instance. With discontinuance of drug administration
there was a rapid improvement in kidney function with
disappearance of azotemia, and complete recovery appar-
ently ensued. The studies of Farr and Ahernethy •“
on renal physiology in lobar pneumonia indicate that
depression of kidney function is not a usual accompani-
ment of this disease. Indeed, in the experience of these
authors, patients below the age of 40 showed a marked
elevation of the urea clearance during the acute phase
of the disease, with persistence of the increased function
for about one month. In the older age group the urea
clearance showed little change.

The impression that the diminution of the urea clear-
ance which occurred in the two cases noted may have
been an expression of sulfapyridine toxicity is strength-
ened by the fact that acute hemorrhagic Bright’s disease
has developed in two other patients who received, the
drug.

REPORT OF CASES

EFFECT OF SULFAPYRIDINE OX THE
URINARY TRACT

The solubility of sulfapyridine is less than that of
sulfanilamide. 'This may account in part for the occa-
sionally erratic absorption of the former drug and

Leon: ilie i i e.umua oi ah uhhuh«.hw * . t .

I A M. A. 113 : 529 (Feb. 11) 1939. Long, IV H. : Sulfapyridine, ibid-
11° • 33S (Feb 11) 1939. Agrnnat, A. L. ; Dreosti, A. O., and Ord-
inal”.’ U: The Treatment of Pneumonia rvith 2 (n-AminobenzenitiIfon-
nmidu) Pyridine (M. & II. 693), Lancet 1 : .>09 (I*eb. 11 ) 1939.

IS. Erf, L. A., and MacLeod, C. M.: Hemolysis from Sulfapyridine
read at tbe tllirtv-first annual meeting of the American Society for Clinical
Investigation, Atlantic City, N. J., May 1. 1939. to lie published.

19 Johnston. F. D.: Agranulocytosis Following Treatment with 3L
& n. 693, Lancet 2: 1200 (Nov. 19) 1938. , Coxon. R. V.. and Forbes,
t K.: Agranulocytic Angina Following Administration of 31. X L;

;V,:,I n. 1410 r Dec j;) 193 s. Barnett. II. L.; Hartmann. A. F. : I erley ,
\ JL. and Ruhoff. 31. The Trratment of P..enm«»ciac Infectims

in Infants and Children with Suliapyridine. J. A. M. A. ll~.il t <

1 1 ) 1939. I.ong. ,;

Cash 1. — A white woman aged 25, whose past history "tu
noncontributorv, was admitted to the hospital on the cig 1 1
day following the onset of type III pneumococcus pneumonia.
Consolidation of the right middle, right lower and
pulmonary lobes was present. The temperature was 104- ■.

pulse rate 132 and respiratory rate 40, The blood culture was
sterile. The blood pressure was 112 systolic, 66 diastolic.
Urinal vsis gave norma! results. Erythrocytes mimjcrcn
3.790,000, hemoglobin was 74 per cent, and leukocytes tiumbcrct

20 . Antopol, William, and , Robinson II.: V/^i'ffe'ino) Pit dine
ithology After Oral Administration of 2 . (SulfandHainino) ,, 39 .
Inlfapyridine), Proc. Soc. Expcr. Biol. & Med. -I0.4-S (March)

21 . Gross, Paul; Cooyer, P. B„ .and Lewis. Marion. l ' r ,, t , J0:
etions Caused by Sidfapj ndinc, Troc. Soc. Expcr. Biol. X 31c I.

22. ( ’Southnorth Hamilton, and Cook. Crispin:

:in and Nitrogen Retention Associated with Sulfapjndme, J. A. .

23/ Farr, L^fef ^ Abernetby T J. : Renal Phy-iology in Mur
leumonin. J. Clin. Invcstigatton 10: 421. 193/.

CHEMOTHERAPY— MacLROD

1409

You*. \ir. 115
XrMiirR 15

21,450, ol which 8*1 per cent were polymorphonuclear cells.
Sitlfapvridiue treatment was commenced shortly after admission,
a total of 25 Cun. being given hv mouth in the ensuing four days.
Nausea and vomiting occurred after 4 Gtn. of drug was given.
The free sulfapyridinc level in the hlood was 12.6 mg. per
hundred cubic centimeters thirty-six hours after the drug was
started, and with this there was associated a marked diminution
in the volume of urine excreted. The patient's temperature and
pulse rate fell to normal on the day following admission and
agglutinins for the type III pneumococcus were demonstrable
in her hlood serum. The skin reaction with the type III pneu-
mococcus polysaccharide was positive at this time. The respir-
atory rate remained markedly elevated for four days after
the crisis.

The urine output remained low despite a large intake of
fluid, and with this there was associated pain across the tipper
abdominal area anteriorly, together with drowsiness and pitffi-
ncss of the face. The hlood pressure was 142 systolic, 88
diastolic. Urinalysis showed a trace of albumin, with an occa-
sional granular cast hut no red cells.

Five days after sulfapyridinc was discontinued the hlood level
of the free drug was 0.8 mg. per hundred cubic centimeters and
the urine showed 12.4 mg. The urine volume on this day was
only 200 cc. The hlood urea nitrogen level was 61 mg. Two
days later the hlood urea nitrogen had fallen to 23.6 mg. and
urea clearance showed the kidney function to he 62 per cent
cf normal.

From the third to eighth hospital days the excretion of uro-
bilinogen in stools and urine increased markedly and was
associated with a fall in the red cell count and the hemoglobin
level. On the twelfth hospital day the red hlood cell count
was 2,000,000 and hemoglobin SO per cent ; consequently a trans-
fusion of 500 cc. of whole unci t rated blood was given. No
reaction occurred during or after transfusion.

Edema of the face continued and the hlood pressure rose to
162 systolic, 92 diastolic on the day before transfusion was
given. The urea clearance was S4.S per cent. The plasma
albumin level was 2.69 mg. per hundred cubic centimeters and
the plasma globulin 2.69 Gm. The urine showed 1.4 Gm. of
protein excreted in twenty-four hours and large numbers of
granular casts. Centrifuged specimens of urine showed only
from 2 to 4 red blood cells per high power field.

Bilateral pleural effusion occurred with a rise in temperature
and marked elevation of the pulse rate. Thoracentesis was
performed on two occasions with the withdrawal of large
amounts of sterile pleural fluid.

Diminution in urinary output persisted for twenty days, and
was followed by a period of diuresis with disappearance of
edema and upper abdominal pain. Four weeks after the onset
of the renal complication the urea clearance had risen to 90
per cent of normal. The urine continued to show a trace of
albumin and a few granular casts for one month after the
urea clearance had returned to normal, hut on discharge four
months after admission the urine was normal. The blood pres-
sure was 128 systolic, 78 diastolic. The red blood count was
4,840,000 and hemoglobin 96 per cent. The urea clearance
was 96.3 per cent of normal.

Cask 2. — A white woman aged 43 was admitted to the hos-
pital on the day following the acute onset of t 3 r pe III pneumo-
coccus pneumonia which involved the left lower lobe. Her
past history' was noncontributory. The temperature was 104 F.,
pulse rate 120, respiratory rate 36. The blood culture was
sterile. Erythrocytes numbered 4,200,000, hemoglobin 78 per
cent, leukocytes 20,400, of which 90 per cent were polymorpho-
nuclear cells. The blood pressure was 130 systolic, 6S diastolic.
Urinalysis showed a faint trace of albumin. Sulfapyridinc ther-
apy was commenced shortly after admission, a total of 12 Gm.
being given over a three day period. Nausea and vomiting
occurred but were not severe. The highest blood level attained
was 10.7 mg. per hundred cubic centimeters of the free drug
on the last day of administration. In addition to sulfapyridine
the patient was given 100 cc. of unconcentrated type III
antipneumococcus rabbit serum twelve hours after admission.
No toxic reaction due to serum occurred. The skin reaction
with the type III polysaccharide, which was negative on admis-
sion, became positive following serum ; consequently no further

antibody was given. Temperature, pulse and respiratory rates
reached normal thirty-six hours after admission and remained
normal for forty-eight hours, when the fever returned, asso-
ciated with severe pleural pain. The administration of sulfa-
pyridine was recommenced and between the seventh and eleventh
days following admission an additional 13 Gm. of the drug
was given. The skin reaction with the type III polysaccharide
remained positive during this time. A massive left-sided pleural
effusion occurred.

Examination of the urine on the day following withdrawal
of sulfapyridinc showed many granular casts as well as numer-
ous red cells and pus cells. A heavy trace of albumin was
present.

The patient complained of upper abdominal pain and began
to show increasing pallor associated with a fall in the red blood
count to 3,000,000 and of the hemoglobin level to 64 per cent.
Concurrently edema of the face and extremities appeared and
the output of urine diminished sharply. The patient’s condition
was fairly satisfactory until the twenty-fifth hospital day, when
she suddenly developed acute cardiac failure with gallop rhythm
and pulmonary edema, a markedly enlarged liver and rapidly
increasing generalized edema. The urine showed 14.4 Gin. of
protein per liter with numerous pus cells, red blood cells and
granular casts. The urea clearance was 6.4 per cent of normal
with blood urea nitrogen of 71.6 mg. per hundred cubic centi-
meters. The blood pressure was 184 systolic, 104 diastolic.

The patient's subsequent course was very stormy, owing to
the mixed picture of heart failure and acute hemorrhagic
Bright’s disease with uremia. After two weeks, improvement
in kidney function began to appear with a gradual loss of
edema and improvement in the cardiac condition.

Prolonged convalescence was necessary, but after three months
the patient became edema free, and kidney function, as measured
bv the urea clearance test, had risen to 37.7 per cent of normal.

In the first of these patients the earliest symptoms
of acute nephritis occurred during the time sulfapyridine
was being administered. Although moderate dosage
was used, the blood levels of sulfapyridine were abnor-
mally high, associated with a sharp drop in urine output,
which occurred within twenty-four hours after begin-
ning treatment with the drug. Five days after the drug
was withdrawn the patient’s hlood still contained 0.8
mg. per hundred cubic centimeters of free sulfapyridine.
The occurrence of edema, the elevation of blood pres-
sure and gross abnormalities in the urine were of
gradual rather than of acute onset. As far as could be
determined, the renal function returned to normal in
two months.

The course of events in the second patient likewise
differs somewhat from the typical picture of acute
nephritis complicating an acute infection in that the
onset was gradual rather than sudden. The first urinary
signs appeared on the day following the discontinuance
of sulfapyridine therapy and for the succeeding fourteen
days the symptoms increased in severity until the final
explosive onset of acute uremia associated with heart
failure.

Only one patient (patient 2) received antipneumo-
coccus serum treatment in addition to chemotherapy.
The use of serum lias not been associated in our experi-
ence with renal complications.

Both patients have recovered from the acute phase
of nephritis, the first apparently completely, but in the
second case only partial recovery has taken place during
the four months since the onset of nephritis.

COMMENT

It ma}’ appear that undue stress has been laid on the
toxic effects of sulfapyridine. However, it seems impor-
tant that such effects should be geuerallv recognized so
that due caution may be observed in the clinical use of

1410

OX Y GEN T HERAPY—BLAN KEN HORN

Jove. A. jf. .1.
Oct. 7, 1939

this valuable chemotherapeutic agent, not only as applied
m the treatment of pneumonia but in other diseases as
well.

Sulfapyridine gives promise of reducing the death
rate from pneumococcic pneumonia and present indica-
tions make it seem probable that an even greater reduc-
tion in the mortality rate can be accomplished if the drug
is used in conjunction with type-specific antipneumo-
coccus serum.

In the opening paragraph of this paper the ideal
chemotherapeutic agent was defined as “one which, by
inhibiting certain vital functions of the invading micro-
organism or neutralizing its products, terminates the
disease without causing any toxic effect on the host.’’
From this point of view sulfapyridine does not fully
attain the ideal, since toxic effects of greater or lesser
degree arc not infrequent accompaniments of its clinical
use. Moreover, this powerful drug may not necessarily
inhibit the vital functions of the ordinarily susceptible
invading micro-organism, since the virulent pneumo-
coccus has the capacity both in vivo and in vitro to
adapt itself so that the drug does not affect its rate of
multiplication, virulence or specific immunologic struc-
ture.

Sixty-Sixth Street amt York Avenue.

OXYGEN THERAPY

indications and methods of application ;

RELATION TO OTHER THERAPY
CLINICAL LECTURE AT ST. LOUIS SESSION

M. A. BLANKENHORN. M.D.

CINCINNATI

Cyanosis is the main and only important indication
for oxygen therapy in pneumonia. While it can be
said in theory that cyanosis exists in some degree in
every patient with pneumonia, it does not follow that
oxygen is always indicated nor is there any justifica-
tion for the routine use of oxygen to prevent cyanosis.

Cyanosis is a difficult sign to evaluate quantitatively
and, since that is exactly what must be done to decide
about oxygen therapy, there is a tendency to use it
needlessly. This tendency becomes very pressing when
the prognosis looks bad and there is not very much to
be done about it. Now that there is at hand for most
pneumococcic pneumonia a good remedy, the need for
oxygen is definitely reduced. I find in our hospital at
Cincinnati that more of our patients have got well and
that we have used much less oxygen since we began the
use of serum or sulfapyridine in the early stages of
pneumonia.

The exact therapy of pneumonia with oxygen lias
been developed by keeping patients in oxygen-filled
rooms for continuous treatment, which treatment is
tested by measuring the actual oxygen content of
arterial and venous blood. With this experience some
of the guesswork goes out and it can be seen that severe
anoxemia does occasionally occur in the early stages of
pneumonia, oftener in the late stages, and that oxygen
sometimes relieves this anoxemia. Severe anoxemia is
most likely to occur when many lobes are consolidated ;
when the respirations become rapid and shallow, i. e.,
above forty per minute ; when there is moisture in much
of the bronchial tree, and when there is wheezing.

: n the Panel Discussion on Pneumonia, Medical Division.
cJSf Scientific Meeting nt the NineUeth Annu^ Scssmn of the
American Medical Association. St. Louis. Ma> Jo.

These cii cumstances can bring on serious oxygen Irani
which may initiate many symptoms that resemble the
toxic effects of infection; viz., steadily rising pulse rate
with finally falling diastolic blood pressure, headache,
dimness of vision, mental disturbances such as delirium,
and coma. Oxygen want may cause or increase abdom-
inal distention, also vomiting. When oxygen is suc-
cessfully given, many, sometimes all, the distressing
signs and symptoms disappear in a few hours and the
treatment then is life saving.

Oxygen treatment may not be successful in relieving
anoxemia for a number of reasons other than reasons
of technic. It cannot succeed if too much lung is con-
solidated or obstructed by exudate. It cannot succeed
if the circulation is failing or if there is toxic depres-
sion of the respiratory center by infection or drugs.
Since none of these causes of failure are easily appre-
hended, the technic of administration of oxygen must
be carefully' ordered and practiced by' the physician to
avoid failure that can be avoided. Important points
are these : The supply to the patient must he continuous
and abundant, so that only' large cydinders are satisfac-
tory'; these must be equipped with reducing valves to
assure steady flow and flow meters are very useful as
well; the inhalation device must be comfortable and
must not hamper the free escape of carbon dioxide and
moisture. There are numerous devices that are Council
accepted. Tents, face masks and nasal tubes can all be
made to serve satisfactorily, but they' all require skilful
and understanding care such as is rarely given by
nurses or attendants. They all must be supervised by
the doctor, who understands both the disease and the
treatment.

Tents are the most expensive, troublesome and diffi-
cult to operate but are the most successful generally,
except of course the oxygen chamber. Tents are best
run by experts, such as the anesthesia department or
gas therapy service in large hospitals. I have found
that hospital assistant residents do the job very well in
the Cincinnati General Hospital and that they' learn a
lot about the physiology' of respiration by' doing that
service. Some tents require a gas washer of soda lime
to take out the carbon dioxide. This greatly adds to
the cost and trouble. Other tents rely' on cooling and
drying the circulating air with large ice chambers, and
much ice is needed for air conditioning. This cooling
and drying to take out carbon dioxide often contributes
much to the comfort of the patient. Tents should
usually have from 35 to 40 per cent oxygen but may
be run for a long time at 60 per cent oxy'gen. Tents
provide a high concentration of oxygen as well as a
cool, dry' atmosphere, which many' patients enjoy if me
tent is right. A hot tent, not properly cooled anti
cleared of carbon dioxide, is a terrible thing to a con-
scious patient; but there is no need for a tent ever to >c
uncomfortable. A gas tester is necessary to keep ten
service up to this standard. Delirious patients some-
times fight the tent and win. for tents are not tougtL
In this circumstance the doctor must do some skiltu
guessing to decide about restraining the fighter or nar-
cotizing him. The first procedure runs up the oxygen
need possibly more than it will be helped by the ten ,
the latter choice depresses the respiration, sometimes
increasing the cy'anosis. The doctor must keep his eye
on cyanosis and try' the various chances.

Face masks and face tents in my hands arc almost as
bad as tents in arousing the fight in a delirious patient.
Nasal tubes or catheters are the best for tins patiem
usually.

Volume 113
Number 15

THERAPY OF PNEUMONIA— LEE

1411

Face masks are not suited to continuous use, such as
the pneumonia patient needs, if the mask is closed. If
the device is open to allow unhampered flow of expired
air. it becomes a face tent of sorts and I think that with
care to details, especially adequate oxygen flow, this
arrangement will work: but I have had no real satis-
faction in their use. The purpose of such a device is
to retain a rich atmosphere during expiration so that
when inspiration conies the inrush of room air through
the mouth or nose will not dilute the stored gas too
greatly.

Nasal catheters are used in many instances, even
when tents are at hand. Such an arrangement is sim-
ple and costs little, but large cylinders with flow meters
are needed as for tents. Catheters are sometimes
tolerated by delirious patients who fight the tent. Suc-
cess of nasal catheters depends on care in placing the
catheter tip and keeping it there. The catheter becomes
a discomfort for several causes, mostly preventable. If
the catheter wiggles about with head motion or bed
motion, this is overcome by holding it down to the face
with adhesive tape. If the inflow is too fast through
a single perforation in the catheter wall, a '‘hot spot 1 '
develops: this is overcome by moving it about and by
humidifying the gas; also by having plenty of openings.
Catheters may fail to deliver enough gas if the tip is
not near the pharynx. In this circumstance the soft
palate may obstruct the inflow and the gas then goes in
one nostril and out the other. If the patient breathes
through the mouth and the method of inspiration is
quick, the inrush of room air dilutes the gas and the
whole result is a weak mixture. I know of no way
to overcome this difficulty entirely if the patient will not
tolerate having his mouth closed with a piece of moist
gauze taped over the mouth for a flutter valve. When
the catheter tip is well in the oropharynx so that the
entire oropharynx is entirely filled with oxygen, this
dilution effect is diminished. The dilution effect is also
less when the volume of each breath is not great ; hence
the catheter flow can supply the entire inspiratory vol-
ume and even more in rapid and shallow breathing. In
some circumstances 40 per cent of oxygen or more has
been provided in respired air through the catheter. The
catheter should be replaced by a clean one every twelve
hours or less. It should be greased with oil that will not
evaporate, as with liquid petrolatum, and the naso-
pharynx sprayed with oil. This protects the mucous
membranes from the drying effect that eventually burns
or smarts painfully, causing the “hot spot.” With nasal
catheters the oxygen dosage must be regulated with
the flow meter; but no one can prescribe the liters per
minute that will relieve cyanosis. A good practice is
to start the flow at as high a figure as the patient will
endure, and 10 liters is about the maximum. If this is
adequate, the color may improve in a few minutes.
When there is a definite change, the flow may be
reduced; from 6 to 8 liters per minute will generally
be tolerated and the cost at this rate of flow is not
great. If 10 liters per minute does not help the color
of the patient in an hour, one should try placing the
catheter tip lower into the oropharynx — at a spot below
the palate but where the swallowing reflex will not
interfere. Two catheters, one in each nostril, may be
used if the patient breathes through the mouth : the flow
to each catheter can then be reduced to a tolerable rate.

Oxygen therapy to be useful must be continuous as
long as cyanosis develops if the treatment stops. It is
not harmful to stop it for a test of doing without,
except in widespread pneumonia when there is much

moisture in the air passages. Here oxygen is helpful
and very necessary. Some patients seem to become
habituated to a rich atmosphere of oxygen, but this
condition does not develop in short time nor has it
been described in lobar pneumonia.

With the best of technic oxygen may in certain cases
be life saving to the pneumonia patient, but it is very
difficult to prove the point. Where oxygen has been
most intelligently used and checked with blood measure-
ments, this form of pneumonia therapy is always
regarded as of minor importance in lobar pneumonia as
compared with serum or chemotherapy. In suffocating
pneumonia, such as in capillary bronchitis ; in wet hem-
orrhagic pneumonia, as in influenza; in pneumonia after
corrosive gases; in asthma complicated by pneumonia,
or in pneumonia complicated by acute bronchiolar
spasm — in these forms oxygen may be the most impor-
tant item in treatment.

Properly administered, oxygen inhalation is com-
patible with any other form of treatment. It should
never substitute for specifics when such are at hand.

Cincinnati General Hospital.

GENERAL THERAPY OF PNEUMONIA

ROGER I. LEE, M.D.

BOSTON

Three spectacular therapeutic procedures in pneu-
monia, namely oxygen, serum and chemotherapy,
especially in judicious combination, bid fair to rob
pneumonia of much of its terror. Certainly the death
rate from pneumonia will be strictly reduced. At this
moment no man can say how much that reduction, albeit
certainly great, will be and furthermore no man can say
whether or no the immediate or remote future will
bring further developments of these therapeutic agents
or new agents.

At this date, May 1939, it is certainly premature to
discard all other therapeutic devices and measures in
pneumonia, and in all likelihood it will always be fool-
hardy to treat the disease pneumonia or any one of its
symptoms exclusively and to ignore the patient. In
truth the patient is the container of the disease. He
then becomes the battleground of what formerly nearly
always was and even now often is a titanic struggle. As
the opposing forces line up and get into action and as
the battle begins and goes on, the unfortunate patient
or container of this devilish battleground is badly shaken
and racked. Furthermore, during this turmoil the
patient has functional obligations, including the trans-
port of oxygen, serum and drugs to carry on. More-
over, according to our present beliefs the patient himself
must actively participate in the battle against the invad-
ing enemy if cure is to result, no matter how specific
drugs and serums seem. The patient who is an invert
container will die.

Essentially the general management of a case of
pneumonia consists in the conservation of strength.
Rest and quiet are the prime considerations. There
should be no delay in putting the patient, and that
includes the suspects, to bed. Within the first twenty-
four hours a patient may probably be moved without
undue increase of risk in an ambulance (not an auto-
mobile) to a hospital, provided the distance is not
over a few miles and provided the bed to bed journey

. ir I me Fane] Discussion on Pneumonia, Medical Division, General

Scientific Meetings, at tile Ninetieth Annual Session of the American
Medical Association, St. Louts, May 16, 1939.,

THERAPY OF

PNEUMONIA— fee

^Therein often is.mi® p „ jrfcc totvnrO non-
cswwSed.

SS£« v*$ S£3‘ . £ ££S

feed himself oi gi' c B quiet I mean tnc ient .

turn over b Y l ™" n , outside disturbance^ . ncludes a ny

of any unnece : ‘ visitors an ‘ examinations.

This obviously manipulations an^ esanlin ations

unncccssai) ^\ 00 d cultures, P • ' {u p v organized

Blood ^"Examinations mUS . nrecisiou and dispatch,
and x-iaj carried out with 1 technical P' 0

in advance <m hat elaborate intravenous

Likewise the sc us seru m ^Eoeclication or fluul

cedurcs as mt sU bcutaneous 1 { a s possible

fluid therapy bc prepared as

administiati h upplv °*

outside the room. impo rtance is t th)S sU b-

Probablv next ^ l0 the patic • v own

adequate amount o divevs \tv of °P"u C ep the urinary

met there is a shoU ld suffice to keel ^ or

view is th E h V neighborhood of aO as insufficient

output m the n g ^ this 1 unnecessary u oik

1 500 cc.). L , tb L as creating, patients

tlAAff “;" r fdlw-t»k« »> "Lntskto tf“

"n%"S“ologic P°"fLoic\n '8 "’fjfjhich are '«»
The desirability ° b * dec ides against

In the areia^, paid to tnc dv desuauie

«£ *?££?£ S 4 “tS *' ‘Ts r o 2 “

EW " 0NM ., lte t ascorbic acid aid '

While there “^^ritamina are djataM «
probably some ;>i L ic ^ fo ,

pneumonia, a v q a min and iron i £1 ‘P the disease,
better to and « ot s teS repeated

: T1 “ e' iSC SnsWetl .into to of tin

'5 %vitliout J ol . 0 "j E ^ 2 ' c S “ 5 Afle? a

complicatcc 1 p as ; n circulatoiy \ . against the

that the dan&c 1 evidence is deffi a monia. In
very *‘f w £dSTdipt* lis therapy »££* digitalis
value of r , on 'Imaged heart and c ‘‘ a L e indications
a previously ‘ rarely indicate k indication!

££^ t i*^^SySr.

ot »' "'“"'S the disease by p c S“ h« 1 "T,

lated early m th io the diseas incompetcn ce

whoSii>^£5.^rSc:^
^rsr E ’k^Ante-i*

l—>’Ch ttaki uaoally c =« ^arily.l*^

^iidinekv d*u* ”en,no*a«*;»; 0 >

There may ' )C ’ s. Many paticn . ^ sa hcyjat e

o{ incidental ^ various members ^creased and d
fanuhai i > swcat ing is n<)t fEome comfort, ease ^
group. 1 not disturbed, _ . c \imim'ti°

the stomach is no ^ malal sc ana use 0 f «*

headache and of S by t he mode c ^ uaUy early,
fever may be atU n leUV itic P^ 111 ’ t han drug*
salicvlate group- * ^ swathe is/ exhibition

mav" he distressing. * be tried. JJJ a5 con tra-
The salicylates may of co re S al dc al

T we doses of opiates has i a good d® d the

°t . . k , • pneumonia an the othei , 0

gssr^ »

or ,^ s £l in -E^SSnc - d ^

W^i0Sif§Sl

As far as 1 know doses, n to me

if in small and non dcobo f does n° tbe rapy-
ficial mild enpho! ‘ t ce j„ pncvti llaps c tlw ‘ ^

,n nnv impo' tani 1 „,, f i pulmonaiy . . t hcse an

^S3SS®hs«

similar p lo not seen various

thin time they 0 n,a - - the -

The evicien- - pn eumo ‘- f here fore tne **»■-

s,?rl«3

Voi.UMK ll,»
Number 15

OPTICS AND VISUAL PHYSIOLOGY

1413

cians arc in no position to discuss the management of
these conditions intelligently.

The general treatment of the pneumonia patient as
I have outlined it seems highly innocuous in contrast
to the era in which bleeding, purging and puking were
almost routine. Likewise physicians have given up
cupping, countcrirritation and poultices. They no
longer subject their patients (and the nurses) to the
iev blasts of winter. However there may be merit in
the air conditioned room in summer and perhaps in
a room where the temperature can be controlled.

Even if slush baths arc not used for reduction of
temperature, certain forms of bathing which have a
sedative effect arc regarded highly. That and the judi-
cious employment of rubbing or of massage are accepted
as a part of good nursing care.

In effect, an attempt is made to manage the patient
so as to conserve his strength, so that he may be
fortified against the devastating tumult of the battle
within him and that he may contribute what he can to
the suppression of the enemy pneumonia. Pneumonia
is always to be regarded as one of the doctor’s most
common major emergencies. Loss of time may mean
loss of life. During the few days of emergency, no
detail is trifling. And while the glory of a victorious
battle will go to the big guns of chemotherapy, serum
therapy and oxygen therapy, this battle, like other
battles, is often actually won by the nonspectacular
infantry ; in this case, the general care of the patient.

264 Beacon Street.

Special Article

REPORT OF THE AMERICAN COM-
MITTEE ON OPTICS AND
VISUAL PHYSIOLOGY

WALTER B. LANCASTER, M.D., Chairman

BOSTON

The committee has held some half dozen meetings
since the last report and has carried on an extensive
correspondence. In fact, the clerical work entailed has
become too large a burden to be carried by our too
willing secretary, Dr. Conrad Berens. The committee
therefore voted to request the parent societies to make
provision for office expenses by each contributing say
$50 to be used for this purpose.

The work of this committee is largely divided among
subcommittees, whose reports form the basis of discus-
sion and action by the whole committee. These sub-
committees will be taken up seriatim :

I. COMMITTEE OX MOTOR ANOMALIES AND
ORTHOPTIC TRAINING
Dr. Conrad Berens, New York, Chairman

Ihe National Orthoptic Council has begun its work;
the first examination was held in New York on March
30 and April 1 and ten candidates were examined.

II. COMMITTEE ON CODE OF LIGHTING
Dr. Alfred Cowan, Philadelphia, Chairman

1 here is no new business.

During the past year a related series of experiments,
which were approved in principle by the committee, has
been carried out on the effects of reading at 1 and 50

Read before the Section on Ophthalmology at the Ninetieth Annual
ocssion of the American Medical Association, St. Louis, May 19, 1939.

footcandles on the total metabolism and pulse rate at
the Harvard Fatigue Laboratory by McFarland, Knehr
and Berens. Negative results were obtained in this
study. The data are of significance in correcting certain
impressions that reading under different levels of illumi-
nation gives rise to marked alterations in metabolism.

From these data it seems justifiable to conclude that
the recommendations concerning illumination in schools
made by the Committee of Illuminating Engineers in
1938 should be used as a guide if new construction is
undertaken or improvements are to be made in some
existing school rooms ; but until the results of further
researches arc available, it might be unwise to make
drastic changes in the present lighting arrangement in
all the schools because the proposed changes would
increase the tax burden and possibly would be unwar-
ranted. Another important possibility is that the recom-
mended standards are too low, especially for the visually
handicapped children in the regular class room.

III. COMMITTEE OX NEW INSTRUMENTS
Dr. Sanford R. Gifford, Chicago, Chairman

A final report was made on the telebinocular for
examining and sifting out school children in need
of expert attention for their eyes. The decision was
reached that this instrument was not well suited for
this purpose and its use was condemned.

At the request of the committee, a method has been
worked out in Boston which the committee wishes to
have tried out in other places where cooperation with
competent ophthalmologists can be secured. It is the
purpose of the committee not to recommend any method
until it has been subjected to the crucial test of applying
it in several independent localities to groups of say fifty
to 100 children, every one of whom is given a thorough
examination under cycloplegia by an ophthalmologist
to check the results obtained by the school nurse or
the teacher who uses the test under ordinary working
conditions. It was on the basis of such check tests that
the telebinocular was rejected.

IV. COMMITTEE ON OPTOMETRV
Dr. S. Judd Beach. Portland, Maine, Chairman

The many difficult problems involved in the relations
between ophthalmologists, optometrists and the public
were earnestly discussed from many angles. An imme-
diate solution is not to be hoped for. Only by gradual
education and evolution can the goal of cooperation
desired by many be attained. The committee voted to
request the Section on Ophthalmology of the American
Medical Association to reconsider the vote taken in
1935 at a special executive session without previous
notice and without discussion. This action in 1935
declared it to be “unethical for members of the Ameri-
can Medical Association to give lectures or courses of
instruction to or consult with any one not associated
with the actual medical service.’’

V. COMMITTEE ON BETTER LIGHT — BETTER SIGHT
Dr William L. Benedict, Rochester, Minx., Chairman

No report was made.

VI. COMMITTEE ON RELATIONSHIP BETWEEN
OPHTHALMOLOGISTS AND OPTICIANS
Dr. Sanford R. Gifford, Chicago, Chairman

Dr. Gifford sent out a questionnaire and secured
valuable information, especially as to the matter of
rebates, retail prices, and so on. He also had confer-

1414

COUNCIL ON PHYSICAL THERAPY

Jour. A. JI. A.
Oct. 7, 1939

ences with some of the leading manufacturers, whom
lie found very anxious to remedy existing defects.

As an entering wedge in attacking the present system,
lie proposed, and the committee endorsed, a plan sug-
gested by Alan Woods as follows:. “In communities
where there are no straight retail dispensers of optical
goods (other than optometrists) physicians who do not
desire to participate in any way themselves in the retail
dispensing of glasses may refer their patients directly
to the wholesale houses who ordinarily act as oculists’
agents in the dispensing of glasses. On such reference,
the wholesale houses will furnish to patients, on specific
prescriptions of such physicians, glasses of comparable
quality, including protected lines, at the minimum retail
price prevailing in the community and will assume
responsibility for breakage, adjustments, collections,
etc., such as are ordinarily assumed by their accounts.

“On other than protected lines the foregoing proposal
should effect a saving averaging 20 per cent or slightly
more on a combination of lenses and frames as com-
pared with the retail price commonly employed. The
results will necessarily vary according to local condi-
tions, but the general results will be as stated.”

VII. COMMITTEE ON GRADING LENSES
Dr. Alfred Cowan, Philadelphia, Chairman

A definition was presented of a first grade lens which
was adopted, with slight modification by the committee,
as follows :

A first class lens is one which, when finished, has the
proper focal power and correct direction of the axis of
the cylinder; is properly transparent; has regularly
smooth, polished surfaces; contains no flaws, scratches
or other blemishes, and is accurately centered with
regard to the visual lines. Regardless of the price, any
lens which meets with these requirements must be con-
sidered first class.

Ophthalmologists, of course, cannot be expected to,
nor can any one else, tell whether the lens which meets
these requirements was originally labeled first, second
or third class.

SPECIFICATIONS FOR ILLUMINATED EYE CHART
AND FIXATION LAMP UNIT

Dr. Benedict presented specifications for illuminated
eye chart and fixation lamp unit, prepared by the
Advisory Committee of Ophthalmologists to the Eye
Health Committee of the American Student Health
Association in cooperation with the National Society
for the Prevention of Blindness.

The members of this advisory committee are Drs.
Benedict, Gradle and LeGrand Hardy; they were aided
by W. F. Little, consulting engineer.

These specifications were accepted by the committee.

COMMITTEE ON POLAROID
Dr. W. II. Luedde, St. Louis, Chairman

The facts presented in the report of our committee
were not challenged by our conferences last October
with Mr. Land, the originator of the Polaroid crystal
layer, but the committee was pleased, at the suggestion
of Dr. Lancaster, to reconsider its conclusions.

It is true that a large measure of the beneficial effect
of the Sun or Daylight glasses is the result of the olive
•ween tint added "to the polaroid in these glasses, but
clinical tests appear to show the superiority of glasses
made with the layer of polaroid substance.

\ United States Forest ranger and official snow
observer in the highest Rocky Mountain region

throughout the winter gave assurance and so did others
tiiat the polaroid glasses were notably superior to the
laige vai iety of simple tinted lenses they had previously
used. If funds were available, adequate clinical tests
of a larger number of persons under different conditions
might be considered.

It might be recommended that the name of Polaroid
Daylight glasses be changed frankly to “tinted” Polaroid
Sunglass instead of making the explanation in fine print
where it may pass unnoticed. The practical elimination
of the most annoying reflected light, which is largely
polarized, is so advantageous in the outdoor use of
glasses to protect against glare that proper “tinted”
Polaroid glasses must be acknowledged to be much more
efficient than mere tinted lenses.

Theoretically, the proper use of the polaroid film
should he a great advantage in night driving to eliminate
the dangers incident to glare of headlights and wind-
shields. It is hardly possible that the expense of this
equipment could be considered exorbitant when weighed
in relation to the saving of human lives.

Council on Physical Therapy

The Council on Physical Therapy has authorized publication
of THE following report. Howard A. Carter, Secretary.

PESCOR SHORTWAVATHERM RX MODEL
NOT ACCEPTABLE

Manufacturer: Physicians Electric Service Corporation, 1054-
1056 West Sixth Street, Los Angeles.

hi the interest of public protection the Council has recently
given attention to the Pescor Shortwavatherin, RX Model.' «
appears from a letter addressed to dealers that ' the device 's
sold directly to the public : to quote, “The low list price of
includes heavy sponge rubber molded pads and cords, etc., awl
should make possible volume from a new ‘customer-channel ,
the surface of which hasn't even been scratched,” and • a
Short Wave Diathermy specially designed for patient’s use at
home . . ,” and, “Patients usually rent Short Wave Dia-
thermia for home use to facilitate treatments, expense ant
departures from business.”

The unit is portable, and accessories include rubber cncasec
cords and two 6 by 8 inch rubber pads. Sinus pad, orificial an
cuff electrodes are also available. The unit is designed 0
operate at from 50 to 60 cycles, 115 to 125 volts alternating
current. It utilizes two vacuum tubes. The manufacturer
claims an output for the device of from 200 to 250 watts a"
a wavelength of 16 meters. A surgical current is also provi e
for which a foot switch and cutting knives are available.

The advertising sheet “Pescor Shortwavatherin RX Mo e
in the opinion of the Council contains several objectionable ea^
tures. Diathermy is recommended for a wide variety o a*
meiits, which are so generalized in nature as to suggest t >a 1
is a general panacea for almost any ill. For instance, it j s a<
cated for cardiac ailments (selected), constipation, gall J ®
diseases, spleen, gastric ailments, goiter (selected), bay c ' c ’
intestinal neurosis, spinal cord ailments, pelvic diseases, P® ncr ?.
ailments, liver diseases and head colds. Other ,/( l j c . s . ll0 "(
statements are “Penetrability beyond requirements, t 5un
power,” and “Simple as A. B. C.” The claim is advance ^
applications may be made by any one, which might ea
unfortunate consequences for uninformed persons who a
self treatment. The firm also states that the umt possesses ;
“Penetrability Meter." No critical evidence has been pres
to the Council to substantiate the value of such a meter.

Another circular addressed to “ Dear Doctor points 011 ,

the appliance is “. . . especially designed for your pa

use at home, or as an auxiliary machine for your ofnee

Volume 113
Number IS

COUNCIL ON PHARMACY AND CHEMISTRY

1415

It also recommends the device for minor surgery, as do the
other pieces of advertising. An apparatus which is sold both to
the public and to the physician, as this appears to be, for both
medical diathermy and minor surgery, can only be, the Council
believes, (1) a dangerous appliance for the layman to use or
(2) an ineffective apparatus for the treatment of disease.

In the opinion of the Council on Physical Therapy, the
Physicians Electric Service Corporation appears to be promoting
an instrument in a way that is detrimental to the public interest
and rational therapeutics. Sales methods which promote self
treatment of disease hy those unqualified to practice medicine,
and appeal to the public with unscientific persuasions, may harm-
fully enhance a feeling of false security on the part of the public.

In the light of the foregoing report, the Council on Physical
Therapy voted not to accept the Pcscor Shortwavathcrm RX
Model for inclusion on the Council's list of accepted devices.

Council on Pharmacy and Chemistry

REPORTS OF THE COUNCIL

The Council has authorized publication of the following
RE roRT. Paul Nicholas Leech, Secretary.

SOLUTION QUININE AND UREA HYDRO-
CHLORIDE, 5% WITH PROCAINE
HYDROCHLORIDE 2%, 30 CC.

VIALS (UPJOHN) NOT
ACCEPTABLE FOR
N. N. R.

When the Upjohn Company presented this preparation for
the Council’s consideration its attention was called to the fact
that the Council had not accepted any sclerosing or obliterative
agents for the treatment of hemorrhoids although it has accepted
sclerosing agents in the treatment of varicose veins. The firm
was asked to supply any evidence it might have to warrant the
Council in accepting a 5 per cent solution of quinine and urea
hydrochloride with procaine hydrochloride for such use. In
reply the firm submitted excerpts from current literature and
textbooks on this subject.

The Council’s referee examined the submitted material and
reported liis feeling that no question should be raised as to the
correctness of the excerpts. He pointed out that some who
report successful use of this procedure have had wide experience
in this condition, while others of the authors quoted probably
"have not been especially interested in this subject but have
written the quoted material as part of the larger question of
surgery. The referee feels that there is no objection to the
occasional use of this method by men who have had wide experi-
ence. He pointed out, however, that acceptance of a product
for New and Nonofficial Remedies with recommendation for use
in this procedure would involve its use by men who may not
be especially well trained in recognition of many of the con-
ditions which simulate or are associated with hemorrhoids. The
referee further pointed out that accidents and unfavorable results
which follow from this method of treatment are rarely reported,
although it is well known that such have frequently occurred.
The Council agreed with the referee that it would be unwise to
place the weight of the Council’s opinion in favor of general
use of the injection treatment of hemorrhoids.

The excerpts from the literature submitted by the firm were
sent to a consultant who probably has had as wide an experience
in the treatment of hemorrhoids and similar rectal conditions
as any one in the country. This consultant reported as follows:

The material submitted by the firm fails to point out the dangers
involved when the injection treatment of hemorrhoids is undertaken with-
out expert knowledge of the various lesions that occur in the rectum, and
of the various complications such as hemorrhage, ulceration and stricture
of the rectum as well as deposition of inert oily- substances in the sub-
mucosa of the bowel, which results in chronic inflammatory foreign bodies.
Used by men specially trained in this work, under definite indications,
the injection treatment of internal hemorrhoids may be safely done as a

palliative procedure. It is my opinion that it is a rare thing to expect
permanent cure, because if well developed internal hemorrhoids are present
almost always there arc also present varicose veins beneath the skin as
external hemorrhoids which cannot be treated by injection and which
subsequently cause dilatation of the veins, making internal hemorrhoids.

The referee is aware of the fact that many drugs, such as
insulin or digitalis, may result in fatal accidents if improperly
used. There are, however, several methods of treating hemor-
rhoids. It is known that the injection method is subject to
accidents — infection, embolism, and so on. It is likewise true
that in the bands of some men this method can be used success-
fully in selected cases. By accepting the recommendations for
the use of injection treatment of hemorrhoids, the Council would
add the weight of its influence in favor of routine or general use
of this method in unselected cases, which will include those in
which the outcome will not be favorable. By refusing recogni-
tion to such claims, the Council denies no one the right to use
sclerosing agents for hemorrhoids if he wishes to do so. They
are already available and arc in New and Nonofficial Remedies
but not with specific recommendations for such use. The
Council has repeatedly allowed some claims and denied others
for many drugs, and has consistently refused to accept any drug
for use in the injection treatment of hemorrhoids.

In view of the foregoing the Council voted that for the present
it continue its policy that no preparation for the injection treat-
ment of hemorrhoids be accepted for New and Nonofficial Reme-
dies and declared Solution Quinine and Urea Hydrochloride,
5% with Procaine Hydrochloride 2%, 30 cc. vials-Upjohn
unacceptable for inclusion in New and Nonofficial Remedies,
since it is recommended for this purpose.

NEW AND NONOFFICIAL REMEDIES

The following additional articles have been accepted as con-
forming TO THE RULES OF THE COUNCIL ON PHARMACY AND CHEMISTRY
of the American Medical Association for admission to New and
Nonofficial Remedies. A copy of the rules on which the Council

BASES ITS ACTION WILL BE SENT ON APPLICATION.

Paul Nicholas LEEcn, Secretary.

ADRENALIN (See New and Nonofficial Remedies, 1939,
p. 229).

The following dosage form has been accepted:

Ampoules Adrenalin in Oil, 1 cc.: A vegetable oil (peanut oil)
suspension of adrenalin base, each cubic centimeter of the suspension
representing 2 mg. of adrenalin.

ASCORBIC ACID (See New and Nonofficial Remedies,
1939, p. 499).

Tablets Ascorbic Acid, 25 mg.

Prepared by Smith-Dorsey Co., Inc., Lincoln, Neb.

Cevitamic Acid-Abbott (See New and Nonofficial Reme-
dies, 1939, p. 500).

The following dosage form has been accepted:

Tablets Cevitamic Acid-Abbott, 0.05 Gm.

NICOTINIC ACID (See New and Nonofficial Remedies,

1939, p. 495).

Tablets Nicotinic Acid, 50 mg.

Prepared by Smith-Dorsey Co., Inc., Lincoln, Neb.

STEARNS HALIBUT LIVER OIL WITH VIOS-
TEROL (A. R. P. I. PROCESS). — A brand of halibut

liver oil with viosterol-N. N. R.

.Prepared by the internatomal Vitamin Corporation, New York Tlie
viosterol (A. R. P. I. Process) is manufactured by the American
Research Products, Inc., a division of General Mills, Inc., Minneapolis
f F de L c, aBrec ” en ‘ " lth E I. du Pont de Nemours Compand

(May^lO^ lW8^™xpires^t955)r^’ d ' Stnbu,or >- U ' S- patent 2,117,100
Stearns Halibut Liver Oil with Viosterol (A. R. P. I. Process) /W.;,
°(U Cr <z%\ '(' Cr - , Capsules .— Each capsule contains 8,500 units

(U. S. P.) of vitamin A and 1,700 units (U. S. P.) of vitamin D.

Stearns halibut liver oil with viosterol (A. R. P. I. Process) is pre-
pared by combining refined halibut liver oil, one or more other fish liver
oils, and viosterol (A. R P I. process) in such proportions as to bring

If t-iiamT S Dt Z y ef.OOO tS A

electrons. ^ R ' F ' Process) is er E°sterol activated by low velociTy

1416

EDITORIALS

Jour. A. M. A.
Oct. 7, 1919

THE JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION

535 North Dearborn Street - - - Chicago, III.

Cable Address - - - - “Medic, Chicago”

Subscription price Eight dollars per annum in advance

Please send in promptly notice of change of address, giving
both old and new; ahvays state whether the change is temporary
or permanent. Such notice should mention all journals received
from this office. Important information regarding contributions
will be found on second advertising page following reading matter.

SATURDAY, OCTOBER 7, 1939

PERIODICITY OF INFLUENZA

Like other epidemic diseases, influenza tends to fluc-
tuate in its frequency and in its virulence. Furthermore,
this intermittence was evident not only in the case of
the great pandemics, such as the one of 1917-1918, but
also in the minor epidemics which occurred both before
and after that calamity. It has been difficult however
to relate the fluctuations which actually occurred with'
any definite time or seasonal factor. When the litera-
ture on influenza was reviewed by Jordan 1 in 1927 the
theory of Brownlee, who attempted to relate endemic
“influenza” to a periodicity of thirty-three weeks, was
dominant. Jordan pointed out, howevei , that the evi-
dence available was not sufficient to establish definitely
the conclusion that a nonseasonal cycle as predicted by
Brownlee was an inherent and general charactei istic
of influenza in postpandemic periods, because the obsei-
vations did not cover a sufficient number of different
areas to give them generality, because they failed to
cover a sufficient period of time in the life history of
influenza and because for the years 191S-1923 the facts
adduced, although apparently consistent with the
hypothesis of a thirty-three week cycle, seemed to be
also consistent with the simpler assumption of a cycle

approximating twelve months.

Equally speculative has been the explanation foi the
irregular intervals existing between the great pandemics.
The various explanations that have been advanced,
according to Jordan, fall into two main categories:
those postulating a change in the distribution or nature
of the virus, and those attributing the phenomenon to
something in the condition of those attacked. To these
a third may be added ; namely, a decrease of the oppor-
tunities for spread of the infection. After consideration
of the evidence up to 1927, the most plausible of these
hypotheses, he thought, rested in a change m the viru-
lence of the infecting microbe as the essential cause of
the rise and fall of pandemic influenza. The coming

“ Jordan> E o. : Epidemic Influenza. Chicago. American Medical

Association, 1927.

into existence of a peculiar strain of influenza virus to
cause the pandemic manifestations has not been wholly
disproved by any subsequent studies and has, in fact,
received some theoretical support by demonstration of
different strains of influenza virus both in man and in
certain lower animals.

During the last twelve years much further study lias
been accorded this subject, although no pandemic has
appeared. Recently Webster 2 has again challenged
Brownlee’s thirty-three week single phase cyclic hypoth-
esis and has presented a two phase theory which he
thinks may explain the observed periodicity of influ-
enza. While not denying the part played by seasonal
influences "in influenza mortality, the twelve month
cycle, Webster says, does not permit of predictions with
any accuracy nor can it account for the major epidemics
in the summer and autumn. From his analysis of the
past forty-nine years (1890-1939) he postulates a
diphasal activity of influenza most strikingly evident
in the three pandemic waves of 1918-1919. This repre-
sents a modification of Brownlee’s single phase thirty
three week theory with a seasonal factor and accounts,
Webster believes, for all the main phenomena. Phase 1,
that occurring at approximately the thirty-third week
interval, has been the major phase, although phase
(the intermediate) about sixteen weeks aftei phase
has led to a number of serious outbreaks (as in
February-March 1924 and January-March 1932, he
says, and to the first and third pandemic wares o
1918-1919). Some variation of the thirty-third wee'
period is occasionally evident and indeed at present 1 j
evidence suggests that a thirty-six week period ems
now. The cause of variation of the interval, W e >s
believes, may be one intrinsic to the virus oi he due
part to a seasonal element. The well known season^
incidence of interpandemic influenza may he du
only to meteorologic conditions and to a lowered t
tance of the population in the winter-spr ing mont is ^
to an intrinsic increase in activity on the part o

rus. . . e

The factual data on which this theory is based
stricted. Adequate testing of the theory S1
elude more complete analysis of morbidity ra es
e study of minor outbreaks and of relapses an r
nces. On this theory, however, it should >c P° s
predict to some degree future epidemics an .
eaks. The most likely time for a major epi
ould be, he says, February 1941 (phase 1 cm )’
though a phase 2 outbreak of some seven y
issible in February 1940. ot

Critical analysis of this interesting t leory a

yet lead, however, to complete conviction- ^
evious study Webster attempted to emon ^ w ] 1 j c h
:riodicity of cancer and oth er neoplastic diseas

2 Webster, J. II. D.: The Periodicity of Influenza, Edinburg
: 591 (Sept.) 1939.

Volume H3
Number 15

EDITORIALS

141 7

he says is closely similar to that demonstrated for influ-
enza. This is a most surprising concordance, since
there seems little else of parallelism in these two dis-
eases. Furthermore the cycle of thirty-three weeks of
Brownlee’s hypothesis, which in the main Webster
accepts, has not yet been freed from all the criticisms
previously made by Jordan and others. Webster also
states that in this cycle missed periods arc often seen,
especially in the summer and autumn months, and the
half-periods (phase 2), which Webster suggests are due
to a double strain or grouping of infected strains, can-
not as yet be accepted as a wholly established phenome-
non. ' No matter how this hypothesis withstands further
critical analysis, its usefulness as an instrument of
prophecy will receive practical trial in connection with
the predicted outbreaks of February 1940 or Febru-
ary 1941.

THE RENAISSANCE OF SILK IN
SURGERY

Clinical experience has demonstrated that the prob-
lem of ideal wound healing is complicated. It involves
not only the presence or absence of bacteria in the
wound, the nature of the organisms and the resistance
of the patient but also a number of other factors. Aseptic
healing of an incision requires a systematic, meticulous,
aseptic operating room technic in all its many details,
minimum traumatization of the tissues, complete hemos-
tasis and, less important, but nevertheless significant,
the selection of proper ligature and suture material.
After more than half a century of use of an absorbable
suture, many surgeons now seem ready to discard such
materials to return to the use of silk in the repair of
clean wounds and incisions. The older masters of the
craft who, after unsatisfactory experience, rejected
catgut and returned to silk include such leaders as
Theodore Kocher, Heidenhain, Hagler and, in our own
country, William Stewart Halsted.

In a now oft quoted paper, published in The
Journal in 1913, Halsted 1 thus summarized his objec-
tions to the use of catgut :

The relatively high cost of catgut, its bulkiness, the incon-
veniences attending its use and sterilization, its inadequacy, the
uncertainty as to the time required for its absorption, and the
reaction which it excites in a wound, induced me to discard it
completely for clean wounds in the surgery both of the human
subject and of animals. With the fine silk in our wounds, which
for twenty-three years have, as a rule, been closed without
drainage, suppuration almost never occurs. But catgut, even
that which we have no cause to believe is not sterile, irritates
the wound for some reason, perhaps because it serves as cul-
ture medium for saprophytic organisms which are carried into
it from the deep epithelium and follicles of the skin. It should
be borne in mind that during the greater part of the period of
its disintegration the catgut suture is not only not serving its
purpose but is playing the role of necrotic tissue, of a culture

1. Halsted, William Stewart: Ligature and Suture Material: The

Employment of Fine Silk in Preference to Catgut and the Advantages of

Transfixion of Tissues and Vessels in Control of Hemorrhage; Also

an Account of the Introduction of Gloves, Gutta-Percha Tissue and Silver

Foi! . j. A. M. A. 60: 1119 (April 12) 1913.

medium. It is well within reason to expect that the technic may
be at least so perfect when silk is employed that the wound
will become infected not once in a hundred cases.

Recent clinical and experimental studies seem to bear
out Halsted’s position. Thus, Shambaugh and Dunphy 2
demonstrated in dogs that operative wounds repaired
with silk tolerate bacterial contamination better than
similar wounds repaired with catgut; that the healing
of experimental suppurating wounds is not appreciably
delayed by the presence of buried silk sutures and
ligatures, provided a fine grade of silk is used, the
sutures are cut close to the knot, and continuous sutures
are not employed. They also showed that experimental
suppurating wounds repaired with fine silk may heal
completely without the removal or the spontaneous dis-
charge of the silk sutures. Jenkins, 3 in his analysis of
1,294 cases of abdominal wound disruption, mentions
among the causes imperfections in the catgut and rapid
digestion as a result of sensitivity to catgut protein,
to chromic acid and to infection. Kraissl 4 demonstrated
the possibility of an allergic reaction to catgut in
patients with edema of the wound edges and disruption
of abdominal wounds. He was able to sensitize guinea
pigs to plain and to chromic catgut and to chromic acid
with the result that 30 per cent of these animals dis-
rupted the abdominal wound following a celiotomy. All
of a series of twenty-six control guinea pigs healed
normally except one. It appears likely therefore that
the local reaction in patients allergic to catgut predis-
poses to infection and favors wound disruption. The
incidence of this allergy, according to Kraissl, increases
with a history of allergy or of a previous operation.

Superiority of silk over catgut, according to Meleney, 5
is due to the following facts: 1. Hemostasis is better,
for the silk knots do not become untied as do catgut
knots. 2. The cellular and fluid reaction about silk is
minimal while about the catgut it is maximal; silk is
almost inert in the tissues, while catgut is dead tissue
which must b"e digested. 3. The use of silk automatically
requires the surgeon to be more gentle with the tissues.

Whipple 0 stated at a conference last year that, since
silk has been adopted in his clinic, the improvement in
wound healing has been so striking as to leave no room
for argument as to both immediate and late results.
He emphasizes that one should not attempt to use silk
unless one is willing to change one’s technic and instru-
ments. The essentials of this technic include the use
of the finest grades of silk, interrupted sutures, careful
hemostasis and a constant effort to tie sutures without
tissue tension.

2. Shambaugh, Philip, and Dunphy, J. E,: Postoperative Wound
Infections and the Use of Silk: An Experimental Study, Surcerv 1 -;
379 (March) 1937.

3. Jenkins, H. P.: A Clinical Study of Catgut in Relation to Abdom-
inal Wound Disruption, Surg., Gynec. & Obst. 64 : 648 (March) 1937.

4. Kraissl, C. J.; Kesten, B. M„ and Cimiotti, J. G.: The Relation
of Catgut Sensitivity to Wound Healing, Surg., Gynec. & Obst. GG: 6’8
(March) 1938.

5. Meleney, F. L.: Infection in Clean Operative Wounds, Sure..
Gynec., & Obst GO: 264 (Feb., No. 2A) 1935.

A Whipple, A. O.: The Choice and Use oi Ligature and Suture
Material in the Repair of Clean Wounds, Internat. Abstr. Surg., p. 109- in
Surg., Gynec. & Obst.. August 1939.

CURRENT COMMENT

Jems. A. JI . A.
Oct. 7, 1939

1418

MAGNESIUM IN NUTRITION

In recent years numerous quantitive studies have
greatly enhanced our understanding of the influence of
mineral elements in animal economy. The belief that
magnesium is essential for growth in the higher plants
was confirmed in 1906, when Willstatter discovered that
it forms an integral part of the chlorophyll molecule.
Until 1932, however, when Kruse and his co-workers 1
published their observations on magnesium deficiency
in the rat, the indispensability of this element for the
animal organism had not been clearly established.

The extent to which a deficiency of magnesium may
occur in the human dietary is not definitely known.
Furthermore, the nature of the pathologic changes that
might be expected to occur as a result of a deficiency
of magnesium has only of late been disclosed by experi-
mental studies on animals. Duckworth 2 has recently
presented the symptomatology of experimental mag-
nesium deficiency. The fragmentary evidence available
indicates that one effect of magnesium deficiency is a
disturbance of normal calcium metabolism. Extensive
pathologic depositions of calcium salts in the yellow
elastic fibers of the endocardium and in the aorta, the
jugular and the larger arteries as well as in the soft
tissues have been described in calves whose regimen
was low in magnesium. Similarly, in rats which
received an inadequate amount of magnesium in the
diet an increase in the percentage of calcium in the
heart, kidney and muscles has been observed. The mani-
fold effect of magnesium deprivation was shown by
Kruse, 1 who found that magnesium deficiency in rats
was characterized by vasodilatation, hyperemia of
the cutaneous vascular system, increased hyperirrita-
bility, cardiac arrhythmia and fatal tonic-clonic spasms.
Similar effects have been observed in dogs on a mag-
nesium-poor diet. Determinations of the magnesium
content of the serum of dogs on such rations have
shown that there is an early and progressive decrease
in the amount of the metal present and that the value
remains low during the convulsive period. New prob-
lems regarding the causation of tetany have arisen as
a consequence of its occurrence in animals suffering
from magnesium deficiency.

The human requirement for magnesium has been
studied by a number of investigators. On the basis of
balance experiments, the daily magnesium requirement
of children from 4 to 7 years of age has been estimated
to be not less than 13 mg. per kilogram of body weight.
In a group of preschool children investigated by Daniels
and Everson, 3 75 per cent were found to be receiving
less than the optimal amount of this element as judged
by retention of magnesium under certain conditions.
The meager information that is available regarding the
magnesium requirement of pregnant women indicates
that from 350 to 450 mg. daily is necessary during preg-

1 Kruse, H. D. ; Orent. Elsa R., and McCollum, E. V.: J. Biol. Chem.

^Duckworth, John: Nutrition Abstr. & Rev. 8:841 (April) 1939.

5". Daniels, Amy L., and Everson, Gladys J.: J. Nutrition 11:327
(April) 1936.

nancy. The daily magnesium requirement for the
maintenance of adults has been reported to be as low
as 0.2 Gm. and as high as 0.6 Gm. Duckworth assumes
that the lower estimate is more nearly correct. Judging
from data available on the magnesium content of freely
chosen American diets, the requirement will be met
provided the daily energy intake is in the vicinity of
2,500 calories. The possibility of adult human deficiency
cannot be ruled out, however, until further information
is available concerning the magnesium requirement.

Hirschfelder 4 has suggested that the clinical occur-
rence of magnesium deficiency under certain conditions
is within the realm of possibility. This investigator
observed low levels of magnesium in the plasma in
several patients accompanied by hyperirritability of the
neuromuscular system often associated with muscular
twitchings and convulsions. Nevertheless, so little is
known of the function of magnesium in the organism
that clinically observable abnormalities in man cannot
at present be said with certainty to be due to mag-
nesium deficiency' or to a disorder of magnesium
metabolism. The systematic study of magnesium
metabolism by accurate analytic and experimental
methods is little more than begun. Future investiga-
tions may be expected to add considerably to our knowl-
edge of this problem.

Current Comment

OXYGEN AND CARBON DIOXIDE
IN PNEUMONIA

Although oxygen has been employ'ed in pneumonia
for nearly two decades, not all of the factors concerned
in its administration have been thoroughly elucidated.
In an experimental investigation of this subject by Cohn
and his collaborators, 1 five series of experiments were
performed on carefully' picked dogs, embodying the
determination of the normal plrysiologic variations m
oxy'genation and acid-base balance occurring in f K
blood of the dogs, the determination of the effect o
experimental pneumonia on the oxygenation and acic
base balance of the blood, the determination of the effec
of breathing air enriched with oxygen alone on norma
dogs and on anoxemic dogs, the determination of t ie
effect of the breathing of air to which carbon dioxi c
had been added on normal and pneumonic dogs, am t ie
determination of the effect of breathing air enric ie
with both oxygen and carbon dioxide on norma an
pneumonic dogs. Careful controls were employed m a
experiments. The experimental bronchopneumonia 'W
produced by the intrabronchial injection of 1 p er cen
hy'drochloric acid. Although the pneumonia was accorn^
panied by pronounced anoxemia, significant change i
the acid base balance of the arterial blood was no
observed. The investigators also found that oxygen
enriched atmosphere increase d the oxygen saturation

4. Hirschfelder, A. D. : Clinical Manifestations of High and L°
Plasma Magnesium, J. A. M. A. 102: 1138 (Ap”I ' ) afld

1. Cohn, D. J.; Tannenbaum, Albert; Thaltnrner, BIo ^j

Hastings, A. B.: Influence of Oxygen and Carbon Diox.d 1939.

of Normal and Pneumonic Dogs, J. Biol. Chem. 128.

Volume 113
Number 15

MEDICAL NEWS

1419

the arterial blood of normal dogs slightly and of pneu-
monic dogs greatly, without alteration in the acid-hase
balance. Addition of carbon dioxide to the inspired un-
caused a slight increase in the arterial saturation of
both normal and pneumonic dogs. The addition of
carbon dioxide to the inspired air was accompanied by
a change in the acid-base balance of the blood indicative,
they believe, of respiratory acidosis. This acidosis was
more severe in pneumonic than in normal dogs. More-
over, oxygen-enriched atmosphere containing carbon
dioxide was accompanied both by increased oxygenation
of the blood of the normal and pneumonic dogs and by
respiratory acidosis, which was greater in the pneumonic
than in the normal dogs. Both normal and pneumonic
animals kept in high carbon dioxide atmosphere showed
a change in acid-base balance indicative of physiologic
compensation. The evidence available indicates, the
investigators believe, the decreased ability of pneumonic
dogs to eliminate carbon dioxide. Since oxygen alone
achieves the desired reoxygenation of the blood when
this is possible, the addition of carbon dioxide is, they
believe, of doubtful benefit. Furthermore, the usual
rapid respirations induced by carbon dioxide represent
an added burden to an already overburdened respiratory
and cardiovascular system. In view of the conflicting
clinical evidence on the value of adding carbon dioxide
to oxygen in the treatment of pneumonia, these clear-
cut experimental studies can be adduced as offering
evidence that the use of oxygen inhalations alone may
be indicated in the treatment of pneumonia.

Association News

ANNUAL CONFERENCE OF SECRETARIES
OF STATE ASSOCIATIONS AND
EDITORS OF STATE
JOURNALS

The Annual Conference of Secretaries of Constituent State
Medical Associations and Editors of State Medical Journals
will be held in Chicago November 17 and 18. The first session
will be convened at 10 a. m. Friday, November 17. All meet-
ings will be held in the Assembly Room of the American Medi-
cal Association Building, 535 North Dearborn Street, Chicago.

Officers of state medical associations and county medical
societies who wish to attend this conference will be heartily
welcome, as will individual members of the Association who
may desire to be present.

ADDRESSES BY OFFICIAL STAFF
Dr. Paul C, Barton:

October 11 — Dubuque County Interprofessional Society,
Dubuque, Iowa.

October 20 — North Shore Alumnae of Chi Omega, Evanston,

111 .

Dr. W. W. Bauer:

October 12 — Fifth District, Federation of Women’s Clubs,

Lamoni, Iowa.

October 15-19 — American Public Health Association, Pitts-
burgh.

October 25-26 — Parent Teacher Association, High Schools,
Nashville, Tenn.

October 27-28 — Eastern Tennessee Education Association,
Knoxville, Tenn.

Dr. Morris Fishbf.in :

October 10— Town Hall, Grand Junction, Colo.

October 12 — Associated Town Halls, Inc., Jefferson City, Mo.
October 13 — Northwest Division of Iowa State Teachers
Association, Sioux City, Iowa.

October 26 — Bethany College, Bethany, W. Va.

October 27— Eastern Ohio Teachers Association, Cambridge,
Ohio.

Dr. Rock Sleyster:

October 11 — Delaware State Medical Society, Wilmington, Del.
October 18 — Jackson County Health Forum, Kansas City, Mo.
October 30 — Oklahoma City Clinical Society, Oklahoma City.

Dr. Paul A. Teschner:

October 16 — University Clinics’ Nurses Class, Chicago.
October 26 — Annual Meeting, Wisconsin Anti-Tuberculosis
Association, Milwaukee.

Dr. Nathan B. Van Etten:

October 9 — The Columbia Medical Society, Columbia, S. C.
October 11 — Indiana State Medical Association, Fort
Wayne.

November 1 — The Interstate Post Graduate Medical Asso-
ciation of North America, Chicago.

Medical News

t ■>

(Physicians will confer a fayor by sending for

THIS DEPARTMENT ITEMS OF NEWS OF MORE OR LESS
GENERAL INTEREST: SUCH AS RELATE TO SOCIETY ACTIV-
ITIES, NEW HOSPITALS, EDUCATION AND TUBLIC HEALTH.)

ALABAMA

Personal. — Dr. William E. Bones, Montgomery, associate
in child hygiene, state department of health, has been appointed
to the staff of the Council on Medical Education and Hospitals
of the American Medical Association, Chicago. He graduated
at Vanderbilt University School of Medicine, Nashville, Tenn.,
in 1931.

Changes in Health Officers. — Dr. George E. Maddison,
Monroeville, formerly health officer of Monroe County, has
been appointed health officer of Henry County, succeeding
Dr. Carl T. Martin, Abbeville, who resigned to enter private
practice. Dr. William A. Dodson Jr., Fayette, has been named
health officer of Winston County, succeeding Dr. Paul H.
Hilbert, Double Springs, who has joined the health depart-
ment in Cincinnati, it is reported.

Special Society Elections. — Dr. Charles N. Carraway,
Birmingham, was elected president of the AJabama Association
of Railroad and Industrial Surgeons September 12 at its meet-
ing in Birmingham; Dr. Napoleon S. Johnson, Clanton, vice
president, and Dr. Jacob U. Ray, Woodstock, secretary for
the twenty-third consecutive year. — —The Alabama State Pedi-
atric Society reelected its officers at the recent annual session
in Birmingham: Drs. Stewart H. Welch, Birmingham, presi-
dent; M. Vaun Adams, Mobile, vice president, and William
R. Britton, Montgomery, secretary-treasurer. The next annual
meeting will be in Birmingham, the time to be determined
later.

ARKANSAS

Changes in Medical School Staff. — Recent changes include
the appointment of Dr. Charles R. Henry as professor of
obstetrics and gynecology and of Forrest R. Davison, Ph.D.,
assistant professor of pharmacology. University of Vermont
College of Medicine, Burlington, as assistant professor of
physiology and pharmacology. Dr. Edgar J. Poth, assistant
professor of surgery, Stanford University School of Medicine,
San Francisco, has been appointed head of the department of
surgery.

District -Meeting.— The Fifth Councilor District Medical
Society was addressed in Camden October 5 by Drs. William
Hibbitts, Texarkana, Texas, on "A Brief Review of Intestinal
Obstruction”; Dorman B. Barber, Alexandria, La., “Latent
Scurvy, and Charles W. Mayo, Rochester, Minn., “Surgery of
the Right Colon.” A public session was addressed, among
others by Mayor Don Harrell, Camden ; Dr. Leopold H. Reeves
Fort Worth, Texas, “The Implications of Socialized Medi-
cine ; Dr. Mayo, “Time and Its Relation to Disease,” and
Governor Carl Bailey..

1420

MEDICAL NEWS

Jour. A. }I. A.
Oct. 7, 1539

CALIFORNIA

Society News. — The Los Angeles Society of Ophthalmology
and Otolaryngology was addressed September 25 among others
r P r - Vlc , tor Goodhill on “The Histopathology of Syphilis

of the Ear.” At a meeting of the Los Angeles Society of

Neurology and Psychiatry September 20 the speakers were
JJrs. Archie M. Roberts on “Psychiatry in Internal Medicine”
and Jesse L Henderson, Compton, “Psychotherapy,” and
Jlhomas D. Cutsforth, Ph.D., “Personality Problems of the
Alcoholic.

Study of Methods for Preserving Blood.— The Rosen-
berg Foundation has given 56,000 to the University of California
to establish a blood bank at the San Francisco Hospital. The
grant, which will be administered by an advisory committee
composed of the deans of the medical schools of California and
Stanford universities and the director of health of San Fran-
cisco, will be used to stimulate investigation of methods for
preserving blood in centralized pools or banks and for distribut-
ing it in good condition. The grant stipulates that the work
is to be done by the University of California; Miss Cordula
Hull, assistant in medicine at the university, has been named
to carry on the research.

DELAWARE

State Medical Meeting in Wilmington. — The Medical
Society of Delaware will hold its annual session at the Dela-
ware Academy of Medicine, Wilmington, October 9, under
the presidency of Dr. Meredith I. Samuel, Wilmington. The
society is celebrating its sesquicentennial this year. The
speakers on the program will include;

Dr. Eli K. Marshall Jr., Baltimore, Sulfapyridine as a Bacterial Chemo-
therapeutic Agent.

Dr. John H. Foulger, Wilmington, subject not announced.

Dr. John T. Bauer, Philadelphia, The Difficulty in Early Diagnosis of
Primary Cancer of the Lung.

Dr. William Edwin Bird, Wilmington, Bight Paraduodenal Hernia.

Dr. Fred H. Albee, New York, Massive Resection of Bone Sarcoma with
Immediate Bone Graft Replacement.

Dr. Charles William Dunn, Philadelphia, Hormone Therapy: Uses
and Abuses.

Dr. George Howard Cross, Chester, Pa., Ophthalmology and Its Rela-
tion to Industry.

The sesquicentennial of the state society will be held in a
building which dates nearly as far back as the society itself.
The old Delaware Bank Building, now the Delaware Academy
of Medicine, was chartered in 1795 and the present building
was erected in 1816 at Sixth and Market streets, where it
stood until 1931, when it was removed to its present location
along the Park Drive on land adjacent to that once held by
Tyman Stidham, the first doctor in Delaware. The building
was reerected as it stood originally with the exception of a
few modern interior alterations. The original hand-hewn
rafters joined with wooden pegs, the staircase and floors have
been preserved, as 'well as the original fence surrounding the
building; all are as they appeared one hundred and twenty-
three years ago. A feature of the sesquicentennial is a his-
torical exhibit to help picture the medical background of the
state. The display includes photographs of presidents of the
society, old books, instruments, diplomas, fee bills and many
other items of special interest. The women’s auxiliary to the
state medical society will meet October 10.

FLORIDA

Society News.— Drs. Edward W. Cullipher and Leonidas
W. Dowlen addressed the Dade County Medical Society,
Miami, recently on ’Common Foot Ailments and Endo-
crinology of Menstruation” respectively. Dr. Michael Smith,

West Palm Beach, addressed the Palm Beach County Medical
Society recently on “The Modern Conception of Tuberculosis.

District Meeting.— The third annual meeting of the South-
west Medical District Society was held at Lakeland Septem-
ber ’8 at the Yacht and Country Club under the presidency
of Dr Herman W. Watson. Dr. John F. Wilson, president
of the Polk County Medical Society, gave the address of wel-
come The speakers included Drs. George F. Highsmith,
Arcadia, on “Prevention and Control of Venereal Diseases ;
Daniel F H. Murphey, St. Petersburg, "Pituitary Gland Dys-
function”; Charles L. Farrington, St. Petersburg, “Osteomye-
litis” and Emile Woods, Tampa, “Low Blood Pressure and
Pregnancy.” After dinner, J. Hardin Peterson, U. S. Con-
gressman, was to discuss “Current Legislation of Interest to
the Medical Profession.”

IDAHO

New Industrial Bureau Head.— Dr. Augustus F. Gallo-
way Jr., Kellogg, has been appointed medical officer of the
state bureau of industrial hygiene to succeed Dr. Samuel
V\ eissross Boise, who resigned to enter private practice in
Spokane, Wash.

ILLINOIS

Fifty-One Deaths in Typhoid Outbreak.— Fifty-one
deaths had occurred in the outbreak of typhoid at the state
hospital for the insane near Mantcno, the Chicago Tribune
reported September 30. At this time fifty-five patients were
said to be still under observation and eleven of them were
suspected carriers.

Society News. — The Lee County Medical Society was
addressed in Dixon September 21 by Drs. Guy S. Van Alstyne
and James J. Callahan, Chicago, on “The Management of
Breast Tumors” and “Fractures About the Elbow,” respec-
tively. At a meeting of the Fulton County Medical Society

in Canton September 21 Dr. Carlo S. Scuderi, Chicago, spoke

on fractures. Dr. Robert S. Berghoff, Chicago, discussed

“Senile Ectasy — A Clinical Discussion of Vascular Changes"
before the Cass County Medical Society, Rushville, Septem-
ber 20. The meeting was in honor of physicians of the county
who have been in the practice of medicine for fifty years.

Dr. Carl F. Vohs, St. Louis, discussed “Medical Economics

in Relation to General Practice” before the Sangamon County

Medical Society, Springfield, September 7. At a meeting oi

the Peoria City Medical Society September 19 Dr. Laurence
H. Mayers, Chicago, spoke on “Differential Diagnosis of Acute
Abdominal Pains.”

Chicago

Society News. — The Illinois Association for the Crippled
Inc. will hold its third annual meeting at the Knickerbocker
Hotel October 10 under the presidency of Dr. Edward L.
Compere.

University of Chicago News. — Dr. Parker Dooley, assis-
tant professor of pediatrics, Cornell University Medical Col-
lege, New York, has been appointed assistant professor of
pediatrics in the School of Medicine of the Division of Bio-
logical Sciences, University of Chicago, it is announced. Dr.
Francis B. Gordon, assistant professor of bacteriology at the
university, will return to the faculty this fall after a years
study with Dr. Christopher II. Andrewes at the National Insti-
tute for Medical Research, London. Subjects of new courses
at the university include forensic medicine, background study
of human evolution and abnormalities of voice and speech.

Scientific Programs of the Chicago Medical Society.
— The Chicago Medical Society is planning a series of all day
programs to be held on the third Wednesday of each moiim
from October through April. There will be clinics, demon-
strations, lectures and round table discussions on the genera
subject. The day portion of the program will be held m one
or another of the teaching institutions of the city. The eve-
ning meetings will be held at the Chicago Womans U> >
Theater on Eleventh Street near Michigan BouIevard._ Petal
programs will be furnished each month. The topics to
considered at these meetings are:

October 38, Fractures at the Cook County Hospital. 8: 30 P-
Treatment of Skull Fractures, Dr. Harry E. Mock.

November 3 5, Nutritional Deficiency Diseases at Thorne ita , ^
Chicago Campus of Northwestern University. 8: 30 P- ■“'! u
Vitamin B Complex and Pellagra, Dr. Tom D. Spies, C . ,

December 20, Cardiovascular-Renal Diseases (place not .j ofl

8: 30 p. m., Arteriosclerosis Obliterans: The Modern C P ^
of Its Social Significance, Diagnosis and Treatment, Dr.

Wright, New York. . r u kt’s

Jan. 17, 1940, Industrial Medicine and Traumatic Survey at .St. , jr
Hospital. 8: 30 p. m., Evaluation of Disability Due to Cardio
Disease.

Feb. 23, 3940, Topic and speaker to be selected. ninto-

March 20, 1940, Endocrinology at the University of Uncago c.

8:30 p. m., Misuse of Biologicals in Medical Practice. w „

April 17, 1940, Obstetrics and Care of the N e 'V-"°™’ «• J v

Maternal and Infant Mortality in Chicago, 1935-1939. _

A luncheon for members and guests will be arrange a
ear the institution in which the clinical program is to
ented. A dinner will be held at the Chicago Worn , ■ e( |
efore the evening meetings. Members and guests ar ^

iat admission will be by ticket only. Tickets must b - cc

ot later than the Saturday preceding the meeting, u H ™
f the luncheons will be 50 cents and of the dinn •

'or clinic, luncheon and dinner tickets apply to > the , one
fedical Society, 30 North Michigan Avenue, Chicago, P"
lentral 3026. All members of the Illinois, Wisconsin, os
ndiana, Michigan and other state medical societies
ially invited to attend these all day programs.

Volume 113
Number 15

MEDICAL NEWS

1421

INDIANA

Changes at Indiana University.— Dr. David A. Boyd Jr.,
instructor in psychiatry and assistant physician in the Neuro-
psychiatric Institute, University of Michigan Medical School,
Ann Arbor, lias been appointed head of the department of
mental and nervous diseases of the Indiana University School
of Medicine and Medical Center, Indianapolis, and Dr. LaRue
Carter, member of the sciiool faculty since 1914, has been
named chairman of the division of neurology in the same
department. According to the announcement, growth of the
department under the leadership of Dr. Max A. Bahr, super-
intendent of the Central State Hospital, Indianapolis, has made
the selection of a full time director necessary, although Dr.
Bahr will continue with the department so far as his duties
at the hospital permit.

KANSAS

Postgraduate Course on Heart Disease. — A five day
postgraduate course on the study of heart disease will be held
in Emporia this month, according to an announcement from
the state medical society. Dr. David Schcrf, New York, will
conduct the course.

Society News. — Dr. George F. Green, South Bend, Ind.,
discussed “Factors Tending to Reduce the Mortality in Appen-
dicitis" before the Shawnee County Medical Society, Topeka,

September 11. At a joint meeting of the Wyandotte County

Medical Society and the Kansas City Veterinary Society Sep-
tember 19 the speakers were Dr. Louis B. Gloync and F. B.
Croll, D.V.M., on prevention and treatment of rabies. The
medical society was addressed September 5 by Drs. Albert J.
Rettenmaier on “Pelvic Appendicitis" and Maurice A. Walker,
“Use of Barbiturates in Surgery.”

Personal. — Dr. John A. Billingsley, Kansas City, has been
appointed state ophthalmologist for the division of the blind
by the Kansas State Board of Social Welfare, succeeding
Dr. Clifford J. Mullen, who resigned September 1. Dr. Mullen
was the first appointee after the department was • organized.

Drs. Henry N. Tihen, Wichita, Noble E. Melencamp,

Dodge City, and Hugh A. Hope, Hunter, have been appointed
to the medical advisory committee of the Norton Sanatorium
for Tuberculosis. Drs. Forrest L. Loveland and Fred P.
Helm, Topeka, the latter ex officio as secretary of the state
board of health, retain their membership until 1940.

Lectures on Medical History. — A course on medical his-
tory will again open the library and museum of medical history
at the University of Kansas School of Medicine, Kansas City,
it is announced. Lecturers in the course include:

Dr. Sanford V. Larkcy, librarian, William H. Welch Medical Library,
Johns Hopkins University School of Medicine, Baltimore, October 9,
Primitive Medicine; Egyptian Medicine.

Dr. John Farquliar Fulton, Sterling professor of physiology, Yale Uni-
versity School of Medicine, New Haven, Conn., jan. 15, 1940, His-
tory of Physiology.

Dr. Henry E. Sigerist, William H. Welch professor of the history of
medicine and director of the Institute of the History of Medicine at
Johns Hopkins, March 4, 1940, The Future of Medicine in the Light
of History.

Chauncey D. Leake, Ph.D., librarian of the medical school library,
lecturer in medical history and bibliography, and professor of pharma-
cology, University of California Medical School, San Francisco,
March 11, 1940, The History of the Development of Therapeutic
Drugs; The History of Anesthesia.

LOUISIANA

Personal. — Dr. Thomas C. Paulsen has been appointed
physician to the Louisiana State University, Baton Rouge, and

medical director of its hospital. Dr. Roy W. Wright has

been appointed director of Charity Hospital, New Orleans, to
fill the vacancy left by the death of Dr. George S. Bel. Drs.
Charles B. Odom and Joseph O. Weilbaecher Jr. were named
assistant directors.

New Dean at Louisiana Medical Center. — Dr. Beryl I.
Burns, since 1932 professor and head of the department of
anatomy, Louisiana State University Medical Center, New
Orleans, has been appointed dean of the school to succeed
Dr. Joseph Rigney D’Aunoy, who resigned in August. Born
in Missouri, Dr. Burns graduated at the_ State University of
Iowa College of Medicine, Iowa City, in 1924; he took_ a
degree of doctor of philosophy at Northwestern University
Medical School, Chicago, in 1933. He has served on the
teaching staffs of the University of Michigan Medical School,
Ami Arbor, Iowa college of medicine and the University of
Utah School of Medicine, Salt Lake City, where he served
as dean from 1929 to 1932. Dr. D’Aunoy had been serving
as dean of the medical school, pathologist and director of
laboratories at Charity Hospital and professor, of pathology
and bacteriology. In his letter of resignation he intimated

that the fulfilment of all these offices would endanger his health
but asked to remain active as medical consultant to Charity
Hospital and as professor in the medical school. Immediately
after Dr. D’Aunoy’s resignation- an executive committee was
appointed comprising Drs. Urban Maes as chairman, John R.
Schenken, Edgar Hull, James T. Nix, Richard Ashman, Ph.D.,
and Dr. Burns. On Dr. Burns’s appointment as dean, it was
decided to continue the executive committee to be active in all
school affairs. Dr. Schenken was appointed to a newly created
position as assistant to the dean.

MARYLAND

Personal. — Dr. Daniel H. Kress and his wife. Dr. Lauretta
E. Kress, recently marked their retirement from active practice
with a farewell gathering on the lawn of Washington Sani-
tarium, Takoma Park, where they have been on the staff for
thirty-two years. They will live in Orlando., Fla.

Camp for Diabetic Children. — The third annual camp for
diabetic children was held at the Christ Child Farm for Con-
valescent Children, Rockville, during August. Diabetic chil-
dren of limited means, 6 to 12 years of age, were eligible.
The camp was under the supervision of Drs. Eugene Clarence
Rice Jr., Kemp Hammond Mish, Samuel Benjamin and Ben-
jamin Manchester, Washington, D. C.

Anonymous Donor Aids Venereal Disease Control.—
A model program on venereal disease control was formally
launched in Centerville recently, with Dr. Thomas Parran,
surgeon general, U. S. Public Health Service, officiating.
According to The Health Officer, federal and state funds for
the support of this program will be supplemented by an anon-
ymous donor’s contribution of §10,000 a year for the next
three years.

Semiannual Meeting of Medical and Chirurgical
Faculty. — The. semiannual meeting of the Medical and Chi-
rurgical Faculty of the State of Maryland was held at the
Vindobona Hotel, Braddock Heights, Frederick County, Sep-
tember 28. Dr. Victor F. Cullen, acting president of the
faculty, delivered the address of welcome. The speakers
included :

Dr. Boyd R. Sayers, Washington, D. C., The Health of Workers.

Dr. Harry II. Kerr, Washington, D. C., A Solution for Our Medical
Economic Problem.

Dr. Horace L. Ilodes, Baltimore, Treatment of Pneumonia with Sulfa-
pyridine.

Dr. Robert II. Riley, Baltimore, The State Pneumonia Program.

Dr. Ridgely W. Baer, Frederick, president of the Frederick
County Medical Society, also spoke.

MICHIGAN

Personal. — Dr. August C. Orr, who has been director of
the child hygiene division of the North Dakota state depart-
ment of health, has been appointed director of the sixth
district of the Michigan State Department of Health with

headquarters in Newberry. Dr. Clark D. Brooks, Detroit,

has been appointed a member of the Detroit Board of Educa-
tion to serve the unexpired term of the late Dr. Angus McLean.

Society News. — The nineteenth annual Michigan Public
Health Conference will be held at the Pantlind Hotel, Grand

Rapids, November 8-10. Dr. Fred J. Hodges, Ann Arbor,

addressed the Genesee County Medical Society, Flint, Septem-
ber 27 on “Neoplasms of the Stomach.” Dr. Charles F.

Geschickter, Baltimore, discussed “Conditions of the Breast”
before the Calhoun County Medical Society, Battle Creek,
September 5.

MINNESOTA

Personal. — Dr. Russell H. Frost, Wabasha, has resigned
as superintendent and medical director of Buena Vista Sana-
torium to accept a similar position at the G. B. Cooley Sana-
torium, Monroe, La. Dr. Russell R. Hendrickson, St. Cloud,
who was superintendent of Fair Oaks Lodge Sanatorium,
Wadena, for several years, has succeeded Dr. Frost at Buena
Vista.— — Dr. Alloys F. Branton, Willmar, has been appointed
executive secretary of the Minnesota Hospital Association.

Field Clinics for Crippled Children.— Field clinics were
held in Worthington September 9, the first of a series con-
ducted throughout the state by the bureau of services for
crippled children of the state social security board. Cooper-
ating with the bureau are the Minnesota Public Health Asso-
ciation, the division of rehabilitation of the state department
of education and Gillette State Hospital. Other clinics were
held in Hibbing September 16, Marshall September 23, Winona
September 30 and Bemidji October 7. They will be held also
at Fergus Falls October 28 and Mankato November 18. Mem-

1422

MEDICAL NEWS

bers of the Minnesota-Dakota Orthopedic Club are serving
as clinicians. A letter from the attending physician of the
patient is all that is required for entrance to the clinic, which
is open to all physically handicapped children under 21 years
of age whose parents cannot provide the needed care.

MISSOURI

Society News— At a meeting of the St. Joseph Clinical
Society in St. Joseph. September 14, Drs. Earl M. Shores,
Jacob Kulowski and Leon Paul Forgrave presented a sym-
posium on arthritis and Drs. Horace W. Carle, Judson M.
Hughes and Frederick Gregg Thompson one on the acute
abdomen. Dr. Winton T. Stacy discussed "Toxemias of Preg-
nancy.” In the evening, Dr. Morris Fishbein, Chicago, Editor
of The Journal, spoke on “American Medicine and the
National Government.” This was a joint meeting and dinner
with the Buchanan County Medical Society.

NEW JERSEY

Society News. — Dr. John A. Kolmer, Philadelphia,
addressed the Gloucester County Medical Society, Woodbury,
in September on "Advances in the Treatment of Bacterial Dis-
eases, with Special Reference to Sulfanilamide.” Dr. Wil-

liam Wolf, New York, addressed the Bergen County Medical
Society at Englewood Hospital September 12 on practical
endocrinology.

State Society to Investigate Deaths of Motorists— The
committee on traffic accidents of the Medical Society of New
Jersey has asked county societies to investigate sudden deaths
and illnesses of persons driving automobiles. The committee
hopes by this means to determine whicli types of persons are
potential hazards to themselves and others while driving a car.
It is believed that data will be obtained that will be useful
to the state motor vehicle department. A list of suggested
questions to be answered in connection with each case was
prepared by the committee. Among them were the following:
If the case did not involve the death of the driver, what was
the diagnosis of the illness? Would, in your opinion, a physi-
cal examination at the time the license was issued have revealed
the diagnosis? Would the physical examination have revealed
sufficient evidence to warrant a refusal of license on the basis
that the driver might constitute a hazard to himself or to
others? Should this driver have been denied a license on the
basis of a known physical defect?

NEW YORK

Poliomyelitis in Buffalo. — Eight new cases of poliomye-
litis reported in Buffalo September 28 brought the total num-
ber of cases in the current outbreak there to 273, with eight
deaths. Opening of schools, scheduled for September 6, was
postponed on the advice of the board of health. Schools in
the adjacent towns of Batavia, Oakfield, Alden, Alexander and
Pavilion have been closed after operating from two to three
weeks. About forty cases have occurred in Batavia.

District Meeting. — The Third District Branch of the
Medical Society of the State of New York held its annua!
meeting September 22-23 in Liberty. The speakers were:

Dr. George G. Ornstein, New York, Diagnosis of Carcinoma of the

Lung. .

Dr. Louis R. Davidson, New York, Pneumonectomy in Man.

Dr. Jesse G. M. Bullowa, New York, Specific Therapy of the Pneumo-
cocci c Pneumonias.

Dr. Arthur H. Biakemore, New York, Wiring and Electrothermic
Coagulation of Aneurysms. , . . , .. ~ ,

Dr. Howard K. Thompson, Boston, Chronic Arthritis from the Stand-
point of the Practicing Physician. .

Drs Charles SI. Carpenter and Stafford L. Warren, Rochester, N. Y.,
Biologic and Therapeutic Effects of Artificially Induced Fever.

Dr. Clay Ray Murray, New York, Problem Fractures About the Elbow
Joint.

Dr. Terry M. Townsend, New York, president of the state
society, gave an address at an informal dinner.

New York City

Society News— At the first stated meeting of the New
York Academy of Medicine for this season October S the
subiect of discussion was “Treatment of Pyogenic Infections
with Special Reference to Chemotherapy.” Dr. Emanuel Lib-
man introduced the discussion; Drs. Dallas B. Phemister Chi-
cago and Edmund P. Fowler Jr., spoke on "Osteomyelitis
and "Otitis Media and Its Extensions,’ respectively.

Friday Afternoon Academy Lectures. — The fourteenth
series of Friday afternoon lectures at the New York Academy
of .Medicine will begin November 10 with an address by
Dr. John Russell Twiss on “.Medical Management of Disorders

Jous. A. M. a;
Oct. ?, IMS

of the Biliary Tract.” The series for the remainder of ibis
year will be as follows:

Dr. Hurry Gold. Treatment of Cprdiac Arrhythmias with Special Con-
sideration of Paroxysmal Tachycardia.

ttichard A. Kern, Philadelphia, The Treatment of Visceral Allergies.
i‘, , , Whipple, Surgical Indications in Disorders of the Gall-

bladder.

Dr. Alvan L. Barach, Recent Advances in Helium and Oxygen Therapy:
Principles and Methods.

Diseases Under Investigation at Rockefeller Institute.
— T be Hospital of the Rockefeller Institute for Medical
Research announces the diseases now under investigation and
invites physicians Jo refer cases suitable for study. These
diseases are nephritis, heart disease, rheumatic fever, measles
and acute, respiratory diseases. Young children with nephrosis
are especially desired and patients with nephritis in the initial
acute stages will be accepted if space is available. Older
patients with advanced heart disease, any eariy acute form of
rheumatic fever, measles in the preemptive stage, acute lobar
pneumonia and bronchopneumonia in adults, both preferably in
early stages, are also desirable. No charges are made for
treatment, room, board or other services. Physicians should
communicate with the resident physician before sending patients.

NORTH- CAROLINA

New Dean at Nursing School. — Miss Margaret I. Pinker-
ton, superintendent of nurses at Barnes Hospital, St. Louis,
has been appointed dean of the school of nursing at Duke Uni-
versity, Durham. Miss Pinkerton took the degree of bachelor
of science in nursing from Teachers College, Columbia Uni-
versity, New York, in 1933 and held administrative positions
at Stuart Circle Hospital, Richmond, Ya., University of Vir-
ginia, Charlottesville, and Washington University, St. Louis,
before going to Barnes Hospital.

Society News. — Dr. Franklin Webb Griffith, Asheville,
addressed the Buncombe County Medical Society, Asheville,
September 18 on "Urgent Surgery on Infants.”— — Dr. Joseph
Lindsay Cook, Winston-Salem, addressed the Guilford County
Medical Society, High Point, recently on “Advances in the

Treatment of Syphilis.” Speakers before the meeting of the

Catawba Valley Medical Society, Morganton, September 1-
were Drs. Walter Eugene Daniel, Charlotte, on “A Comparison
of Sulfanilamide, Sulfapyridine and Sulfanilyl-Sulfanilamtde ,
Joseph Samuel Holbrook, Statesville, “Recent Advances in the
Diagnosis and Management of Cardiovascular Diseases, ana
Kenneth Lee Cloninger, Conover, who reported a case ot
myasthenia gravis.

OREGON

Society News— Dr. Samuel G. Henricke, Portland, was
elected president of the North Pacific Pediatric Society a
meeting in Spokane August 26; Dr. Morris Briagen i
Portland, was made vice president and Dr. Jerald b. f> a
strand, Salem, secretary.

State Medical Election— Dr. Karl H. Martzloff, Po-
land, was chosen president-elect of the Oregon State tie
Society at the annual meeting in Gearhart September 0-?

Dr. Charles E. Hunt, Eugene, was installed as president,
presidents elected were Drs. George E. Henton, For >
Frank L. Ralston, La Grande, and Frank K. Power, Sa ■
Dr. Morris L. Bridgeman, Portland, was reelected secre )
and Dr. James E. Buckley, Portland, was elected treasurer.

PENNSYLVANIA

Clinic Day Honors Hungarian Surgeon— The Guthrie
llinic and the Robert Packer Hospital, Sayre, held a gra
linic August 9 in honor of Dr. Laj os Adam, profess
urgery, University of Budapest. The speakers were.

Professor Adam, Experiences with Local Anesthesia k* T n chfding

Dr. William D. Stroud, Philadelphia, Coronary Disease inc ^
Angina Pectoris and Its Differential Diagnosis .froui ■

Disease; the Indications for Digitalis and Its Admimst™ •

Dr. John F. Erdmann, New York, Surgery of the Gallbladder.

Dr. Walter E. Dandy, Baltimore, Injuries of the “fTLeumonia will)

Dr. Jesse G. M. Bullowa, New York, Treatment of Pneumonia
Sulfapyridine. . ,

Society News— Physicians from the University 0 m
urgh School of Medicine, Pittsburgh, Pitted a P™S< e{l _
efore the Venango County Medical Society, Fran {•J’ 1
imber IS. They were Drs. George, J Wright on M ^
itestinal Manifestations of Neurologic Diseases , * Com .
lershenson, “Diagnosis and Medical Treatment oi - IrK iicn-
loner Gastrointestinal Diseases ,; John P. Gnff ’„- scase5> ”
ons for Surgical Intervention in Ga ( str0 '?‘ es ^”^ral Practi-
nd Curtis C. Mechlmg. "Proctology for the General r

oner.” Dr. Arthur C. Morgan Ph./ade phia, addressee ^

avette Countv Medical Society, Connellsville, September

Volume 113
Number 15

MEDICAL NEWS

1423

medical education. Dr. Henry Joseph Tuinen, Philadelphia,

addressed the Cambria County Medical Society, Johnstown,

September 14 on "Management of an Irritable Colon.”

Dr. Thomas R. Gagion, Pittston, addressed the Northampton
Countv Medical Society, Easton, September IS on “The Eye
Findings in General Disease.” Dr. Lloyd E. Wurster, Wil-

liamsport, addressed the Lycoming County Medical Society,
Williamsport, September 8 on “Opportunities for Mutual Ben-
efit and Cooperation Between Roentgenologist and Practitioner,”
and Dr. Lee M. Goodman, Jersey Shore, reported a case of

typhoid. Dr. Calvin M. Smyth Jr., Philadelphia, addressed

the Harrisburg Academy of Medicine September 19 on surgi-
cal diagnosis.

TENNESSEE

Society News. — Drs. Robert H. Miller, Memphis, and
Robert S. Cowles, Greenevillc, addressed the Greene County
Medical Society, Greenevillc, August 1 on “Some Points on
the Mechanics of the Body, Especially the Lower Extremity”

and “Tularemia" respectively'. At a meeting of the Hardin,

Lawrence, Lewis, Perry' and Wayne Counties Medical Society
at Natural Bridge recently the speakers were Drs. John How-
ard King, Nashville, on “The Commoner Skin Diseases”;
John H. Tilley, Lawrenceburg, “Traumatic Injury of the Liver
with Report of a Case," and David W. Hailey, Nashville,
“Undulant Fever.” Dr. Arthur R. Kempf, Springfield, dis-

cussed “Urogenital Diseases” before the Robertson County
Medical Society' in Cedar Hill recently. Dr. Bailey B. Sory
entertained the members with a barbecue.— Dr. Guy Sydney
McClellan, Nashville, addressed the Nashville Academy of
Medicine and Davidson County Medical Society September S
on leukorrhea, and Dr. Clarence S. Thomas, September 12,
bronchiectasis.

TEXAS

Personal. — Dr. Albert M. Dashicll, Bryan, recently director
of the fourth public health district, has been appointed field

director of maternal and child health. Dr. Clarence Burke

Brewster, Fort Worth, has been made city health officer to
succeed the late Dr. Arthur H. Flickwir. Dr. Isaac P. Bar-
rett succeeded Dr. Brewster as health director of the public
schools in Fort Worth.

Society News.— Dr. Frank C. Hodges, Abilene, addressed
the Baylor-Knox-Haskell Counties Medical Society August 15

in Munday on "Fractures of the Hip.” Drs. R. R. Curtis

and Joseph H. Greenwood, Temple, addressed the Bell County
Medical Society recently in Belton on “X-Ray Diagnosis of
Diseases Affecting the Chest” and “Vitamin K” respectively.

Dr. Henrie E. Mast, Lubbock, discussed cystoscopy at a

meeting of the Lubbock- Crosby Counties Medical Society in

Lubbock August 1. Speakers before the Dallas County

Medical Society', Dallas, September 14, were Drs. Charles B.
Shuey on “Allergy”; Charles H. Warren, “Amebic Abscess
of the Liver," and Paul M. Wolff, “Surgical and Nonsurgical
Treatment of Women’s Diseases.”

VIRGINIA

New Health Officers.— Dr. Philip R. Cronlund, Washing-
ton, D. C., has been made health officer of Lee County to suc-
ceed Dr. James M. Suter, Jonesville, who will attend Johns
Hopkins University for the coming year. Dr. William M. Moir,
Indianapolis, replaces Dr. Earle C. Gates in Washington County
and Bristol ; Dr. Gates will also spend a year at Johns Hop-
kins. Dr. Thomas S. Englar, Baltimore, appointed in Albemarle
County and Charlottesville, succeeds Dr. Robert D. Hollowed,
who has gone to Shelby County, Tenn., and Dr. Marvin E.
McRae, Richmond, succeeds Dr. Eugene B. Shepherd, Chatham,
resigned, in Pittsylvania County.

WASHINGTON

Personal. — Dr. Floyd W. Baugh, Burlington, has been
appointed health officer of Skagit County. Dr. Adolph J.
Osterman, Mount Vernon, has served temporarily since the

death of Dr. Benjamin F. Brooks. Dr. William E. Steele,

Longview, has been appointed chief medical adviser to the state
department of labor and industries, a position he held several
years ago.

Society News. — Dr. Paul G. Flothow, Seattle, addressed
the ^Pierce County Medical Society, Tacoma, September 12

on “Affections of the Sympathetic Nervous System.” Drs. .

Robert D. Forbes and Cassius H. Hofrichter addressed. the
King County-. Medical Society, Seattle, October 2, on "Diges-
tion After Gastric Resection” and “The Liver and Bile Pas-
sages from a Medical Standpoint” respectively. Dr. Walter

L. Voegtlin, Seattle, addressed the Spokane County Medical
Society, Spokane, September 14 on "Treatment of Alcoholism
by Establishing a Conditioned Reflex.” Dr. Morris Fisbbein,
Chicago, Editor of The Journal, addressed a special meeting
of the society September 25.

WISCONSIN

Society News. — Drs. William H. Oatway Jr. and Reuben
H. Stiehm addressed the University of Wisconsin Medical
Society, Madison, September 26 on "Mechanical Aids to Col-
lapse Therapy in Pulmonary Tuberculosis” and “Subclinical
Tuberculosis” respectively. Dr. Carl Erik Johan Hedvall,
director of the tuberculosis clinic at the University of Lund,
Sweden, was to have been the speaker but was compelled to
leave for Sweden before the meeting.

GENERAL

Biological Abstracts Widens Scope. — Announcement is
made that Biological Abstracts is undertaking a wider service
in abstracting current research literature in bioclimatology and
biometeorology'. A new section “Bioclimatology-Biometeorology”
will appear within the section “Ecology” under the editorship
of Mr. Robert G. Stone, of the Blue Hill Observatory of
Harvard University.

Allotment of Government Radium to Hospitals. — The
first shipments of government-owned radium from the National
Cancer Institute to hospitals have been made, the U. S. Public
Health Service announced September 25. The entire supply
of radium has now been allotted and no more applications can
be considered until more radium is acquired. Eight Gm. is
being lent and the remaining supply owned by the cancer insti-
tute, 1.5 Gm., will be used for research and for treatment of
cancer patients at the Marine Hospital in Baltimore.

Bequests and Donations. — The following bequests and
donations have recently been announced:

Presbyterian Hospital, New York, approximately $8-43,000 by the will
of Susan Dnnnat Griffith.

Hospital for Joint Diseases, New York, about $33,000 by the will of
the late Fanny Baehrach.

Temple University Hospital, Philadelphia, $23,000 by the will of
Evalyn Shearer.

Women and Children’s Hospital, Chicago, $10,000 by the will of Mrs.
Emma L. Dickinson.

Jewish Hospital, $5,000; Lucian Moss Home for Incurables of the.
Jewish Hospital, $7,500; University Hospital, $1,000, all in Phila-
delphia; Eagleville Sanatorium for Consumptives, Eagteville, Pa., $5,000,
and National Jewish Hospital, Denver, $1,000 by the will of bliss Rosa
Cohen.

Two Impostors. — A Chicago physician has reported another
case of the impostor who takes orders for surgical supplies.
The man reported claimed to be a representative of Hayes
and Company, Indianapolis, and took a deposit of $2 on an
order for surgical supplies. A letter addressed to the “Hayes”
firm several weeks later was returned marked “undeliverable."

From Michigan comes a report of a man who called on

a physician to ask for a loan because his car had broken down.-
The would-be borrower claimed to be ‘‘Dr. Riley” of Flint and
declared that he was a classmate of his victim, who lent him
$10. Becoming suspicious after the “classmate” left, the physi-
cian, who did not remember the man, looked him up in the
medical directory and did not find his name. He immediately
called his bank to stop payment on the check, but the check
had already been cashed. Later it was found that other physi-
cians had been victimized the same way.

Mead Johnson Award for Vitamin Research.- — The
American Institute of Nutrition announces that nominations
will be received for the 1940 award of $1,000 established by
Mead Johnson & Co. to promote research on the B complex
vitamins. The recipient will be chosen by a committee of the
institute and the formal presentation will be made at the annual
meeting in New Orleans March 13, 1940. The award will be
given to the laboratory (nonclinical) or clinical research worker
in the United States or . Canada who in the opinion of the
judges has published during the previous calendar year, Jan-
uary 1 to December 31, the most meritorious scientific report
dealing with the field of these vitamins. If in the judgment
of the committee circumstances and justice dictate it, the prize
may be divided between two or more parties. It may also be
recommended that the award be made to a worker for valuable
contributions over an extended period but not necessarily repre-
sentative of a given year. Nominations for work published
in 1939 must, be in the hands of the secretary by Jan. 5, .1940.
The nomination should be accompanied by such data relative
to the. nominee and his work as will facilitate the task of the
committee in its consideration. Leonard A. Maynard, Ph.D.,
Laboratory of Animal Nutrition, Cornell. University', Ithaca,-
N. Y., is secretary' of the institute. . .

1424

FOREIGN LETTERS

Joes. A. M. A
Oci. J, 1935

Nine Leading Causes of Death. — The Bureau of the
Census has made public a study of the 1,450,427 deaths reported
in 1937 showing that nine groups of diseases caused 72 per
cent of all the deaths. The causes are: diseases of the heart
23.9 per cent ; influenza and pneumonia 10.2 ; cancer and other
malignant tumors 10; nephritis 7.1; cerebral hemorrhage and
softening 6.9; tuberculosis (all forms) 4.8; congenital malfor-
mations and diseases of early infancy 4.4; motor vehicle acci-
dents 2.7, and diabetes mellitus 2.1. The report also classifies
the deaths by age groups and presents the leading causes of
death in each group. Congenital malformations and diseases
of early infancy accounted for 51.4 per cent of deaths under
1 year. In early childhood (1 to 4 years) influenza and pneu-
monia led with 26.9 per ■ cent. Influenza and pneumonia also
caused most deaths in youth (5 to 19 years), 12.6 per cent,
with motor vehicle accidents second, 10,9 per cent. From 20
years onward heart disease leads all other causes, with 18.7
per cent in the adult years (20 to 60) and 33.9 in the group
60 years and older. In the last two groups cancer is second
with 11 and 12 per cent, respectively, of all deaths. Tubercu-
losis is a major cause of death in every age period except
infancy; influenza and pneumonia appear at all ages. Drown-
ing is an important hazard in the youth group atone and motor
vehicle accidents loom largest at this age. In contrast to the
1,450,427 deaths, there were 2,203,337 births in 1937.

FOREIGN

Personal. — Drs. Alfred J. Clark, professor of materia
medica, University of Edinburgh. Scotland, and Thomas R.
Elliott, emeritus professor of medicine, University of London,
have been appointed members of the Medical Research Council
to succeed Prof. Henry S. Raper and John A. Ryle, who retire

September 30, the Lancet reports. Mr. William C. Wilson,

director of the surgical research laboratory in the University
of Edinburgh and of the surgical research unit in the Edin-
burgh Royal Infirmary, has been appointed to the regius chair
of surgery at the University of Aberdeen, succeeding Dr. James
R. Learmonth.

Deaths in Other Countries

Sir Frederick Spencer Lister, director of the South Afri-
can Institute for Medical Research, Johannesburg, died Sep-
tember 6, aged 63. Dr. George Redmayne Murray,

emeritus professor of medicine, Victoria University, Manches-
ter, England, died September 23 at Moberly, Cheshire, England.

CORRECTION

Head of Department of Pathology. — In the Educational
Number of The Journal August 26, page 852, Dr. C, C.
McClure, radiologist, Vanderbilt University Hospital, Nash-
ville, Term., was erroneously listed as head of the department
of pathology. Dr. E. W. Goodpasture is chief of that service.

Government Services

New Army Medical Officers
The following officers of the Medical Reserve Corps, U. S.
Army, have been commissioned as first lieutenants in the
Medical Corps:

Robert S. Anderson, Fort Myer, Va.
Austin \V. Bennett, Templeton, Calif,
George S. Boyer, Fort Riley, Kan.
James W. Brown, Whitefish, Mont,
Leo J. Butler, San Francisco.
Roosevelt CafarelH, Amherst, Va.
Richard B, H. Dear, Fort Bragg,
N. C.

William N. Donovan, Fort Moultrie,
S. C.

Carl N. Ekman, St. Paul.

Wolcott L. Etienne, Washington,

D. C.

Everett C. Freer, Fort George G.

Meade, Md. 0 .

Wendell P- Harris, Hot Springs
National Park, Ark.

Wilbur W. Hiehle, Ancon, C. Z.
Kenneth E. Hudson, Yale, Okla,
Rj* -■* — !,"f" Orleans.

V. K Vi Va.

W. I.:- ' . DV * \

George G. McShatko, Portland, Ore.
Ralph L. Marx, Pawnee, Okla.

Alva E. Miller, St. Joseph, Mo.

Charles K. Morris, Binghamton,
N. Y.

Myles P. Moursund, Silver Spring,
Md.

Byron A. Nichol, Portland, Ore.

Lawrence A. Potter, La Crescenta,
Calif.

Donald E, Reiner, Santa Maria,
Calif.

Ralph E. Reiner, Santa Maria,
Calif.

Hallman E. Sanders, Hot Springs
National Park, Ark.

Alton H. Saxer, Logan, Utah.

Howard E. Sellards, Fort McClellan,
Ala.

Paul C. Sheldon, Terre Haute, Ind.

Rolland B. Sigafoos, Omaha.

John M. Talbot, Portland, Ore.

Frederick C. Weekley, Dallas, Texas.

Francis P. Wells, Washington,
D. C.

Foreign Letters

LONDON

(From Our Regular Corrcspcntdent)

Sept. 16, 1939.

The Problem of Medical Literature

In a previous letter (The Journal, August 26, p. 868) a
lengthy correspondence in the Lancet on the problem of medi-
cal literature, in which medical writers and medical librarians
took part, was described. The problem is the extent of medi-
cal literature and the difficulty a writer has in gaining access
to what has been written on a particular subject, notwithstand-
ing the Quarterly Cumulative Index Mcdicus and the Surgeon
General's Index Catalogue. One practical suggestion which
emerged was the coordination of medical libraries, which has
already been begun by four libraries in London. The corre-
spondence has been continued and the Lancet has joined in the
fray by an editorial entitled “The Mess of Medical Literature."
Earlier in the year it estimated the number of scientific peri-
odicals in the world as between 30,000 and 40,000. A large
proportion of the papers in them — some would say three fourths
— did not deserve to be published. An estimate was not given
of the number of medical periodicals or of the proportion ol
their papers which do not deserve publication. Three sug-
gestions were made by the Lancet: (1) some control over the
volume of medical literature, (2) an effort to ensure complete
indexing, (3) cooperation between abstracting journals to secure
completeness without overlapping. Of the two great American
indexes to which we are indebted, the Lancet says that the
Quarterly Cumulative Index Mcdicus does not include all exist-
ing medical periodicals or the titles of all the articles in the
indexed periodicals, and that the Index Catalogue is even less
complete, invaluable as it is for early records. Prof. Samson

Wright (physiologist) dissents and says that the Lancet seems
to argue that we must make available a copy of every med'ea
journal published and criticizes the Quarterly Cumulative In ef
Mcdicus for not noting all the papers printed. He suggest’
that there is a better case for reducing the number of journa j
taken by our libraries and for the abstracting journals wAto
extend but to limit their scope. There is no need to hoi e >'
with the journals of small countries, as their writers mo«
their weakness from the point of view of world publicity a "
publish any exciting discovery in English, French or
journals or write reviews or lecture on the subject abroa
But the problem remains what to do with the journals P u ^
lished in the half dozen principal languages. Many of t «
journals publish no original matter at all or very littk ®
slightest value. In a country like Germany, where medica
lications are almost the monopoly of one firm, where e 4W
supervision has always been notoriously inadequate an " ie ^
stress has always been placed on bulk rather than quality, w
and more journals are becoming wholly or largely value ess ^
sources of original material. A group of committees o CS P C
should be set up to report on the journals in each s P ec,a ^
If a journal should fail to reach a reasonable standar
merit, the libraries should cancel their subscription to i ^
the abstracting journals should ignore it. No investtgz c > ^
standing would then send any contributions to it. ,e ' ^
weapon could be used to control new journals. uj ' ^
need competent medical abstracting service in the Eng is
guage. It is preposterous that a library should have ^
$750 a year for an abstracting service in German,
a journal like Physiological Abstracts, which covers tic ^
field of medical science excepting purely clinical papers.
subscription is only $16, while that of the German cquu ^
which publishes the same number of abstracts, is § 5 -

Volume 113
Number 15

FOREIGN LETTERS

1425

annual subsidy of $15,000 for three years would establish
“English Medical Abstracts.” The Royal Colleges of Physi-
cians and Surgeons and the Royal Society of Medicine and
various learned societies could provide this.

Medical Service for the Civilian Population
The central and local emergency committees of the British
Medical Association will be responsible during the war for
the supply of medical personnel for the fighting forces and
for the civilian population. The allocation of practitioners for
first aid posts at home for the treatment of casualties from
air raids is now complete, and the appointments to the civilian
hospitals arc almost complete. The fir,st aid posts have been
set up with the intention of protecting casualty hospitals from
a rush of minor and ambulant cases and of providing early
treatment in districts where the hospital is some distance away.
The function of the first aid post is (1) to treat and send to
their homes those who are slightly injured and those suffering
from nervous shock; (2) to arrest hemorrhage, relieve pain
and so prepare persons who may be found to need institutional
treatment that they can be transferred to the casualty hospital
with the least possible harm. A physician will be in charge
of each first aid post who has instructed the lay personnel
workers under his control.

TETANUS ANTITOXIN

The Ministry of Health Emergency Service lias recommended
that as far as possible all persons with open wounds shall
receive a prophylactic dose of tetanus antitoxin, which is being
stored at more tlian fifty centers throughout England and
Wales so as to be quickly available for use both at the first
aid posts and at hospitals. While some authorities have advo-
cated a prophylactic dose thrice that used with marked success
in the great war, it is considered that a smaller one may be
adequate. The dose recommended is therefore 2 cc. of the
liquid serum provided, which at present represents 2,600 inter-
national units. This should be administered at the first medi-
cal unit at which the injured person is received. To avoid
anaphylactic reactions, a second dose should not be given. The
prophylactic antitoxin is in bottles containing fifteen or thirty
doses. For treatment antitoxin is supplied in single sealed
ampules containing not less than 20,000 (actually 24,000) inter-
national units in a volume not exceeding 8 cc.

GAS GANGRENE ANTITOXIN

Supplies of gas gangrene antitoxin are being held in the big
centers throughout the country and will be available for sur-
geons whenever required. The arrangements allow for the
administration of Welch, Vibrion septique and Oedematiens
antitoxins either separately or combined. While little is known
regarding the dosage for prophylaxis and therapy, the provi-
sional proposal, which may have to be modified in the light
of experience, is to administer 1,000 units of Welch, 1,500 of
Vibrion septique and 1,000 of Oedematiens antitoxin as a
combined injection for cases in which the surgeon desires to
combine serum prophylaxis with surgical treatment. This com-
bined treatment is contained in a volume not exceeding 10 cc.
For treatment a combined injection containing not less than
7,500 units of Welch, 3,750 of Vibrion septique and 2,500 of
Oedematiens is recommended. For cases in which the causal
organism has been identified, supplies of the separate anti-
toxins are available.

TREATMENT OF SPECIAL TYPES OF INJURY'

It is proposed to provide special centers at which certain
types of disability can be collected and treated by the appro-
priate specialist staff. But in the early stages of an emergency
■t is considered likely to be impracticable to switch over sud-
denly from a central peace-time to a decentralized war-time

organization. While, therefore, it will at first be necessary
to treat any type of case at the advanced base hospitals, spe-
cial centers will be established as soon as possible. In the
case, however, of the neuroses uncomplicated by any injury,
endeavor must be made from the outset fo send those requir-
ing special treatment to special institutions.

BERLIN

(From Our Regular Correspondent)

Aug. 21, 1939.

Report of Public Health Service in Germany

The report on the public health service, prepared by the
division of public hygiene of the reich’s department of the interior,
has appeared. Austria and the Sudetenland are not included
in the report. Officially the report is designated as “interpreta-
tive and determinative of the health development of the entire
German people.”

The number of marriages has somewhat increased (from
618,971 to 644,363 ; that is, from 9.1 to 9.4 per thousand), though
the opposite was to be expected in view of the considerably
reduced birth rate during the World War. Vital statistics per-
taining to births yield the following figures : 1937, 1,275,212,
in the whole country 18.8 per thousand; 1938, 1,346,911, in the
whole country 19.7 per thousand. Families with two and three
children still appear everywhere to be on the increase. The
general mortality rate has remained almost unchanged (11.7 per
thousand). Stillbirths and infant mortality have continued to
decrease: 2.3 stillbirths per hundred born alive (2.4 per hundred
in 1937) ; 6 per hundred infant deaths during the first year
(6.4 per hundred in 1938). Individual causes of deaths of
nurslings compared with those of 1937 show a slight reduction
per thousand; syphilis, however, a slight increase of from 0.21
to 0.23. Mortality from intestinal catarrh receded from 5.72 to
5.59. Likewise, premature deaths resulting from premature
births and low vitality were fewer (30.89 as compared with 32).
While scarlet fever declined in the last three years, diphtheria
showed a further advance. The increase in measles may signify
the beginning of another rising wave. The same may apply to
whooping cough, which however shows a heightened mortality.
Epidemic meningitis has risen considerably: 1,826 cases in 1938
against 1,574 in 1937 and 1,322 in 1936. Nothing definite is
known of the causative factors. Epidemic poliomyelitis' has
greatly increased, especially in the Rhenish and south German
areas, but mortality has decreased.

The morbidity and mortality rates for tuberculosis have
further declined; notably that of tuberculosis of the respiratory
organs: tuberculous diseases in 1937 numbered 63,570; in 1938,
60,420. The morbidity rate for tuberculosis of the respiratory
organs per 10,000 inhabitants was 8.9 in 1938 against 9.4 in
1937; the mortality rate was 5.4 itl 1938 as compared with 6 in
1937. The total mortality rate for tuberculosis of all kinds
was 6.3 in 1938 compared with 6.9 in 1937. Typhoid showed
a further slight decrease in morbidity but took a relatively
larger toll of lives (in 1938, 11.5 per hundred cases; in 1937,
9.9). Paratyphoid and epidemic dysentery show a similar pic-
ture. The morbidity and mortality rates for puerperal fever
and febrile miscarriages have fallen somewhat except for puer-
peral fever in large cities (209 in 1938 against 192 in 1937).
Deaths from influenza receded from 1.3 to 0.9 per 10,000
inhabitants. The nation was spared a more serious epidemic
of influenza in 1938. However, more deaths occurred from
pneumonia due* to influenza (1937, 8; 1938, 8.3). The higher
age levels, no doubt, account considerably for this increase.
Other infectious diseases show a decreased morbidity status:
Trachoma, which in 1935-1937 was represented progressively by
611, 620' and 697 cases, fell to 533. There were eighty-four
cases of anthrax in 1938 against ninety in 1937 (six deaths
against seven in 1937) ; thirty-seven cases of psittacosis against

1426

FOREIGN LETTERS

twenty-two in 1937 (six deaths). Trichinosis appeared in twenty
cases without mortality. In the government district of Aurich
(province of Hanover) there were 345 cases of malaria.

The number of suicides in large cities remained the same:
3 per 10,000 (6,419' in 1938 against 6,217 in 1937) ; that of
fatal accidents rose from 6,851 to 7,486 (3.3 in 1937, 3.5 in 1938
per 10,000 inhabitants). This increase is attributed more to
the spread of industries than to traffic congestion ; in fact, fatal
traffic accidents were 3 per cent fewer than in 1937. On the
other hand, the number of those injured on the streets has
increased by 4 per cent, that of street accidents, in general, by
3 per cent. However, the use of automobiles also increased by
15 per cent. Traffic fatalities mounted to 7,404, injuries to
181,254. In general, health conditions are reported as favorable.
Infant mortality, as mentioned, has decreased. In individual
districts the figures fluctuate between 11.5 per cent in poor
mountain regions and 3.8 per cent. Serious cases of rickets are
almost completely absent in the report.

Excessive propaganda for the use of flour in the nutrition of
children is complained of. The education of mothers in infant
nutrition has to contend with old customs, especially in the
country, and makes progress slowly. Desire on the part of
mothers to nurse their babies usually ceases when the govern-
ment premium is no longer paid. Sometimes the necessity for
resuming work is the cause. Reports on preschool children are
generally favorable. The report on children of school age, in
spite of its generally favorable tenor, points out posture defects,
a tendency to scoliosis and flatfoot. Dental caries continues to
be an unsatisfactory problem. The report on conditions of the
nation’s youth criticizes chiefly immoderate cigaret smoking and
premature manual labor.

The most unfavorable sections in the report on adults concern
farmers’ wives. Hard manual labor and birth frequency arc
assigned as the reasons. The increased need of houses caused
by increase in marriages and better knowledge of sanitation is
far from being met despite active building. Sanitation is not
what it should be in many regions, partly because married
women are engaged in outside work, partly because of the large
size of the families. However, some of this is due to a certain
scarcity of water. The former lack of beds and bedding has now
disappeared almost everywhere. The report on venereal dis-
eases refers to the fact that syphilis is found in relatively fewer
cases but that gonorrhea has considerably increased in many
districts.

No increase of mental diseases is reported. However, a
heightened nervousness in youths and adults is recognized. “A
decidedly unpleasant picture is presented in the statistics of
the use of alcohol and nicotine.” More favorable economic
circumstances and heavy advertising are held responsible for
this. The fight against narcotics has yielded good results.

In spite of the energetic steps taken the number of abortions
is everywhere deplorably high. This has led to still more exten-
sive investigations. In 1938 a large number of physicians,
midwives and persons in ordinary walks of life were sent to
jail or the penitentiary. The number of miscarriages is also
surprisingly high and is not exclusively due to the use of
abortion, but largely, both in country and town, to the exceed-
ingly unfavorable environment in which very young primiparas
as well as hard working multiparas often have to live.

Medical Pact Between Germany and Japan

Motivated by Germany’s and Japan’s cultural pact, an agree-
ment suggested by Japan has been signed in Tokyo looking
forward to an exchange of German and Japanese physicians.
For this purpose Dr. Haedenkamp, leader of the foreign division
of Germany’s chamber of medicine, is now visiting in Japan.
This medical pact is primarily planned to deepen the intellectual
relations between the two nations. Individual features of this
pact are the exchange of physicians, reciprocal information

Jour. A. M. A
Oct. 7, 1939

regarding the application of medical methods and legislation
pertaining to social politics and public hygiene. The pact is
provisionally limited to three years. By means of this pact the
cooperation between the two countries in the field of medicine,
in operation for decades, is to be continued.

OSLO

(From a Special Correspondent)

Sept. 12, 1939.

Manganese in Factory Smoke and Pneumonia in Sarnia
Some fifteen years ago Sauda, on the west coast of Norway,
was noted for its salubrious qualities in spite of a heavy annual
rainfall. But ever since electrical smelting of certain ores,
some containing manganese, converted this rural community
to an industrial town, pneumonia has been disturbingly frequent
and characterized by a mortality of over 35 per cent. The
general mortality of Sauda is still somewhat lower than that of
Norway as a whole, thanks to the recent influx into Sauda of
many young adults. But the morbidity from pneumonia is four
times greater and the mortality eight times greater than in the
rest of Norway. It has been calculated that between the ages
of 15 and 29 the mortality from croupous pneumonia over a
period of several years in Sauda is 22 per 10,000 living souls,
whereas it is only 1 in Oslo and only 1 in the country taken
as a whole. During the past fourteen years nearly one third of
all the deaths in Sauda have been due to croupous pneumonia.

In 1928 the late Prof. Axel Holst conducted an inquiry into
this mystery. Even then the manganese-containing smoke flow
the smelting furnaces was suspected, but the results of bis
observations were in conflict with this suspicion and he gave
an open verdict as to the solution of the problem. In the autumn
of 1929 his son, Dr. P. M. Holst, instituted prophylactic injec-
tions every autumn of a vaccine prepared from pneumococci
obtained from local cases of pneumonia. But the results "’ cfe
disappointing. Between 1934 and 1937 Dr. Dagfinn Elstad
sought to determine the part, if any, played by manganese W
the persistence of a high pneumonia rate. Since the su* mer
of 1938 Dr. Riddervold has conducted tests among both patients
and healthy persons with a view to determining the types o
pneumococci prevalent in the community. Now, in 1939, ,e
evidence collected by Dr. Elstad seems to point to manganese
as the chief offender, the more so because the production 0
manganese alloys from year to year since 1930 has followe a
curve remarkably similar to those of the morbidity and morta i >
from pneumonia.

Meeting of Tuberculosis Specialists
Scandinavian tuberculosis specialists met this summer a
Trondheim, where some 125 doctors took part in a disctisst®
on the two main subjects on the agenda: (1) the relation b et j'^ a
the primary infection and destructive pulmonary tuberca >
and (2) the indications for thoracoplastic operations,
the genesis of pulmonary tuberculosis once more in the me 1
pot, it was not surprising that disagreement had to be no
with regard to the first item. Dr. Heimbeck, the presi ^
voiced the opinions of the Norwegian school, which tcac ies
pulmonary tuberculosis usually begins with large, nonap
infiltrations. The Swedish school, represented by Dr. a ttt
and Dr. Hedvall, attaches more importance to small,
initial foci as the beginnings of pulmonary tuberculosis,
other main subject, thoracoplastic operations, found tie spe
ists less widely divided. From the Vardaasen ana ° .

Norway, came a report to the effect that tubercle aci < ^ ^
been banished from the sputum and cavities bad been c “ sc ,

76 per cent of the cases in which operation was per
Attention was drawn to the superiority of the immediate
obtained with sanatorium patients over the immci is c ^
obtained with patients operated on. Did this comps*

Volume 113
Number IS

DEATHS

1427

unfavorable to tbe surgical hospital, reveal defects in the after-
treatment of patients handicapped by the atmosphere of a
surgical ward?

Opinions at this meeting on Calmette’s BCG vaccine were
remarkably favorable. A Swede, Dr. Andersson, of Gothenburg,
reported briefly on a follow-up examination of about 1,000 chil-
dren who between 1927 and 1937 had been given prophylactic
treatment with BCG. Not one of them was found to be suffer-
ing from tuberculosis. There was general agreement at the
meeting as to the considerable, if not absolute, protection con-
ferred on tuberculin-negative reactors by BCG vaccination, and
approval was expressed of the suggestion that persons found
to be tuberculin negative at and after puberty should be treated
with BCG.

The Norwegian Red Cross

These arc stirring days. Norway is not fighting in the war
but it is already involved. Its merchant fleet, so large in pro-
portion to the population of the country, must choose between
starvation at home and great risks of sinking at sea. The choice
was made unequivocally within a few days of the outbreak of
war between Great Britain and Germany when' the Norwegian
Federation of Seamen issued a statement to tbe effect that the
Norwegian seaman means to go to sea whatever happens. He
will do so the more happily for the knowledge that at home
every possible precaution is now being taken to ensure the
safety of tbe country.

Colonel Meinich, president of the Norwegian Red Cross, on
August 22 gave an address on the wireless about the Red Cross
and the Geneva convention. Speaking in connection with the
seventy-five year jubilee of the first Geneva convention, he
reminded the public of the part the Red Cross has played and
will continue to play in time of w r ar. In the autumn of 1938,
when war had seemed near, the Norwegian Red Cross issued
an appeal for 1,886 men and women to volunteer for air raid
precaution work. The response has been such that 1,097 men
and 457 women have undergone the necessary training and are
ready for service. The headquarters of the Red Cross in Oslo
has issued instructions to every chapter to have in readiness a
complete mobilization scheme, a copy of which is to be sent to
headquarters. Such a mobilization scheme comes under two
headings according as it deals with personnel or material. It
may be noted in passing that through the League of Red Cross
Societies (with its office in Paris), of which the Norwegian
Red Cross is a member and Mr. Norman H. Davis is chairman,
the Norwegian and American Red Cross societies are in touch
with each other.

Marriages

Carl Scott Lingamfelter Jr., Dumbarton, Va., to Miss
Marguerite Mae Clarke of Richmond, August 5.

Leonhard W. Levisohn, Cimarron, N. M., to Miss Edith
Blumenthal of New York in Denver, June 4.

Frederick Louis Landau Jr., Bronxville, N. Y., to Miss
Hattie Belle Simons at Riverdale, June 17.

Frederick E. Kolb, Lake Linden, Mich., to Miss Lucile
Plekenpol at Cedar Grove, Wis., July 1.

Edward E. Haddock, Richmond, Va., to Miss Katherine Lois
Scott of Red Wing, Minn., July 31.

Matthew G. Sanders, Fort Dodge, Iowa, to Miss Cecelia
Maloney of Chicago, June 24.

Russell L. Laymon, Miami, Fla., to Miss Marjorie Rich in
Washington,. D. C., July 7.

Clifford Rigby, Rexbury, Idaho, to Miss Wilma Murley of
lacoma, Wash., July 6.

Ernest F. Getto, Du Bois, Pa., to Miss Olga Gagliardi of
Jeannette, July 24.

Otis H. Law, Pontiac, 111., to Miss Sue Field of Miami,
Fla., May 14.

Deaths

Reginald Henry Jackson ® Madison, Wis.; Columbia
University College of Physicians and Surgeons, New York,
1899; past president of the Medical Society of the State of
Wisconsin; member and past president of the Western Surgical
Association; member of the Southern Surgical Association;
fellow of the American College of Surgeons ; surgical preceptor,
University of Wisconsin, 1914-1924, and clinical professor of
surgery, 1924-1928; chief of staff, Methodist Episcopal Hospital;
founder in 1912 and chief of staff of the Jackson Clinic; aged 63;
died, September 7, at his summer home at Breese Point on Lake
Mendota of coronary occlusion.

Samuel Calvin Smith ® Philadelphia; Jefferson Medical
College of Philadelphia, 1905; fellow of the American College
of Physicians ; instructor in medicine at his alma mater, 1920-
1922; served during the World War; consulting cardiologist to
the Misericordia Hospital, 1925-1930, and the Chester County
Hospital, West Chester; on the staff of the Veterans Admin-
istration Facility, Coatesville, 1931-1932 ; in 1928 was awarded
the honorary degree of doctor of science from Bucknell College;
aged 58; died, July 31, in the General Hospital, East Strouds-
burg, Pa., of injuries received in an automobile accident.

Buckner Magill Randolph, Warrenton, Va. ; Medical
College of Virginia, Richmond, 1898; professor emeritus of
clinical medicine at the George Washington University School
of Medicine, Washington, D. C., clinical professor of medicine
and director of clinics from 1922 to 1930, professor of materia
medica and therapeutics, 1909-1922; chief of medical service
of the Walter Reed General Hospital, 1917-1919; aged 67; died,
July 1, at the Veterans Administration Facility, Washington,
D. C.

Isaac Ernest Greenberg, Rockaway Beach, N. Y. ; Long
Island College Hospital, Brooklyn, 1916; member of the Medical
Society of the State of New York; served during the World
War; served at various times and in various capacities on the
staffs of the Rockaway Beach (N. Y.) Hospital, Queens General
Hospital, Jamaica, St. Joseph’s Hospital, Far Rockaway, and
the Long Beach Hospital, Long Beach; aged 47; died, July 22,
of carcinoma of the rectum.

Mary Priestley Sheriff Rupert ® Bala-Cynwyd, Pa.;
Woman’s Medical College of Pennsylvania, Philadelphia, 1904;
formerly demonstrator of medicine at her alma mater, clinical
professor of medicine and lecturer in nutrition and dietetics and
founder of the laboratory of clinical pathology; fellow of the
American College of Physicians; aged 59; died suddenly, July
21, in Portland, Maine, of cerebral hemorrhage.

Roy Groesbeck ® Salt Lake City; Western Reserve Uni-
versity School of Medicine, Cleveland, 1913; formerly member
of the city board of health ; lecturer in surgery at the University
of Utah School of Medicine, 1917-1919, and since 1918 examin-
ing physician in the department of physical education ; on the
staff of the Dr. W. H. Groves Latter Day Saints Hospital ;
aged 50; died, July 5, of coronary occlusion.

Ellis S. Montgomery, Pittsburgh; Western Pennsylvania
Medical College, Pittsburgh, 1890; member of the Medical
Society of the State of Pennsylvania; past president of the
Allegheny County Medical Society; fellow of the American
College of Surgeons ; ^formerly surgeon to the Baltimore and
Ohio Railroad; aged 79; on the staff of the Passavant Hos-
pital, where he died, July 12.

Joseph Thomas Welch, Long Branch, N. J.; Dartmouth
Medical School, Hanover, N. H., 1893; veteran of the Spanish-
American and World wars; past president of the board of
health and a member of the board of education; on the staffs
of the Royal Pines Hospital, Pinewald, N. J., and the E. C.
Hazard Hospital; aged 72; died, July 23, of carcinoma of the
breast.

Alfred Milton Mead ® Victor, N. Y. ; University of
Buffalo School of Medicine, 1880; past president of the Ontario
County Medical Society; for many years town and village
health officer; past president of the board of education; aged
82 ; for many years on the staff of the Frederick Ferris Thomp-
son Hospital, Canandaigua, where he died, July 3.

Fred Dan Vickers, Deming, N. M.; Albany (N. Y.)
Medical College, 1893; member and past president of the New
Mexico Medical Society; at one time coroner of Montgomery
County, N. ■ Y.; past .president of. the Medical - and • Surgicab
Association of the Southwest; formerly on the staff of the
Deming Ladies’ Hospital; aged 71 ; died,' July 27.

1428

DEATHS

Jour. A. M. A.
Oct. 7. 1559

Dozier Henry Gibbs ® Los Angeles ; Vanderbilt University
School of Medicine, Nashville, Tenn., 1917; member of the
American Urological Association; fellow of the American
College of Surgeons; on the staffs of the Hospital of the Good
Samaritan and the Children’s Hospital ; served during the
World War; aged 43; died, July 10.

James William Ward, San Francisco; New York Homeo-
pathic Medical College, New York, 1883; fellow of the Ameri-
can College of Surgeons; past president of the city board of
health ; formerly dean and professor of gynecology at the
Hahnemann Medical College of the Pacific; aged 78; died,
July 12, of coronary occlusion.

Austin Maurice Curtis, Washington, D. C. ; Northwestern
University Medical School, Chicago, 1891 ; professor of surgery,
Howard University College of Medicine; past president of the
National Medical Association; served in various capacities on
the staff of the Freedmen’s Hospital ; aged 71 ; died, July 14, of
cerebral hemorrhage.

William Walter Cross ® Oakland, Calif.; Washington
University School of Medicine, St. Louis, 1897; member of the
American Urological Association; on the staffs of the Alta
Bates Hospital and Berkeley General Hospital, Berkeley, and
the Peralta Hospital; aged 66; died, July 12.

Thomas Stewart Dickison, Houlton, Maine; Bellevue
Hospital Medical College, New York, 1893; member of the
Maine Medical Association; past president of the Aroostook
County Medical Society; medical director of the Aroostook
Hospital ; aged 71 ; died, July 13, of uremia.

John Francis Sagarino © Hartford, Conn. ; Columbia Uni-
versity College of Physicians and Surgeons, New York, 1913;
fellow of the American College of Surgeons; served during the
World War; on the staff of St. Francis Hospital; aged SO;
died, July 21, of cerebral hemorrhage.

Augustus Savage Lowsley, Flushing, N. Y.; Medical
College of Virginia, Richmond, 1917; surgeon emeritus on
the staff of the Flushing Hospital ; aged S3 ; died, July 17, in
the Community Hospital, Long Beach, following an operation
for a ruptured appendix.

Walter Allen Hodges ® Pasadena, Calif.; St. Louis Uni-
versity School of Medicine, 1905; served during the World
War; medical director and superintendent of the La Vina
(Calif.) Sanatorium; aged 57; died, July 22, of cerebral
hemorrhage.

Augustin Aloysius Wolfe, New York; College of Physi-
cians and Surgeons, Medical Department of Columbia College,
New York, 1894 ; member of the Medical Society of the State
of New York; aged 77; died, July 10, of chronic myocarditis.

Charles Derastus Thomas © Peoria, 111.; Rush Medical
College, Chicago, 1888; fellow of the American College of
Surgeons; on the staff of the Proctor Hospital; trustee of
Bradley College; aged 75; died, July 18, of myocarditis.

Jenner Perry Chance, Carmel, Calif.; Minneapolis College
of Physicians and Surgeons, 1900; veteran of the Spanish-
American and World wars; aged 68; died, July 3, in the
Veterans Administration Facility, West Los Angeles.

Chester Harold McCallum, Erie, Pa.; Jefferson Medical
College of Philadelphia, 1905; member of the Medical Society
of the State of Pennsylvania; aged 58; on the staff of St. Vin-
cent’s Hospital, where he died, July 15, of pneumonia.

Perry McDowell Tibbins, Beech Creek, Pa.; Jefferson
Medical- College of Philadelphia, 1905 ; member of the Medical
Society of the State of Pennsylvania; bank president; aged 58;
died, July 29, of peritonitis following appendicitis.

Daniel John Milton Miller Ventnor, N. J. ; University of
Pennsylvania Department of Medicine, Philadelphia, 1878 ,
member of the American Pediatric Society; aged 82; died,
July 6, in the Bryn Mawr (Pa.) Hospital.

Isaac Evans Nash ® Port Chester, N. Y.; University
and Bellevue Hospital Medical College, 1924; at one time chief
of the urological service, Harlem Hospital, New York; aged
40 ; died, July 27, of coronary sclerosis.

Tames Hugh Hackett ® Milwaukee; University of the
Citv of New York Medical Department, 1S94; aged 74; for
many years on the staff of St. Mary’s Hospital, where he died,
July 23, of carcinoma of the stomach.

Alpvander Thomas Leonard, San Francisco; L.R.C.P.,
Edfnburgh a r nd LR.C.S., Edinburgh, 1882; member of the
California Medical Association; fellow of the American College
of Surgeons ; aged SI ; died, July 2.

Charles Benjamin Hare, Los Angeles; Rush Medical
College, Chicago, 1908; fellow of the American College of
Surgeons; served during the World War; aged 66; died, July 2,
of peritonitis following an operation.

William Henry Palmer, Janesville, Wis. ; Chicago Medical
College, 1882; fellow of the American College of Surgeons;
aged 78 ; formerly surgeon to the Mercy Hospital, where he
died, July 29, of heart disease.

Francis M. Kujawa ® Buffalo; University of Buffalo
School of Medicine, 1917; served during the World War; aged
46 ; died, July 12, in the Buffalo General Hospital of coronary
occlusion and arteriosclerosis.

Bert Lynn Savitz ® Shanksville, Pa.; Hahnemann Medical
College and Hosptial of Philadelphia, 1931; aged 33; died,
July 12, in the Somerset (Pa.) Community Hospital of embo-
lism and pneumonia.

Eugene Ernest Simpson, Shreveport, La.; University of
Louisville (Ky.) Medical Department, 1896; aged 68; died,
July 7, at Rochester, Minn., of laceration of the jugular vein,
self inflicted.

Lenore Leeds Doughty, Cincinnati; Miami Medical Col-
lege, Cincinnati, 1906; aged 56; died, July 5, in the General
Hospital, Saranac Lake, N. Y., of spontaneous subarachnoid
hemorrhage.

James Wesley Harper, Pittsburgh; Medico-Chirurgical
College of Philadelphia, 1910; member of the Medical Society
of the State of Pennsylvania ; aged 53 ; died, July 19, of coronary
occlusion.

Emmet Leo Reilly, Pittston, Pa.; Temple University School
of Medicine, Philadelphia, 1937 ; on the staff of the Pittston
Hospital; aged 27; was killed, July 25, in an automobile
accident.

William Staughton Snow, Middletown, Ohio; Pulte Medi-
cal College, Cincinnati, 1896; member of the Ohio Stat
Medical Association ; aged 66 ; died, July 28, of cerebral hemo -
rhage.

Ray Nelson Lewis, Apollo, Pa.; University- of Louisville
(Ky.) Medical Department, 1909; served during the «» r
War ; aged 63 ; died, July 16, of a self-inflicted bullet wound.

William Henry Whitehead, Austell, Ga.; University of
the City of New York Medical Department, 1876; aged t> >
died, July 10, of uremia and chronic nephritis.

Robert Lee Kimmins, Meridian, Texas; Missouri hie™
College, St. Louis, 1887; at one time physician to the city sclio

of Beaumont; aged 72; died in July.

Adolf Natzler ® Los Angeles ; Ludwig-Maximihans
Universitat Medizinische Fakultat, Munich, Bavaria, Genu )>
1907; aged 56; died, July 4. j

James Robert Norrel, Indianapolis; Cleveland College a
Physicians and Surgeons, 1898; aged 64; died, July >
bronchopneumonia. ,

George Hector Craig, Broadview, Sask., Canada; Maui °
Medical College. Winnipeg, 1905; aged 63; died, July >
coronary sclerosis. . . ,

George W. Smith, Peoria, 111.; College of Physicians al L
Surgeons, Keokuk, Iowa, 1887; aged 76; died, July >
pneumonia. , ■

Knute Olai E. Heimark © Duluth, Minn, (licensed i
Minnesota in 1899); aged 65; died, July 17, of b
pneumonia. . .. *

Thomas William Wilson, Moscow, Pa.; Eclectic A e 1 .

Institute, Cincinnati, 1895 ; aged 66 ; died, July 31,

'jasper S. Stone, Healdsburg, Calif.; Medical College
Ohio, Cincinnati, 1873; Civil War veteran; aged - >

James B. Clay, Dyersburg, Tenn.; Meharry Medical C^
lege, Nashville, 1900; aged 68; died, July 25, of diabetes mem
Ephraim George Hughes ® Long Beach, Calif.; Je
Medical College of Philadelphia, 1907 ; aged 59 ; die , J
Zachary Fuller, Bandera, Texas ; State University o
College of Medicine, Iowa City, 1876; aged 85; died m jm
George Roy Galloway, Avery, Okla.; University ^
College of Kansas City, Mo., 1896; aged 67; died, J 7

CORRECTION , { .

Dr. Shaw Not Dead.-Dr. George Flanagan ^ KAI>
oronto, Ont., whose death was reported m 1 1 j ’ us ly
eptember 2, page 959, is not dead. Hisdeath «as J 0nW \o.
ported by the College of Physicians and Surgeons

Volume 113
Number 15

BUREAU OF INVESTIGATION

1429

Bureau of Investigation

A "GOITER CURE” FRAUD

Post Office Debars Lyell Carver’s Swindle from
the Mails

Lyell Carver of Kansas City, Mo., a familiar figure in mail
order frauds, lias been debarred from the use of the mails by
the Post Office Department. Operating under various trade
styles for a good many years, Carver has put out "cures” for
epilepsy, diabetes, goiter, sexual debility and perhaps some
other things.

In The Journal, Feb. 19, 1927, appeared a discussion of
the fraud order the Post Office had issued against Lyell Carver’s
“Oritone Laboratories” and their "Oritone.” This mail order
fake was represented as a

•a r«rl)w lm t t
r |> rarrttl**

n--.tr: :

tW mmrwr IW« 1 •

rwm tmdmr 1
M. I»0I w

m <Wt_ l*r
1M iM I

"fountain of youth” which
would cure “lost manhood”
and restore sexual powers
lost through diabetes, paraly-
sis or other serious ailments.

It was claimed to be “a sen-
sational discovery” made by
"the greatest living authority
... on Gland Therapy.”

The Journal’s exposure
brought out that Carver ob-
tained “sucker lists” from
the “Melton Laboratories,”
another mail order outfit that
the Post Office had declared
fraudulent. The article
showed, further, that Carver
was then also conducting
another piece of mail order
fakery, the “Oriental Labora-
tories,” which put out the
“Thyogland Treatment,” an
alleged cure for goiter.

Thus, when Carver's Oritone
business supposedly was
thwarted by the fraud order,
he still had his Thyogland
fakery to fall back on, and,
besides, the literature of
“Lyell H. Carver & Co.”
soon was playing up “our
new Diabetone remedy for
Diabetes.” Apparently it was
the same thing that this con-
cern also advertised as
“Oriental Diabetone.” Fur-
ther, his Oriental Labora-
tories had once advertised
“Stedatone” for “fits, epi-
lepsy, catalepsy, and kindred
disorders, no matter how
bad.”

The fact is that Carver
seemed determined to evade

the intent of the Post Office fraud order of 1927 against his
Oritone,” for around 1930 he was advertising “Neurotone
Tablets for Men,” to be used “for glandular neurocoma” and, in
his circulars, giving exactly the saute formula for Neurotone
as he had given the government for his “Oritone for Men.”
In the same connection he put out “Neurotone Capsules for
Women,” said to contain various glandular substances. In
addition, there were glandular tables “For Prostatitis (Men
Only)’’ and others “For Kidneys and Bladder (Either Sex).”

- Again the Post Office Department has found it expedient
to issue a fraud order, this time against the name of Lyell
H, Carver himself. Under date of June 27, 1938, that depart-
ment ordered Carver to show cause on Aug. 1, 1938, why a

“Goitre Agony Stopped
In One Day”

New, Easy Method Gives Amazing Results in Thou-
sands of Cases— Requires Only a Few Minutes
a Day in the Privacy of Home

Treatment Sent Free To Prove This

Are you «uf/*ring from ■ choking, itrang ling, health -deitroylng ColtreT Are you being humiliate
by an unilrhtlr growth which rnara your appearance end makes life • nightmare of mmriest feint Don't
be discouraged. A wonderful new scientific treatment has been perfected which reduces Goitre, often In 1
iJay — without danger, Inconvenience er pain.

When these swetion* are supplied' the Goitre tends to reduce in * per-
fectly natural way. Combined with these extracts are Ingredient* of proven ment which soften the Goitre,
reduce the swelling *nd pare the way to a tjulek retort ry.

THOUSANDS CURED

AND IT PONT TAKE MONTHS E1T11F.H

Read These Letters of Proof

CUUO IN II DATS

■ rare *U. Cane

•alU. Om ■*•“

I a mi

Mn UmU
I n *4

Mirrk Pra** •

trocmaa bat tbtoclaxd
HILTS

*im N«k».

Da. I*, in*.

A l«U> tra- Btaaa CRT
*ku*4 mr lit Da cSj^raaftly la

II, Ulfe mm* lx IfM lUO
KM, >IM We* Wiped.

siitr-dttl »— n mid.

C*Hr« IS jmmrm. lin t It*

* tap wth I ,1#

r*od at aftt-c Before

- * — — — t I CM a
■last.

fraud order should not be issued against him in the sale of
"Thyogland” for goiter. Carver appeared with his attorney,
who asked for an extension of time in which to file a brief
and this extension was granted and the brief was duly filed
and considered.

In his recommendation for a fraud order against Carver,
Hon. Calvin W. Hassell, Acting Solicitor for the Post Office
Department, pointed out that the Thyogland business was
founded in April 1922 and that, though Carver represented
Thyogland as a cure for goiter, he was not a physician, phar-
macist or chemist. Nevertheless, his literature claimed that
in the sale of Thyogland,

“Each case, is considered separately, treatment being given to meet the
individual needs as nearly as they can be determined from the information
supplied by the sufferer.

“Every user of Thyogland has the added privilege of sound and helpful
Advisory Service based upon the experience gained in giving this treat-
ment to over 30,000 cases of

goitre. The value of this service

should not be underestimated.
Report forms are supplied with
the treatment and all reports sent
in are given careful and intelli-
gent attention so that the sufferer
may have every possible aid in the
efforts to correct the ailment.

“Those who do not thoroughly
understand nervous people and
who cannot sympathize with them,
should not attempt to treat them
medically or by any other method.
WE FIND IT REQUIRES OUR
UTMOST SYMPATHY, PA-
TIENCE, TACT AND KNOWL-
EDGE TO GIVE TREATMENT
TO THIS CLASS OF PA-
TIENT. . . .

“We point with real pride to
the experience of those thousands
of patients to whom we have
given treatment during our many
years of continuous service to
goitrous people. Consider well the
indisputable evidence of these
facts and experiences. In your
own interest we appeal to your
good judgment and common sense.
You cannot afford to believe that
recovery is not possible for you
when treatment is given in such a
thoroughly comprehensive, result-
ful and satisfactory manner as
ours.’ 1

Thousands of sufferers hare successfully used thl* new scientific treatment In the prlracr of their
■ ■ Coitrr* wrra «u!ekljr reduced after everything els* failed. These remarkable results
certain gland extracts In the treatment which supply the vital tland secretions found

nit. Wi ukW Tfcr*a'**B

t» d*rm Mir i>4 IW •w.iiim

b fmlmg few* n I

Iraki* **d H Am* act W«l.«r
mm I* walk Ilka H WUr*.
la tut I l**l Wurr la avarr
war Mum tWakfaL Ba-
tor* I r,H aa W4 1 raid Wrdtr

ta* w tail atWra a k aa t Hr*-

TBANXJ Otm ADTXrnsrNG
O’Kartk*. Ok I*.

_ Aara*t a. ms.
nit klalarw kaaw twt I
rw»<— d jaw (ntWMt atrWkt.

Wrfr rakd nr tat • In
wwnta at i tha la unite I
Ini aa nark Wttar. Tkau ra-

AmPAVIT

ANkaatk uaar af aar
frtrad, weald rthH tW W

C ttaata. Arrida.1t b taa
•tad* IWt tWa* talk
uaalata m ukaa fr*w tW
artrlaal httna a W iim l u
t kta _ Cjarur. a ad iWt

IW alrw* af Orbstml Lak.

aratarHa. at — rttr,

IkHUi

LTH4# H. CAXTXX. hH.

LYELL H. CARVER, Pres.

ORIENTAL LABORATORIES. INC.
KANSAS CITY, MO.

DEAR SIR:

Send This Free Coupon

ENCLOSE TOUR SYMPTOM BLANK

Without cort or obligation on my port yon may send me yenr |1 treatment of Thyogland Formula for goitre.
It (a fully understood that this treatment la not to eoit me anything, either now or at any other time. I will use
thla treatment as directed and will report my progress to you. If It helps me, I agree to tell my friends about It
or I will tend you the names of those I know are suffering from goitre.

Street or P. 0. Address—

Some of the Carver advertising.

The Solicitor’s memoran-
dum on the case pointed out
that Carver's advertising car-
ried a large number of testi-
monials from persons claim-
ing to have been cured of
various types of goiter, some
of many years’ standing. It
also showed that each pros-
pective “patient” was sent a
questionnaire to fill out, the
answers to which were sup-
posed to reveal his* symp-
toms.

The Thyogland Treatment
consisted of four prepara-
tions, whose composition was reported by government chemists
to be as follows :

“THYOGLAND OIL
FOR GOITRE

Iodine Resub 8 % Creosote 3 J%

H%

Camphor 1 J A%

Massaging Oil Q. S. to 100%“

Guaicol

This was to be rubbed into the goiter, night and morning
“until goiter has been entirely absorbed.”

“THYOGLAND TABLETS
For Simple Goitre

Thyroid Substance U. S. P

Potassium Iodide

Z A gr.

1 Vt gr.“

The adult dose was one tablet three times daily.

1430

CORRESPONDENCE

Jom. A. M. A
Oct. 7, 1939

“THYOGLAND TABLETS
Thyrex Tablets (for Toxic Goitre)

Sodium Bicarbonate 0.05 Gni

Sodium Arsenate . ' 0 001 Gm

Sodium Phosphate ! ! . . . ! .' 0.12 Gm.'

0.10 Gm.

Calcium Oxalate (LOS Gm!”

“THYOGLAND TABLETS
Glandex Tablets (for Toxic Goitre)

Pituitary Gland (desiccated) 0,05 Gm.

Suprarenal Gland (desiccated) USP 0.05 Gm!

Pancreas (desiccated) 0.05 Gm.

Corpora Lutea (desiccated) 0.05 Gm.”

One tablet of this and one Thyrex tablet were to be taken
together before meals.

At the hearing of the Carver case the Post Office presented
scientific evidence which showed that goiter cases are divided
between toxic and nontoxic and that there are many cases of
swelling of the neck in the region of the thyroid gland which
the layman might easily mistake for goiter even though they
had no relation to it; and, further, that the information fur-
nished by those who filled out the question blank would not
enable even a physician properly to diagnose the case and
prescribe the necessary treatment in all types of goiter. In
addition, the expert testimony brought out that in certain types
of toxic thyroid the administration of Carver’s treatment would
be dangerous, in spite of the promoter’s claims to its being “a
safe remedy” ; that it might change a case of simple goiter to
one of a toxic or dangerous type, and that, where there are
changes in the tissue of the thyroid gland due to the disease
of hyperplasia extending over a long period of time, the con-
dition would not respond to any medical treatment.

The Solicitor, in commenting on Carver’s claim that his
offer to refund the price of the treatment to dissatisfied users
eliminated the possibility of fraud, pointed out that this same
contention is made by the promoters of practically all fraud-
ulent mail order schemes, and that the customer, even should
he succeed in getting his money back, has nevertheless been
defrauded in having been given false hopes ; and, further, that
in some cases the customer may not discover he has been
swindled and so may not seek a refund.

Carver, while admitting he was not qualified as a physician,
claimed he had read a number of books on goiter and had
been associated with certain physicians during the operation
of his business. He presented several affidavits from physi-
cians in which it was stated that they had used the Thyogland
Treatment in goiter cases and that it was their opinion, based
on this experience, that the thing would have some value in
goiter. Carver admitted he had written these affidavits him-
self and then got the physicians to sign them.

For these and other reasons the Solicitor recommended to the
Postmaster General that a fraud order be brought against Lyell
Carver, and it was issued on Sept. 24, 1938. It now remains
to be seen whether Carver will again bob up in the field of
mail order quackery operating under a new trade style and
exploiting a new “cure.”

In closing it may be worth mentioning that a list of com-
plaints ordered by the Federal Trade Commission from June 10,
1929, to April 15, 1930, against certain concerns and individ-
uals for making false claims for their respective wares included
the name of Lyell C. Carver.

MISBRANDED “PATENT MEDICINES”
Abstracts of Notices of Judgment Issued by the Food
and Drug Administration of the United States
Department of Agriculture

[Editorial Note.— The abstracts that follow are given in
the briefest possible form: (1) the name of the product; (2)
the name of the manufacturer, shipper or consigner; (3) the
composition; (4) the type of nostrum; (5) the reason for
the charge of misbranding, and (6) the date of issuance of the
Notice of Judgment — which is considerably later than the date
of the seizure of the product and somewhat later than the con-
clusion of the case by the Food and Drug Administration.]

Happy Day Headache Powders.— Gulf Laboratories Co., Inc., Lafayette,
La. Composition: In each powder, approximately 2.4 grains of acetanilid,
3 2 grains of aspirin', 0.4 grain of caffeine, and 0.2 grain of phenolphtha-
lein, with milk sugar and citric acid. Fraudulent therapeutic claims.—
IN. J. 2S707 ; November 1938-1

National Pain Relief. — National Medicine Co., Nashville, Tenn. Coa*
position: Essentially extracts of plant drugs- including red pepper ad
ginger, a small amount of an ammonium compound, camphor, chloroform,
alcohol (4.2 per cent by volume), glycerin and water. Fraudulently
represented as a remedy for dysentery, diarrhea, fluttering of heart, short-
ness of breath, etc. — [N. J. 28988; November 1938.1

See q It. — Seeqit & Tiques, Inc., New York. Composition: Tablets each
containing about 4 2 A grains of aminopyrinc and y$ grain of caffeine-
Fraudulently represented as a harmless remedy for menstrual discomforts
and as a product endorsed by many physicians. — [N. J. 28679 ; Ncvtnihtr
1938.1

Correspondence

DISTURBANCES OF THE PENDULAR
MOVEMENT OF THE ARM
IN WALKING

To the Editor : — A short time ago Robert Wartenberg
Cerebellar Sign, The Journal, April 15, p. 1454) reporter
his observations on the decrease or cessation of the arm-
swinging movement in walking in cases of homolateral disease
of one of the cerebellar hemispheres. After considering similar
observations by Holmes, Thomas, Marburg, Dusser de Barenne
and others, Wartenberg designated this phenomenon as cere-
bellar sign” and concluded bis discussion by saying that it
would be of interest to study the swinging movement of the
arm in unilateral frontal disease.” I had occasion to observe
this phenomenon in two cases of unilateral injury of the frontal
brain :

1. A man aged 42 was wounded in the left side of the fore-
head by a shell splinter in 1916. Examination in 1932 reveal
in the middle of the left side of the forehead a scar with a
bone defect covering the middle of the first and second comolu
tions of the left lobe of the frontal brain. The patient shone
signs of disturbance of frontal equilibrium on the contralatera
side, such as past pointing with the right arm, rocking an
falling to the right and, besides, a contralateral deviation > n
going forward and a homolateral deviation in going backwar •
In this case, in which no other disturbances of the pyranu a^
motor or the sensory- system were manifested, the
movements of the contralateral arm in walking were mar c )
reduced in comparison with the other arm.

2. A man aged 44 had been similarly wounded in 1917 by
shrapnel bullet in the left side of the forehead above the ej
brow. On examination in 1932 a scar 7 cm. long and ^
wide was found on the left frontal bone going obliquely UP'
from the lateral corner of the eye and gradually narrow!
toward both ends. The bone defect corresponded to the scc0 ^
and third convolutions of the frontal brain. This patient P
sented, besides the sign of heterolateral disturbance of
equilibrium similar to that of the first patient, a habitua
ing of the head to the right shoulder and an automatic resu ^
tion of this attitude on passive change of the position o ^
bead. Along with an otherwise entirely intact motor an *j n „
sory system he manifested a complete loss of the s " lrl
movement of the contralateral arm in walking.

length
in qu e3 '

Both of these cases, which were discussed at greater
in connection with their bearing on the phenomenon ,r
tion (Halpern, L. : On the Disturbances of the Pendular i
ment of the Arm in Walking, Harefuah 7:ii [May-June ^
and on the problem of the relation of the frontal n
equilibrium (Halpem, L. : Ueber das Symptomen 1
Stirnhirnlasion unter spezieller Berucksiclitigung der to ^
des Gleichgewichts, Monatschr. j. Psychiat. it. heuro .
[Sept.] 1936), indicate (a) that disturbances of the s ' vl '^
movement of the arm do occur also in cases of im0
of the frontal brain and (6) that in cases of uni atcra

Volume 1 15
•Number J5

QUERIES AND MINOR NOTES

1431

of the frontal brain this disturbance is manifested in the swing-
ing- movement of tiie contralateral arm in walking.

A comparison of my observations with those of Wartcnberg
indicates further that the disturbance of the swinging move-
ments of the arm is not of pathognomonic significance for the
cerebellum but constitutes a symptom of disturbance in walk-
ing which is manifested homolaterally or contralaterally
according to whether the cerebellum or the frontal brain is
involved. Finally, these observations prove that frontocere-
bellar cooperation covers not only the regulation of static
equilibrium but the balancing of the body in walking and
certainly the performance of walking in general.

L. Halpern, M.D.,

P. O. B. 499, Jerusalem, Palestine.

Neurological Clinic, Mayer de Rothschild
Hadassah University Hospital.

STANDARDIZATION OF BLOOD
PRESSURE READINGS

To the Editor : — The special article on this subject in The
Journal July 22 induce^ me to emphasize paragraph 5. Equal
and not excessive pressure should be made by the bell of the
stethoscope in taking the blood pressure. Particularly in chil-
dren, and occasionally in adults in whom the blood pressure
is low, especially when the diastolic blood pressure is low, it
is necessary to place the bell of the stethoscope in such a
manner that the entire ring of pressure is equal and that the
upper ring of the bell does not press harder than the lower.
If the upper half of the ring of the pressing bell of the
Stethoscope should be pressed harder, the pulse beat will con-
tinue to be heard long after the true diastolic point has been
reached. The extra pressure of the bell of the stethoscope
acts in the same manner as if there were an increase of pres-
sure in the cuff. The pulse beat can also be heard without
the cuff by pressing the upper segment of the stethoscope bell
or diaphragm on the artery.

The interpretation of the Korotkow sounds of auscultatory
blood pressure estimation may be simply explained in the fol-
lowing manner: The radial pulse is felt because it strikes
the obstructing finger just as the vibration of a board held
in the hand can be felt when struck by a wave or by a fist.
Similarly the sound of the blow can be heard. When the
cuff is pumped up tightly to beyond the systolic blood pres-
sure, the artery beneath the cuff is completely compressed and
the pulse wave is stopped at the upper end of the cuff. No
pulse can be felt nor sound heard in tbe antecubital space
because the muscle does not transmit sound well, certainly not
at the 12 cm. distance of the cuff. When the pressure is
released sufficiently so as to permit the blood stream to carry
and transmit the sound created by the pulse wave striking the
obstruction, i. e. the partially compressed artery, one can
hear the sound (Korotkow) or feel the pulse. This trans-
mitted sound of the pulse wave striking the obstruction is
heard until there is no more obstruction. This occurs when
the pressure in the cuff is about equal to that in the artery.
There being no obstruction, the pulse wave continues uninter-
rupted and no vibrating element is in the way. The point at
which the sound disappears should be considered the diastolic
pressure.

From this simple exposition of the cause of Korotkow
sounds, one can see that excessive pressure of the upper
segment of the bell of the stethoscope can be the means of
producing sounds at the antecubital fossa, as may other obstruc-
tions either within or without the artery.

E. I. Fogel, M.D., Cincinnati.

Queries and Minor Notes

The answers here published have been prepared by competent

AUTHORITIES. TlIEY DO NOT, HOWEVER, REPRESENT TIIE OPINIONS OF
ANY OFFICIAL BODIES UNLESS SPECIFICALLY STATED IN THE REPLY.

Anonymous communications and queries on postal cards will not
be noticed. Every letter must contain the writer's name and

ADDRESS, BUT THESE WILL BE OMITTED ON REQUEST.

HYPERGLYCEMIA AND DIABETES

To the Editor: — 1. Why is it desirable, if it is desirable, to maintain a nor-
mal blood sugar level other than to prevent ketosis in the treatment of
diabetes? 2. (o) What harm can result (when ketosis is omitted) from
a persistent hyperglycemia in a diabetic subject and what is the mechanism
that brings this about? ( b ) How is the relationship between hyper-
glycemia of diabetes and the complication of diabetes proved (when
ketosis is omitted)? 3. What should be the objectives In the treatment
of diabetes in the aged and in those who are not aged?

W.D., New York.

Answer. — 1. Normal blood sugar values are obviously the
best. In diabetes a normal percentage of sugar in the blood,
as a rule, indicates a blood normal in other respects as well.
Thus far, no one has ever reported a series of 100 or more
cases of diabetes with known hyperglycemia for ten years in
which there has been freedom or even relative freedom from
serious complications of diabetes or, indeed, freedom from evi-
dence of progression in the diabetes as manifested by loss of
weight, strength and ambition. Irrespective of the different ideas
regarding dietetic treatment, there has been in the past unani-
mous agreement in the insistence on aggressive measures to
attain normal values for blood and urine.

2. (a) Persistent hyperglycemia implies persistent glycosuria,
except in the few cases in which there is a high renal threshold.
Hyperglycemia and glycosuria involve accessory annoyances
such as polydipsia and polyuria, the attendant necessity for extra
food to make up for the loss of calories in the urine and the
obvious wear and tear on the system for ingestion, assimilation
and excretion of this unutilized extra food.

Hyperglycemia is a constant stimulus to the islands of Langer-
hans of a pancreas already impaired and overburdened. It allows
no time for recuperation such as the pancreas of a healthy per-
son enjoys between meals and at night.

Such patients are less resistant to infections even though the
mechanism is not surely demonstrable by bacteriologic tests.

They acquire more complications than diabetic patients who
are controlled.

Diabetes is not static and Naunyn’s dictum still holds that
many a case originally was mild but neglected.

Statistically, tbe duration of life in cases of uncontrolled
diabetes is shorter than in cases of controlled diabetes.

If hyperglycemia is allowed, one yardstick is lost by which
to measure the status of tbe patient. There are variables enough
in the management of diabetes without the addition of high
blood sugar of uncertain degree throughout the day.

( b ) It is not proved directly, but there is no more reason for
disregarding this signal of something being wrong than to fail
to stop at a red light at a railroad crossing because one cannot
see the train around the corner. It is granted that one may not
be able to explain by laboratory methods that the person with
uncontrolled diabetes has a lowered resistance to bacteria, but
the great frequency of infections in diabetic patients with hyper-
glycemia is acknowledged. No one claims that hyperglycemia
is responsible for all the complications of diabetes. Diabetes is
a deficiency disease, and when the condition is brought under
control by a correct adjustment of diet and insulin (either
endogenous or injected) tbe occurrence of diabetic complications
becomes rare.

3. The objectives in the treatment of diabetes are tbe main-
tenance of comfort, vigor, a reasonable weight within the normal
zone or slightly below, and control of glycemia and glycosuria,
although all agree that chemical meticulousness is to be avoided
to prevent the exposure of the patient to hypoglycemic reactions.

The same rules bold for old and young relatively. Thus, if
complete control of carbohydrate utilization is sought, it’ is
obvious that the total dextrose excreted in the young will be
considerably more than that in the old because of tbe larger
diets of youth.

1432

QUERIES AND MINOR NOTES

Jour. A. M. A.
Oct. 7, 19J9

HEMIPLEGIA FROM CONTRALATERAL VASCULAR
ACCIDENT

To the Editor : — A man aged 54, short, stocky and overweight, had a tension
averaging 150 systolic and 90 diastolic prior to onset of the following:
An attack of influenza lasting one week left the patient weak for several
weeks. The blood pressure at this time rose no higher than it had
previously. From two to three weeks after the "flu," according to the
history, the patient began to complain of some difficulty in speaking, and
occasionally he broke out with crying spells. Later the patient became
highly excitable, cried freely and complained of speech difficulty and
weakness of the right arm and hand. Examination revealed a blood
pressure of 210 systolic, 100 diastolic, weakness of the hand grasp on the
right side, absence of the abdominal reflex on the right side and a sug-
gestive Babinski sign elicited by the right foot. Diagnosis at the time
was possible cerebral thrombosis affecting the left middle cerebral artery
or its branches, possible angiospasm or a frank hemorrhage of a smaller
vessel. The only significant laboratory work revealed a mild diabetic
condition, later verified by repeated chemical analyses of the blood,
urinalyses and the like. Diet, medication and rest in the course of time
helped bring about an apparent "cure," with this exception: The right
arm and especially the hand is swollen, edematous and painful to such an
extent that the patient is unable to use this member. Pain at the shoulder
is complained of. Various physical therapeutic measures at first seem to
reduce the swelling but with recurrence. I am at a loss to explain this
phenomenon unless he may have a thrombosis of the right axillary vein.
Any suggestions will be appreciated. Henry Rosncr, M.D., Brooklyn.

Answer. — The manifestations of right-sided hemiplegia with
spasticity in a diabetic patient aged 54 certainly speak for a
contralateral vascular accident in the brain. The finding of
a painful edema of the hemiplegic extremity without any
venous obstruction is not uncommon. The insufficient venous
return may be explained by diminished muscular activity and
the increased vasodilation in the hemiplegic limb. It is pos-
sible, however, that an axillary thrombosis followed the venous
stasis, but in that case a palpable cord in the axilla or marked
increase in the size of the cutaneous veins around the shoulder
and the anterior wall of the chest should be found. The injec-
tion of an opaque substance such as skiodan or diodrast into
the cubital vein followed by the taking of an x-ray film
readily demonstrates the patency or block of the axillary vein.

Elevation of the edematous limb on pillows together with
the administration of a mercurial diuretic, such as salyrgan
or mercupurin, helps to empty the arm of the excessive fluid.
The pain in such extremities is usually considered to be thala-
mic; mild sedatives hardly influence it. Repeated injections
of procaine hydrochloride into the stellate ganglion may help
to relieve both the edema and the pain.

CHAULMOOGRA OIL AND TUBERCULOSIS

To the editor:—] should like information regarding the use of chaulmoogra
oil in tuberculous infections of the bronchi, trachea, larynx, pharynx or
nose, whether by application or inhalation of spray. What strength is
used and with what frequency? What type of the oil or similar
substances or derivatives from these are used? What toxic effect are to
be avoided and how? What results are to be expected?

M.D., Pennsylvania.

Answer. — Chaulmoogra oil has been found to have approxi-
mately a hundred times the bactericidal effect found in phenol,
as far as the acid-fast bacteria are concerned. The active
principle of chaulmoogra oil is in its acids, which inhibit the
proliferation of the leprosy bacillus and the tubercle bacillus.

In treating tuberculosis the ethyl esters were at one time
administered in doses of 3 cc. by mouth. However, patients did
not tolerate this treatment well and the substance was then
administered intramuscularly. This often resulted _ m intense
pain, induration and inflammation at the site of injection. It
was next administered intravenously with an initial dose of
1 cc. once a week, and later the intervals were increased to

from two to four weeks. , , „

Various methods of local application were also employed. For
example, Bronfin and Markel treated fifty cases of tuberculous
laryngitis with local applications of chaulmoogra oil and the
ethvl esters of the oil Their observations extended over a
period of from ten to twelve months. The two forms of the
drug were used in different cases and were administered mtra-
tracheally beginning with 5, 10, 25 and 50 per cent of the drug
mixed with pure liquid petrolatum. The authors were unable
to note any difference in action of the two forms. They did no
observe an aggravation of symptoms, as had been reported b
some authors, or an improvement, as other authors had reported.
However they did notice an increase m the local ulceration m
lome cases which they believed was due to the irritating effects
if ’ Tn nn case was there observed a decrease in the
of the drug- Apparently the only possible effect that chaul-

cough or sputum. Apparently^ ^ / g P ermicidaI action on the

tubercle bacilli that have been set free and lodged on the lining

of the bronchi, trachea, larynx, pharynx or nose. This is oi
no significance as far as the actual disease in these parts is con-
cerned, however, since the preparation does not reach the depths
of the lesions.

_ Unfortunately, there is no proof available that chaulmoogn
oil has any beneficial effect in the treatment of tuberculosis in
any form. Moreover, it has been shown that chaulmoogric acid
does not penetrate tubercle. Therefore, chaulmoogra oil has
been almost entirely abandoned in the treatment of tuberculosis.

References :

Bronfin, I. D., and Markel, C. : Chaulmoogra Oil in the Treatment of
Laryngeal Tuberculosis: Observations on Its Local and Constitu-
tional Effects, Am. Rev. Tubcrc. 8:214 (Nov.) 1923.

Lissner, II. H.: Chaulmoogra Oil Esters in the Treatment of Pu!
nionary Tuberculosis: A Preliminary Report, ibid. 7:257 (June)
19 23.

Walker, E. L., and Sweeney, M. A.: J. Infect. Dis. 26:238 (March)
1920.

Wells, H. G., and Long, E. R. : The Chemistry of Tuberculosis,
Baltimore, Williams and Wilkins Company, 1932.

POTENTIAL HERNIATION

To the Editor : — In examining men for employment I have been considering
a bulging through the inguinal canal on effort as a hernia. I consider
such as an incomplete hernia and in executing a waiver just put down
"rupture." Am I wrong in mnking such a diagnosis? No one seems a
agree with me that a hernia exists. Will you settle this matter for me-
I do not wish to do an injustice to any man and want to be fair W|
both employee and employer. M.D., Connecticut.

Answer. — A bulging in the inguinal canal is fre ( l ue " t 'l
spoken of as a bubonocele. The term is confusing rather t a
helpful. Conditions of this nature are often called potent!
hernias.” All men have potential hernias. In 33 per cen
bulging high up in the inguinal canal can usually be dctccte .

Conditions of this kind are generally symptomless, ana an
a palpable mass protrudes beyond the fascial pillars tonn 5
the external opening of the inguinal canal they should no
considered as being “ruptures.” When there is a pers . isten raa |[
symptoms, operation is sometimes recommended. Barely a
cyst may be found within the inguinal canal, and
large pedunculated pad of properitoneal fat is rcsponsio
the symptoms. In industrial work, for a symptomless . b
which does not extend beyond the inguinal canal what is
times spoken of as a “prophylactic herniotomy > s no f
mended. If instructions were given to the men to K P Jj
legs together when doing heavy lifting and av0 ! d ,?' mnn M
positions, a large number of industrial hernias probaby
be avoided.

In

inguinal hernias of the direct type it is more diffi
determine when an abdominal weakness actually be ^
hernia unless there is an area of bulging, which can be
well as felt, particularly in comparison with the unattec j e fi n jte
These conditions are not usually considered as b emg a j
herniation and it is believed that such men should not e
for employment.

OBSTETRIC DEATHS

To the Editor :—' What in your opinion constitutes an e * eusoble con-
death? Of course I realize that those instances of violence o oo! ,

ditions which place the cose in the medical exominer I
be excluded from the list. M.D., N c

Answer. — In assessing the responsibilities for obs ^
death, many different factors must be consiclerc . ’ thir j

patient; second, the attendant, usually a physic ’ . r actors .

the institution or home conditions and undeterm nhvsi c > an
If, for instance, the patient neglected to report to a
or, after having reported, neglected to follow . one

relative to the proper care of herself, as m , t ] ie stand'
would say that that was an excusable death t . In

point of the physician but not from that of patient and

other words the death would be assessed to tne P- fol .

not to the physician. If, on the ec l arn psia and it

lowed the physician’s advice and died * ron \ e . jh e death
was decided that the treatment was not adequat ,
would be assigned to the physician. during confine;

If the patient died from infection acquired woU |d

ment, and improper or inadequate technic was - d a ll
be considered an inexcusable death If, on from sepsis,

proper precautions were taken and the patien . . u . ou ]d not
it would be an excusable death an . d bhe . p ^.;„ nc d to unde-
be charged with it. It would probably institution and dies
terminable causes. If a patient enters a available non

from hemorrhage, and proper equipment js not a ^ ^
prompt and adequate treatment of the hemo S j hand,
would be assigned to the institution If ' ; dkij it

all facilities were available and used and the pat.cni

Volume 113
Number IS

QUERIES AND MINOR NOTES

1433

would be considered an excusable death, especially if the patient
was admitted in a moribund condition not having been under the
care of a physician or not entering the institution in time to
afford proper opportunity for therapeutic measures.

An excusable death from the standpoint of obstetric practice
would therefore be one in which there had been proper coopera-
tion between patient, agency and physician and in spite of
intelligent and sufficient treatment being used death occurred.
It is difficult to define excusable in general terms, since each
case must be properly evaluated and considered on its merits in
connection with the environment and the circumstances involved.

TONSILLECTOMY VERSUS ELECTROCOAGULATION

To the editor : — Please tell me the modern attitude on the problem of the
surgical removal of tonsils versus the removal by electrocoagulation.

M.D., Connecticut.

Answer. — It is fair to say that the best opinion today favors
the surgical removal of tonsils. There are times when electro-
coagulation is useful, particularly in the aged and the debili-
tated and when small remnants are to be removed. The reason
electrocoagulation is not used oftener is probably that it requires
numerous sessions and that it is exceedingly difficult to tell
when one has done too much or too little. Bleeding may occur
just as it does following surgical removal, and this bleeding is
more often of an obstinate type and starts as long as two weeks
after the intervention. Lastly, there is always the possibility
of an infected piece of tonsil being buried beneath a heavy scar,
which may cause more trouble than the untreated tonsils did
originally.

MILIARIA RUBRA OR PRICKLY HEAT

To the editor: — Since living in south Texas, for the last two summers, I
have been suffering from prickly heat (miliara rubra). Remedies recom-
mended by both medical and lay friends have been of no avail. I have
tried alcohol sponging, followed by the so-called Mexican heat powder
labeled to contain camphor, zinc oxide, boric acid and starch; I have
used several other powders; I hove bathed in water with sodium bicar-
bonate; I wear the lightest possible cloth; I have taken all kinds of
laxatives. There has been no relief of the prickly heat, except for a
short time. What is known as to the pathophysiology of miliaria rubra?
I noticed a peculiar bitter taste of my perspiration when suffering from
miliaria. Is it a metabolic dislurbancc? Can you recommend any
remedies other than those mentioned, with some hope for relief? Is there
any literature on the disturbance? Texas.

Answer. — This query centers around the treatment of mili-
aria rubra (prickly heat), but a more intimate description of
the eruption would be advisable to make sure that this diag-
nosis is correct. Does it occur only in the covered parts or
are _ the exposed surfaces also affected ? Is the rash accom-
panied by hyperhidrosis (excessive sweating) ? Are there any
other factors, e. g. external irritation, which may contribute
to its chronicity? Perhaps another careful dermatologic exam-
ination may disclose some important points which have been
overlooked.

Miliaria rubra is generally conceded to be a disorder due to
occlusion of the sweat ducts, which may be due to swelling of
epithelial cells unprotected by sufficient oil. There is accom-
panying dilatation of the capillaries and sweat ducts in the
cutis, and vesicle formation may appear in the malpighian
layer — the latter phenomenon is not connected with the sweat
apparatus. Miliaria is not due to a metabolic disturbance but
it may occur secondarily, in hot weather or climate, to hyper-
hidrosis, which may be associated with one of many general
diseases, among which the metabolic must be included. If
excessive sweating is evident one should search for its cause
snd eliminate or control it, if possible, thereby removing one
important factor in the cause of miliaria rubra. The condition
may be complicated in some persons by all varieties of eczema
and_ intertrigo, and these must necessarily be cleared up. A
miliaria-like eruption is known to occur as a dermophytid
secondary to a ringworm infection, perhaps of the toe webs,
especially in highly sensitized persons. Occasionally contact
with external irritants or the ingestion of drugs may produce
a condition resembling prickly heat.

Soothing preparations are of especial value, preferably lotions
and powders. Starch, almond meal or bran water may be
applied and the area then dried and dusted with 10 per cenl
boric acid powder in equal parts of zinc oxide and starch. A
“lick calamine lotion with or without phenol may be tried.
Sodium biborate 1 : 200 may be used or may be incorporated
in the calamine lotion. From 3 to 5 per cent solution of coal
tar in calamine lotion may relieve the pruritus. An aqueous
solution of aluminum chloride starting with 10 per cent and
increasing, if necessary, to 25 per cent may control the
Perspiration.

NO SERUM FOR EPILEPSY

To the editor: — Is there a qualified physician in Missouri who treats epilepsy
with some kind of serum and supposedly gets good results? Is there any
federal hospital for epileptic patients in the country? A girl aged 15 has
epilepsy. The mother has heard that there is some one in or near Mis-
souri who has hod these good results. Is there any place outside of a
state hospital where this girl could be adequately treated without too
much expense? I shall appreciate any information that you can give
me along this line. M.D., North Dakota.

Answer. — No ethical, qualified physician would attempt to
treat epilepsy with a serum, since there is no recognized serum
treatment of this disease. All the recent medical literature on
epilepsy recommends treatment with the ketogenic diet, dehy-
dration, phenobarbital and diphenyl ethyl hydantoinate. The
treatment can be effectively carried out by any qualified family
physician.

There is no federal institution for the care of epileptic
patients. This child would be best treated by a pediatrician
or internist whom the family physician knows to be interested
in epilepsy.

SCARRING AND PAIN IN JAW

To the Editor : — A patient aged 55 had a radical operative procedure per-
formed in the left floor of the mouth for a malignant condition nine years
ago. There is no evidence of recurrence, but at short intervals of about
two weeks he has attacks of severe pain in the region v of the lower part
of the left jaw. This is made worse by swallowing. The pain is incapa-
citating and at times the patient becomes despondent. All forms of
therapy arc of little avail. The cause of the pain seems to be scar tissue,
of which there is a great deal. Any therapeutic procedures will be appre-
dated. Thomas Dechairo, M.D., Westmoreland, Kan.

Answer. — It would seem that the large amount of scar
tissue in this area might well involve some nerve branches
and, on swallowing, some traction might cause pain. One
should also exclude a recurrence of the original growth.
Spasmodic occlusion of the submaxillary duct, evidenced by
an acute swelling of the submaxillary salivary gland, should
also be eliminated.

Hot wet applications for an hour at a time twice a day and
anodynes followed by exercise in an effort to soften the scar
tissue may relieve the pain.

POISON IVY AND MILK

To the Editor : — When game farms plant poison ivy along stone walls to
furnish berries for winter food for birds, it is found that farm animals
destroy the crop by browsing in dry seasons. If people drink milk from
cows fed on poison ivy leaves, would there be any tendency toward
developing immunity after drinking such milk? Would there be less
injury to the kidneys from injection of extracts as a defensive measure?

Robert 'T. Morris, M.D., Stamford, Conn.

Answer.— -It is theoretically possible that the active principle
of Rhus toxicodendron is secreted in milk. This, however, has
not been demonstrated. It would be much simpler if one were
to try oral immunization to give the tincture of Rhus toxico-
dendron by mouth, so that a known dose is given. This method
of immunization is seldom used. Its value is questionable.

Regarding the inquiry dealing with kidney injury, it is assumed
that the inquirer has in mind the possibility of such damage
through the injection of therapeutic and prophylactic doses of
the extract of Rhus toxicodendron. No such harm occurs from
ordinary doses.

PAIN AND ANALGESICS

To the Editor : — A patient for the past five years has been taking daily
about twenty tablets of empirin compound. I have tried to take them
away from him but after a day he is wild with the pain in his head and
if it is made impossible for him to get any he is semidelirious. I can
find no real help in the literature I have at hand and would like advice
05 ,0 ,he best me,hl>d *° use in * his cose - M.D., Massachusetts.

Answer. — A patient suffering from such pain needs, of
course, a careful diagnostic examination to determine the cause
of the pain to secure its relief by remedying the cause. If it
cannot be done and the pain is located in a definite peripheral
nerve territory, its relief by injection of a local anesthetic
should be attempted; if this is unsuccessful, injection of alco-
hol or, what is more permanent, nerve resection should be
employed. Until the pain has been relieved by either of these
means, the patient is entitled to some analgesic, and it is desira-
ble to change the analgesic formula from time to time so as to
minimize the danger of unfavorable results on the system from
prolonged use of any one drug as well as to lessen the neces-

1434

EXAMINATION AND . LICENSURE

J OUR. A. M. A.
Oct. 7, 1935

sity of increasing the dose because of habituation. Empirin
compound is the non-Council accepted proprietary name of
Bur roughs- W ellcome & Co. for a mixture of acctyisalicylic acid
3^4 grains (0.22 Gm.), phenacetin (acetoplienetidin) 2^4 grains
(0.16 Gm.), and caffeine one-half grain (0.03 Gm.).

acceptable.

W. H. Kellogg, M.D., Berkeley, Calif.

i answer to ut. ^ — ,

,t that at no time has it been implied that a pat.ent b.tten by
rabid animal should not receive Pasteur treatment. In such
an^vent the immediate and careful cleansing of the wound would
he followed promptly by administration of antirabies vaccine.
The whole subject needs further experimental investigation.

-—Ed. -

Medical Examinations and Licensure

DOG BITES AND RABIES

To the Editor:— My attention has been directed to the reply that was given
to Dr. Collins of Seattle concerning the treatment of bites by rabid dogs,
which appeared on page 1283 of The Journal. As one who has hod con-
siderable experience with rabies, both human and animal, clinical and
experimental, I feel that I must disagree with the opinions expressed. They
arc also at variance with the opinion of all authorities with which I
am familiar in the matter of the value of efficient cauterisation. I would
like to have specific references to those who believe that cauterization is
a method " . . . which was considered proper treatment in the days
of Ambroisc Pare but which thinking persons have abandoned just as did
Pare." If the vaccination were 100 per cent effective it would be a
different matter, but it is not always successful in bites destined to have
a Short incubation period. I have witnessed three human deaths which
might have been prevented had cauterization been applied. Cauterization
must always be with pure nitric acid. Phenol and iodine arc not

To the Editor:— On page 1283 of the April 1 issue of The Journal the idea
is put forward that dog bites should not be cauterized but should prefer-
ably be cleansed with soap and water and irrigated with a warm salt
solution. If is an almost universally recognized procedure in health
departments to cauterize dog bites with fuming nitric acid unless cir-
cumstances make it quite clear that there is no need to fear rabies.
The health departments also recommend this procedure to all practicing
physicians in their respective areas as the only approved method of
preliminary treatment. Is The Journal taking a stand against nitric acid
cauterization ? If so, it is surely desirable that this question should be
discussed at much greater length. Health officers are bound to have
difficulty with practicing physicians over the subject of treatment of
dog bites unless it is discussed with sufficient fulness so that both
groups will know what stand is being taken by The Journal and will be
made acquainted with the reasons for that stand. If the general practice
of health departments is wrong, it is quite possible that they will change
it, but not until there are good and sufficient reasons for doing so.

J. L. Pomeroy, M.D., Los Angeles.

To the Editor: — In The Journal April 1, page 1283, a discussion of the
indications for antirabic vaccination appeared. This discussion has certain
possibilities of doing harm. A statement which I think is particularly
dangerous reads as follows: "When the wound resulting from a bite is
treated immediately and carefully in this fashion the administration of
antirabies serum is not advocated in all instances." This sentence appears
after the paragraph deploring cauterization of dog bites and recommend-
ing thorough cleansing with soap and water. This seems to me to place
too much reliance on local treatment, no matter what the nature of this
treatment may be. It is certainly dangerous to imply that the bite of a
rabid animal should not be followed by antirabies vaccine unless specific
indications are given. I myself am unacquainted with any bite of a known
rabid animal resulting in a definite wound which should not be followed by
antirabies vaccine. The published statement may tend to encourage
careless practice with unnecessary danger to some individuals.

Ralph S. Muckenfuss, M.D., New York.

Answer. — Particulate matter introduced into the soft tissues
is carried away rapidly by the lymphatics ; in fact with such
startling speed that brilliant dyes injected into the skin of the
forearm can be recognized as high as the axilla in eight minutes,
and injection of the lymphatics over an area several inches in
diameter about the site of the inoculation takes place within
as short a time as eighty seconds. These facts were graphically
set forth by Hudack and McMaster in a series of papers in the
Journal of Experimental Medicine, and an editorial calling atten-
tion to their reports appeared later in The Journal. It is
therefore pertinent to ask whether one could hope to destroy
by any local application all of a virus which had been carried
into the deeper layers of skin and subcutaneous tissues when
some of it is far out of reach within a few moments of the time

of inoculation. , , . , , .

The second point is that powerful chemicals destroy tissue
just as quickly and certainly as they could destroy any virus or
bacterial contamination. Since it is illogical to think that all
of the contaminating material could be destroyed, no matter
how thorough the cauterization, because a part of it ^already
beyond reach of local treatment, it seems reasonable to think that
the destroyed and devitalized tissue would make development of
infection and increase of contamination greater instead of less.
Certainly this has been demonstrated many times as tar as
bacterial infection is concerned. Whether the same reasoning
can be applied directly to the problem of rabies is not established

with certainty. . , , , ...

In answer to Dr. Muckenfuss’s comments it should be pointed

out

COMING EXAMINATIONS

STATE AND TERRITORIAL BOARDS

Examinations of state and territorial boards were published in Tfll
Journal, September 30, page 1353.

SPECIAL BOARDS

American Hoard of Anesthesiology: An Affiliate of the American
Hoard of Surgery. Written. Part I. Various places throughout tic
> ni States an( l Canada, Feb. 15. Oral. Part II. Philadelphia, Oct
* Sec., Dr. Paul M. Wood, 745 Fifth Ave., New York.
American Hoard of Dermatology and Syphilology: Oral. Phih
delnlua, Nov. 3-4. Sec., Dr. C. Guy Lane, 416 Marlboro St., Boston.

American Hoard of Internal Medicine: Written. Various sec-
tions of the United States, Feb. 19. Formal application must be received
on or before Jan. 1. Sec., Dr. Will jam S. Middleton, 1301 University
Ave., Madison, Wis.

American Hoard of Obstetrics and Gynecology: Written exami-
nation and review of case histories ( Part J) for Group B candidates will
be held in various cities of the United States and Canada, Jan. 6.
Applications for admission to Group B, Port 1 , examinations imuf be os
file not later than Nov. 15. General oral and pathological examinations
(Part II) for all candidates (Groups A and B) will be conducted in
Atlantic City, N. J., June 8-11. Applications for admission to GriwM,
Part I[ examinations must be on file not later than March 15. Sec.,
Dr. Paul Titus, 1015 Highland Hldg., Pittsburgh (6). . . . ,

American Hoard op Ophthalmology ; Written. Various cities ot
the United States and Canada, March 9. Oral. New York, June i lQ.
Formal applications must be received before Jan. 1. Sec., Dr. Job n
Green, 6830 Waterman Ave., St. Louis.

American Hoard of Orthopaedic Surgery: Boston, Jan. 2U-J.
Applications must be filed on or before Nov. 1. Sec., Dr. Fremont A
Chandler, G N. Michigan Ave., Chicago. _ n

American Hoard of Pathology: Memphis, Nov. 22-23# oec., ut.
F. W. Hartman, Henry Ford Hospital. Detroit. _ . .

American Board of Pediatrics: New York, April 30 and
Kansas City, Mo., preceding the Region III meeting of the A 0 !”™*
Academy of Pediatrics. Seattle, June 2. Sec., Dr. C. A. Aldnchp •-*
Elm St., Winnctka, III. v Vn A

American Board of Psychiatry and Neurology: New tor <
December. Sec., Dr. Walter Freeman, 1028 Connecticut Ave. «•' •*
Washington, D. C. _ c..

American Hoard of Radiology: Atlanta, Ga., Dec. •/•lu a •*
Dr. Byrl R. Kirklin, 102-110 Second Avenue S.W.. Rochester,
American Hoard of Urology: Chicago, Feb. 9-11. (The only «
nation session to be held in 1940.) Case reports must be
later than November 9. Sec., Dr. Gilbert J. Thomas, 1009 Nicollet
Minneapolis.

North Carolina June Report
Dr. W. D. James, secretary, Board of Afedical Examiners,
reports the written examination held at Raleigh, June
1939. The examination covered sixteen subjects and lnclu
eighty-four questions. A general average of 80 per cent wa
required to pass. Fifty-seven candidates were examined, a
whom passed. Twenty-four physicians were licensed by reci
procity and five physicians were licensed by endorsement,
following schools were represented:

Per

Cent

Year
Grad.

* ; (1939) . C3939) 9 '" 3, f4
(1937)

School ™ SSE

College of Medical
University of Color
Howard University
„ 0938) 87.1, 89.9, , iq , 0 > 9U

Emory University School oi Medicine. 85

University of Georgia School of Medicine 91.8

Northwestern University Medical School ‘ 'noto) 8J.b

Tulane University of Louisiana School of Medicine. ... *

87.4, 92.6, 93.8 . . f „ „

University of Maryland School of Medicine and 0 . 7 q(. ±

of Physicians and Surgeons (1939) 83,5.84.0. e- 90

Harvard Medical School 093 L fiS-S

Washington University School of Medicine 90.2-

Duke University School of Medicine *

(1938) 93.4, '(1939) 85.3 p ^ . ng39) 88.4

University of Cincinnati College of Medicine noVD 85.9.

Jefferson Medical College of Philadelphia

86.2, 88.4, 89.1, 89.4, 90.6, 92.5 . HQ19) 8 °- 2,

Temple University School of Medicine

82.5, 87.3, 88.1, 88.9 . , „ f . .' ng 37) 90 6.

University of Pennsylvania School Mf-dicmc

(1939) 85.4, 85.4, 88.3, 90.7 91.6, 91.8, 93.9 m39 ) 9^

Medical College of the State of South Carolina H938)

University of Tennessee College of Medicine no 19) 85.2,

Vanderbilt University School of Medicine 9 T9) 85.2, 86-L

Medical College of Virginia

89.6, 90.2, 90.9 Year Kccipr^>'

- , . licensed by reciprocity Grad- . •

School . . H9t8) VifP nI *

Georgetown University School of Medicine M937) Tcnne—f

Howard University College of Medicine ’#1935) Geo fC .

Emory University School of Medicine..... (1938)

University of Georgia School of J Ted t a n e .... - - - - • • ■ ' / j 9 3 7 ) — b*

State University of Iowa College of ^Medicine. (19 )- ^937)

University of Kansas School of Medicine. - (1935) kenJG •

of T nnisville School of Medicine. ... . ••••■*, 193/j) Loui CI • .

isiana School of Medicine. . - Ajggj MaoJ?* 1 ?

School of Medicine. /19I7) New

Hospjtal Medical College //pj/) W. Virgin*

Temple University School of Medicine. ' (,937) V ^ X ’

Woman’s Medical Collecc of Pennsylt ama. '

llcdic.nl Cn1le~r of th» State of South Carolina

< 19357 South Carolina

Volume 113
Number IS

BOOK NOTICES

1435

Mdhirry Medical College........

University of Tennessee College of Medicine

Medical College of Virginia (192S). Virginia,

University of Virginia Department of Medicine

(1937,2) Virginia

University of Wisconsin Medical School

Dalhotisic University Faculty of Medicine

.(1937)

(1920)

(1934)

(1934),

(1935)

(1936)

Tennessee

Arkansas

California

Michigan
Nova Scotia

~ , . LICENSED BY ENDORSEMENT

School

College of Medical Evangelists.

Harvard Medical School :

Duke University School of Medicine

(1935), (1937) N. II. M.Ex.

Year Endorsement
Grad. of
(1936)N. B. M. Ex.
(1933)N. B. M. Ex.
(1934).

Mississippi June Report

Dr. R. N. Whitfield, assistant secretary, Mississippi State
Board of Health, reports the written examination held at Jack-
son, June 21-22, 1939. The examination covered twelve sub-
jects and included ninety-six questions. A general average of
75 per cent was required to pass. Twenty-one candidates were
examined, all of whom passed. Sixteen physicians were licensed
by reciprocity. The following schools were represented:

School TASSED Grad. Cent

University of Arkansas School of Medicine (1939) 87.4

Rush Medical College (1937) 86.1, (1938) 88.5

Tulane University of Louisiana School of Medicine (1939) 88.1,

88.1, 89.1, 89.9, 90, 91.4, 91.7, 92.2

University of Tennessee College of Medicine (1937) 82.8,

85.3, (1938) 82.5, 83.6. 89.5, (1939) 84.1, 86.8, 89.5
Vanderbilt University School of Medicine (1939) 89.1,91.7

School

LICENSED BY RECIPROCITY

Year Reciprocity
Grad. with

University of Arkansas School of Medicine (1913)

University of Colorado School of Medicine (1937)

Atlanta College of Physicians and Surgeons (1908)

Emory University School of Medicine (1924)

(1937, 2) Georgia

Tulane University of Louisiana School of Medicine. . (1931)
(1937) Louisiana

Columbia University College of Physicians and Sur-
geons 4 (1926)

University of Buffalo School of Medicine (1918)

Jefferson Medical College of Philadelphia (1926)

University of Tennessee College of Medicine (1935, 2),

(1936). (1937) Tennessee

Vanderbilt University School of Medicine (1934)

Arkansas

Colorado

Georgia

Alabama,

Alabama,

Virginia
New York
Penna.

Tennessee

Wisconsin June Examination
Dr. Henry J. Gramling, secretary, Wisconsin State Board
of Medical Examiners, reports the written and practical exami-
nation held at Milwaukee, June 27-29, 1939. The- examination
covered twenty subjects and included 100 questions. An average
of 75 per cent was required to pass. Ninety-seven candidates
were examined, all of whom passed. Thirty-six physicians were
licensed by reciprocity. The following schools were represented :

University of Minnesota Medical School. (1934), (1935)
Eclectic Medical University, ’ .(1904)

St. Louis University^ School " .(1927)

Washington University Scho “ .(1913)

University of Cincinnati Coll- " _ .(1938)

Western Reserve University (1934)

University of Oklahoma School of Medicine ..(1924),

(1937) Oklahoma

University of Oregon Medical School (1937)

Jefferson Medical College of Philadelphia (1920), 0932)

Vanderbilt University School of Medicine (1936)

University of Texas School of Medicine (1937)

Medical College of Virginia ...... y 927)

Marquette University School of Medicine (1936)

0 938) Ohio . , ,

University of Wisconsin Medical School (1937)

* This applicant has received the M.B. degree and will
M.D. degree on completion of internship*

Minnesota

Missouri

Missouri

Illinois

Ohio

Ohio

Oregon
Penna.
Tennessee
Texas
N. Carolina
Illinois

Missouri
receive the

Booh Notices

Sports for tho Handicapped. By Georcc T. Stafford, E(1.D„ Associate
Trofessor of Physical Education, The University of Illinois, Urbana.
Cloth. Price, $2.75; school price, $2. Pp. 302, with 17 illustrations.
Xi'mv York : Prentice-Hall, Inc., 2930.

This book aims to present to all concerned with the education
of the handicapped a method of teaching that will motivate the
atypical student to improve not only his physical condition but
also his outlook on life. The percentage of handicapped children
is large enough to warrant serious attention. Most books on
sports are for the normal children. This deals with sports for
the handicapped or abnormal. These recreative activities should
have the following criteria : 1. The activity should have some
corrective or ameliorative value for particular functional defects.
2. It should have a minimum of “expectancy of injury” or
aggravation of the handicap. 3. It should have some recreative
value for the individual with either functional or structural
defects. The book takes up the different handicaps, such as
partial handicaps, more complete disability, functional and
organic heart disease, amputations, ankylosed joints, endocrine
dysfunctions, debilities following long chronic illness or short
acute illness, muscular deficiencies, foot defects, malnutrition,
flaccid and spastic paralyses, respiratory and nasal disturbances,
postural defects and spinal curvatures. The author tells the
kinds of sports that these different students should take up and
then goes into detail as to exactly what sports and how vigor-
ously they should be indulged in. The book is well written and
the subject thoroughly taken up. There are many illustrations.
This book should be useful to those interested in or working
with this class of students.

School passed Grad. Cent

College of Medical Evangelists (1939) 84

University of Southern California School of Medicine. . (1939) 86

University of Georgia School of Medicine (1938) 87

Loyola University School of Medicine (1939) 81

North western University Medical School (1938) 88,

(1939) 85, 86. 86, 86, 86, 87, 87

Rush Medical College ....(1938) 83, 86

School of Medicine of the Division of the Biological

Sciences (1938) 87

University of Illinois College of Medicine (1939) 89

University of Louisville School of Medicine (1938) 86, 87

Harvard Medical School (1938)

University of Minnesota Medical School (1938)

83/ 86*

University of Nebraska College of Medicine. (1936) 84, (1938)

University of Rochester School of Medicine (1936)

University of Oregon Medical School (1937)

Temple University School of Medicine (1938)

University of Pennsylvania School of Medicine (1938)

Medical College of Virginia

Marquette University School of Medicine

H 84, 84, 84, 85, 85, 85, 85, 85, 85, S5, 85, 85, 85,

86, 86, 86, 86, 86, 86, 86. 86, 86, 87, 87, 87, 87, 87,

tT 8 /. 87, 88. 88. 88, 88, 89, 89, 89
university of Wisconsin Medical School

U936) 84, (1937) 85, 88, (1938) 83, 83, 84, 84, 84,

85, 85, 86, 86, 86. 86, 86, 86, 87, 87, 87, 87, 87

87, 88, S8. 88, 89, (1939) 85, 86

(1936)

(1939)

(1935)

85

83,*

87

82

87

S6

83
85

84

85,

LICENSED BY RECIPROCITY

School

University of Georgia School of Medicine (1937)

~ ‘ dicine (1928)

Illinois

1 School (1904).

t) Minnesota

(1921)

TT . . Medicine (1927)

Diversity of Iowa College of Medicine. • •' (1934),

<1936), (1937) Iowa

University of Michigan Medical School (1933),

(1934,2), (1935) Michigan

Year Reciprocity
Grad. with

Georgia

Illinois,

Illinois

Indiana

Chirurglsch-orthopadischo Sportambulanz. Von Herbert Pirker, Dr.
med., Leiter der Chirurg. Abt. des St. Rocliusspltals Wien, und H.
Wunderlich, Pr. med. habil., Fncharzt fur Orthopiidie in Leipzig. Paper.
Price, 27.60 marks. Pp. 391, with 193 illustrations. Leipzig: Johann
Ambrosius Barth, 1939.

The point of view and scope of this book are best brought
out in the preface. Sport surgery, it indicates, is defense sur-
gery in time of peace. A thorough training in sport surgery
must be assumed as a necessity for every physician who (it
matters not in what place or in what community) has a care
for the cultivation and maintenance of the power of self defense
among his people. For this reason sport surgery must occupy
an important place wherever physicians or students wish to
secure the proper knowledge required by their activities in
defense situations or, in fact, by their practice in any com-
munity which has a high regard for defense preparation. The
idea of the book came to expression during the surgical defense
courses for physicians during the war situation in Vienna.
In the darkest “illegal” times, during the winter of 1 934-1935,
the planning and work for this book began, and the political
events of recent years in the German-Austrian territory were
associated with it to the time of its completion. Foreseeing
subsequent political developments, three persons came together
in the late autumn of 1937: a German publisher, a Leipzig
orthopedist and a Vienna surgeon. They planned this book
to offer all that might be required for the practicing physi-
cian (whether he was the best situated sport physician in a
city or in a popular resort or a country doctor who was com-
pelled to make use of the most primitive resources) in the
way of recognizing and treating injuries acquired during sports.

1436

BOOK NOTICES

!Lr, n f ° r f ant£d that !t is necessary for every nrac
ical physician to be personally concerned with the treatment

serious* Z nCS a " d that . tHe id£a is Untenable ‘hat every more
tZ JT T ain r ? qu,res treatment in a hospital

tain scfenHfic S dn V f C - tned 1° ^ ' nt0 th ‘ S book a11 the ’Tnpor-
ant scientific doctrines of recent years which have offerer!

new biologic consideration of injuries to the apparatus nf

movement m such a way that they will be woven into a Lt-

with purely practical ends and will be easily erasned r

s zr*ss$

the many demand, lv hich a Ml, trained clinieian won" call

Jour. A. M. A.
Oci. 7, 19J)

", at ! n£r .. 0f tbe trcnd of the times, since in it a pathologist admits

not necessarilv a ber° CCUr r'^ ° f functional disturbances and
not necessarily because of an anatomic change The author hr

EEAST th v>T‘ r ‘' *«*s *»«

fiefenev Lc iff nd ? mC ' by - demonstratin S that coronary insuf-
look carefnllv f ana r iC S ’ gnS ' Howcver ’ th e pathologists must
should h f r°it hlS m,crosc °P ic evidence. This monograph
i coifn Carefu,Iy „ read hy ‘hose interested in the field, since

tributimis^'tbcTsubject. 511011113 ^ ° f “ »

The authors take up in an orderly way the various methods
T , dla ?, n ° SIng and , nlodes of treating sport injuries in general

‘ , 16 different parts of the body are cou-

th" The svmLo VIt 1,1 f egard . t0 trau matic lesions common to
The symptoms, diagnosis, prognosis, treatment and after-

The r hnnt SCr - lbed h" many ° f the more im Portant conditions
The book is well gotten up, the printing and paper are

excehent and the illustrations, including the reproductions of
roentgenograms, are produced with characteristic efficiency If
there is any criticism, perhaps there are not enough details
with regard to treatment. C!aus

HsU n< ThiTbodS i 0 altlmu n gh 0l prese a n6ng ‘thflatesfln ‘ovarial

sketch y- The author in his preface
states that the book is designed for the medical student as a
correlator between gynecologic pathology and clinical gyne-
co ogy. For this purpose it may serve well, but even the
pathology is not complete enough to give a good background,
the illustrations of gross and microscopic pathologic changes
are excellent, as are those showing patients with various endo-
crine disorders. The bibliography is remarkably incomplete
and even such a subject as vaginitis due to Trichomonas vagi-
nalis is completely ignored. Witherspoon uses this text to
propound his pet theories on stimulation by the estrogenic hor-
mones as the cause of various gynecologic disorders, a fact
that decreases the value of the book for the average student,
who should get broader views.

Die Koronarinsuffizienz. Von Professor Dr. Franz Buchner, Direktor
ues Lud wig- Aschoff-Ha uses, des Pathologischen Institutes der Uni-
versltat Freibure/Br. Kreislaut-Buclierei, Band HI. Herausgeseben in
Verbtndung mit der Deutschen Gesellschaft tiir Krleslaiitrorschung
Paper. Price, C marks. Pp. 8S, with 49 Illustrations. Dresden &
Leipzig : Theodor Steinkopft, 1939.

The concepts of disease and medicine underlying this novel
and interesting treatise are as broad as the concept of life itself.

ie only adequate scientific basis for medicine is that which
views disease as an essential attribute of all organisms. Until
ie science of medicine recognizes this basic fact it proceeds
wit lout recognition of the evolution of diseases in the course
o man s long ancestry. His diseases have evolved along with
t ns ancestry and have left a part of their record in the organ-
isms which have, survived with man in the struggle for exis*
tence. Comparative pathology illumines the path of the evolution
of human, diseases. Even the reactions of plants to infection
and functional disorders shed light on problems of immunity,
resistance, recovery and death. The author approaches this
subject through the field of dermatology, a logical approach
because of the accessibility of the skin of man to the same or
comparable infections as those which affect mammals. The
hook is. divided into chapters on the venereal diseases of animals,
syphiloid of the cat and human granulomatoses, tumors, cancers
and leukoses, itch and demodeciasis, neoscrofula, paratuber-
culosis and paraleprosy, dermatoses, infectious icterus, the com-
parative pathology of epilepsy, the professional hazards of
veterinarians and phytopathology. In a prophetic section on
Ies maladies d’avenir, the author forecasts the increasing medi-
cal importance of brucellosis, psittacosis, icterohemorrhagic
spirochetosis, infectious anemia of the horse, septic pyohemh,
echinococcosis and diphtheria, all infectious and all associated
with the biocenosis created by human society and the integrated
animal life. The author advocates a fusion into one system of
all instruction pertaining to animals and human beings in order
that both may benefit from the comparative approach to clinical
pathology. Even plant pathology has its contribution to make,
notably in the field of the virus diseases. They too have their
bacterial, fungous and nematode enemies and their necroses,
tumors, immunities and processes of healing. This is a thought'
provoking book. Its point of view is the logical social correc-
tive for the opposition to medical research. It puts disease in
its actual setting in relation to nature as a whole.

In this short monograph the author develops the argument
that coronary insufficiency constitutes an important form of
heart disease. By coronary insufficiency is meant an inadequate
blood supply to the heart relative to the work that it is doing.
This coronary insufficiency may be acute or chronic and it may
lead to heart failure. The electrocardiogram expresses coro-
nary insufficiency through its abnormalities, particularly by
deviations of the S-T segment. Anatomically the evidence of
coronary insufficiency is found in microscopic focal regions of
degeneration and necrosis disseminated through the area which
was ischemic. Clinically the expression of the coronary insuf-
ficiency is anginal pain. Coronary insufficiency may arise (1)
through mechanical interference with coronary blood flow, (2)
through impairment in the quality of the coronary blood as far
as its oxygen content is concerned or (3) through an increase
in the work of the heart with which the coronary blood supply
cannot keep pace. Cardiac hypertrophy, as the author points
out, belongs to the last type. The monograph is well docu-
mented, and the arguments presented are quite convincing and
in accord with the newer concept prevailing in this country.
The only section which does not come up to the excellent
standard is that dealing with the theory of the electrocardio-
graphic changes in these conditions. This monograph is illumi-

Medical Entomology with Special Reference io the Health and Well-
Being of Man and Animals. By William B. Hcrms, Professor of P» r *'
sltology in the University of California, Berkeley. Based on the J>°° 5
known as “.Medical and Veterinary Entomology.” Third edition. Clo
Price, $5.50. Pp. 582, with 190 illustrations. New York: Macmillan
Company, 1939.

The text is completely rewritten, based on the author’s Mwl*
cal and Veterinary Entomology (edition 2, 1923). In the inter
val of sixteen years much new material has become availab *•
in medical entomology. This is true especially in the fid ’
related to public health, notably with reference to two of t c
greatest plagues of mankind, malaria and bubonic plague, bot
with insect vectors, the ubiquitous mosquito and the pestiferous
flea, respectively. The book makes extensive use of the resu is
of experiments and of the relation to public health of various
insects. Nearly 100 pages deal with mosquitoes alone, discuss
ing their classification, life history, food, flight, longevity, biting
habits, mating and oviposition, and the special characteristics
of the more banal species. Keys to the genera of culicids an
to the species of anophelincs of the United States are provide ■
A chapter is devoted to mosquitoes as vectors of disease,
addition to the three malarias they are the vectors of filanasi ?,
several kinds of heartworm of dogs, yellow fever, dengue, bir
malaria, equine encephalitis and fowlpox.

Volume 313
Number IS

BOOK NOTICES

1437

The author lias had much experience ill the organization and
operation of mosquito abatement enterprises and his chapter on
this subject is a mine of information, revealing the varied rami-
fications of the ccologic adaptations of the larval and imago
stages of mosquitoes and their interplay with human factors
ranging from public utilities to duck clubs. Cockroaches, bed-
bugs, cone nose bugs, lice, gnats, horseflies, houseflies, blood-
sucking muscids, fleas, ticks and mites all come in for an
exposure of their direct and vector relations to human and
animal disease. The black widow spider is illustrated and dis-
cussed, and other venomous and urticarial arthropods from bees
to centipedes are described. The medical uses of arthropods
have an unexpectedly wide range. They include not only use
of the long known Spanish fly, the use of honey on wounds
and the curious utilization of the mandibles of decapitated ants
arid beetles in suturing wounds, but the more recent application
of malarial infections in the therapy of dementia paralytica and
arthritis, the surgical use of maggots, the use of bee venom
and xenodiagnosis.

This book is not only a valuable textbook for entomologists
and parasitologists but also an important reference work for
the physician, public health officer, sanitary engineer and veteri-
narian. The illustrations arc excellent, and significant bibliog-
raphies are included in each chapter.

Investigations sur lo glaucome (cssals). Par Ic Dr. E. P. Fortin.
Paper. Pp. 47, with 34 illustrations. Buenos Aires : *‘Ei Ateneo,” [n. d.]

For the past ten years Fortin has published in the Argentine
and Spanish journals articles having to do with the maintenance
of intra-ocular pressure. He has been interested in glaucoma
especially from an anatomic point of view. The present pam-
phlet includes many beautiful illustrations of the iris angle and
its environs, together with theories as to the production of
glaucoma. Fortin believes that aqueous is evacuated from the
anterior chamber by the action of the ciliary muscle sliding
forward on the sclera. When the lens bulges forward in accom-
modation, additional space is needed and the aqueous is drained
as the canal of Schlemm becomes more patulous. The action
of the muscle of the ciliary body is compared to the heart action
on the blood stream. Flaccidity of this muscle may cause glau-
coma. The enlarged pupil of glaucoma is due likewise to a
flaccid muscle, as the pupillary and the ciliary musculature have
the same innervation. The pectinate “ligament” is misnamed, as
there is no cordlike structure but simply a meshwork of tissue.
Miotics act to close the ciliary muscle toward the axis of the
eye, and thus the fluid is reduced in pressure. Particles of
pigment cannot be a prodrome of glaucoma, as they would
ordinarily be filtered out through the pectinate “ligament.”
Fortin believes that it is necessary to use physostigmine in the
eye before these particles can be recognized. Iridectomy fails
to relieve glaucoma, even though the canal of Schlemm is
opened, if the pectinate “ligament” is not destroyed. At present
the views of Fortin have not been generally accepted. The
contribution in French leaves much to be desired because of
language difficulties. Its value remains to be seen, although
the ideas are of much interest to physiologists and ophthal-
mologists.

Surgical Treatment of Hand and Forearm Infections. By A. C. J.
Brickel, A.B., -M.D., Departments of Anatoms* and Surgery, Western
Reserve University, Cleveland. Cloth. Price, $7.50. Pp. 300, with 201
Illustrations, Including 35 plates. St. Louis : C. V. Mosby Company, 1939.

This clinical, anatomic and experimental treatise on the sur-
gical treatment of infections of the hand and forearm is well
done and clear. T. Wingate Todd endorses the anatomic
accuracy of the anatomic portions and illustrations. The
colored plates are excellent. Some of the anatomic illustrations
sre done in black and white with the opposing page in color.
The photographs of infected hands do not tell the story as
"'ell as the excellent drawings do. Roentgenograms of the hand
^fter injection of radiopaque material are included. The book
mrnishes a quick reference for the busy practitioner. Every
general, industrial and orthopedic surgeon should be acquainted
with its contents. It is only by means of anatomic knowledge,
clinical research and experience that scientific treatment can
be developed. Treatment is successful only as it is based on
facts.

Worth’s Squint or the Binocular Reflexes and the Treatment of Stra-
bismus. Seventh edition by F. Bernard Cliavasse, M.A., D.M., Surgeon,
Eye Department, Liverpool Eye and Ear Inilrmary, Liverpool. Cloth.
Frice, $8. Pp. C88, with 223 Illustrations. Philadelphia : P. Blakiston’s
Son & Co., Inc., 1939.

The present edition of this classic on squint differs greatly
from all previous editions. As Chavasse comments in the pref-
ace, “The possibility of rewriting the book (previous editions)
was very carefully considered. It then became clear that it was
not possible — or even desirable — to rewrite a classic.” Since
the fundamental researches of Helmholtz, Hering, Tschermak,
Javal and Worth, a new conception of the phylogeny, the ontog-
eny and the physiology of the muscles of the eye has been
created by Sherrington, Magnus and Pavlov. Hence the author
has added a subsidiary title to the book, and he transmits this
point of view in his detailed consideration of such factors in
squint as the anatomy and physiology of the foundations of
binocular reactions, the anatomic and reflex development in the
child and the pathology of binocular anomalies. The last
includes an insight into the obstacles of reflexes, their sight
and nature, heterophoria and dissociation by primary sensory
obstacles, and dissociation by primary’ motor obstacles. The
difficulties encountered in accommodational and' refractional
states in the production of squint are thoroughly discussed.
Both functional and somatic rea-ctions to dissociation, inhibitions
and the effects of secondary correspondences are well illuminated
by case reports. Section rv is devoted to the diagnosis of the
deviation, the state of sensory correspondences and the cause of
the squint. The section on treatment includes treatment of the
cause, of the secondary sensory correspondences and of the
deviation and, finally’, the technic of certain operations. An
appendix of illustrative cases completes the volume. These
are selected to show the salient features of the various types
of strabismus and include many cases observed during the past
fifteen years at the Eye and Ear Infirmary of Liverpool, which
was established in 1820. This edition encompasses far more
than does anything else which has been written concerning
squint. The illustrations are simple and clear. The print is
large and well spaced. While authorities are mentioned by
name, there is no bibliography. An index of seven pages is
ample. Chavasse has indeed rewritten in a manner most com-
mendable a classic that has withstood the test of thirty-five
years. Its usefulness to those interested in the study of binocular
vision and parallelism of the eyes is obvious.

Fundamental Principles of Bacteriology with Laboratory Exercises.
By A. J. Salle, B.S., M.S., Ph.D., Assistant Professor of Bacteriology,
University of California, Berkeley. Cloth. Price, $4. Pp. 079, with 215
illustrations. New York & London : McGraw-Hill Book Company, Inc.,
1939.

This is an interesting attempt to teach general bacteriology
to elementary students by a new approach. Most textbooks are
written from a taxonomic point of view and consequently tend
to overemphasize classification and morphologic and biochemical
characteristics of bacteria. The author has successfully avoided
this and has chosen a harder but more logical method to present
principles that are not only of more interest to the general
student but might even be expected to be retained by him for
a reasonable time. It is not to be expected that critics will
agree entirely with the material selected by the author. To
appreciate many of the discussions, something more than elemen-
tary courses in inorganic and organic chemistry are required.
Tiie book is replete with complicated chemical formulas show-
ing the end products of enzymic action, the structure of dyestuffs
and the decomposition products of proteins, organic phosphorus
compounds and others. While the reader is indebted to the
author for gathering in one volume these complex formulas and
the reactions which they represent, they would seem to belong
in an advanced rather than in an elementary textbook. It is
not necessary to describe in detail the subjects treated. They
cover the entire range of bacterial activity and are presented
in a readable and accurate manner, although with more detail
in some instances than seems desirable. Laboratory exercises
are included and these are rather better than usual. They are
designed to teach principles rather than technic. It is refreshing
to read a textbook which is an honest attempt to present material
that most teachers know should be given to the elementary
student but which is more difficult for the teacher than the more
orthodox courses offered in our colleges.

1438

BOOK NOTICES

Jour, A. M. A
On. 7 , in;

A Text-Book of Pharmacognosy. By George Edward Trcase, B.Plinrm.,
Pli.C., A.I.C., Lecturer on Pharmacognosy In the University Collego of
Nottingham, Nottingham. With Contributions by It. Blenfang, B.S.,
MIS., Ph.D., et al. Third edition. Cloth. Price, $6. Pp. 739, with
243 Illustrations. Baltimore : William Wood & Company, 1939.

This work has won recognition in all English speaking coun-
tries. The present edition has been thoroughly revised and
enlarged. Some rearrangement of the order of presentation
has been made, this order now being : part i, general principles,
including historical introduction ; part n, microscopy, including
discussion of apparatus and reagents and a review of histologic
features of pharmacognostic importance ; part hi, drugs of
vegetable origin, with morphologic and botanic classifications ;
part iv, drugs of animal origin, and part v, physical and chemical
methods of drug analyses. Included are ten maps showing the
geographic source of drugs and a glossary of Latin words used
in naming species. Pharmacognosy at present is definitely a
subject for students of pharmacy and includes much that is of
little interest to physicians. Medical students get little or no
instruction in it. However, physicians who are interested will
find this a satisfactory work and also interesting. Clarity of
presentation is an important feature.

Royal Northern Operative Surgery. By the Surgical Staff of the
Royal Northern Hospital. Cloth. Price, .-£2. 2s. Pp. 531, with 463
illustrations. London : II. K. Lewis & Co., Ltd., 1939.

Printed on fine paper and containing excellent illustrations,
this is a beautiful exposition of the surgical technic carried out
by the members of the staff of an English hospital. The material
is in a strictly anatomic arrangement and covers the entire body
and its structures. The treatment of fractures is not included
except that of the femoral neck. As a rule only one operation is
cited for any given- problem, and this represents the usually
accepted technic for that hospital. As can be expected there
is not much that is new or different in this book, although the
methods described arc usually modern. The authors have
adopted the electrocoagulation method of cholecystectomy advo-
cated by Thorek. The size and purpose of this volume obviate
any attempt at comprehensiveness. Nevertheless it is a pleasant
and refreshing book to peruse.

A Fundamental Approach to Bacteriology. By Corn-Hand Sawln
Jludge PH I)., Associate Professor of Dairy Industry, University of
California San Francisco, and Floyd Russell Smith, rh.D., Instructor In
Dairy Industry, University of California. Taper. Price, $3. Pp. 265,
with 17 Illustrations. San Francisco : J. W. Stacey, Inc., 1939.

This is an approach to bacteriology primarily through the
laboratory. The book is built around laboratory exercises and
demonstrations with explanations and description intended to
prepare the student for an understanding of the work he is
about to perform. The laboratory work covers that usually
presented in courses in general bacteriology, and the selection
of exercises is excellent. The descriptive matter is presented
in a conversational style not infrequently found in secondary
school laboratory textbooks in the sciences. Although accurate
and sufficient for the purpose of an elementary course in bac-
teriology, it is doubtful that this method will appeal to most
college” students. The authors make no claim that the book is
more than a laboratory manual written in a somewhat uncon-
ventional manner and admit that it does not have the “dignity
of the usual text.” Both of these statements are true.

Hair-Dves and Hair-Dyeing Chemistry and Technique. By H. Stanley
, -r o/. r tr p R.H.S.. and the late Gilbert A. Foan. A new

sr ■ srswi stmst - -rss

Publishing Company, Inc., 1939.

This small book is invaluable to the hair dresser and brings
much of value and interest to the layman and physician. The
reader is first impressed by the great complexity of the sub-
ject The number of dyestuffs, good and bad harmful and less
harmful, their innumerable combinations and the careful technic
that must be followed in their successful use explain clearly
why the practicing physician, who is only an amateur at best
in his knowledge of hair dyeing, cannot give adequate ad wee
on how to do it. He can only tell the prospective dyee to
consult the best available hair dresser and to insist on a pre-
liminary patch test, for “para,” the hair dressers name for
paraphenylenediamine, is almost sure to be an ingredient of

C 'on page'l44 directions are given for the patch test, called
the Sabouraud-Rousseau test. The use of eau de cologne as

one of the cleansing agents preliminary to the patch test can
be criticized as introducing other allergens, which may confuse
the interpretation of the result. Criticism can also be made of
this statement, on page 111: "It is interesting and important to
note that in the case of a person idiosyncratic towards an
‘cczematogenous substance’ the abnormal skin reaction seems
to be independent of the concentration of the substance, in which
respect the reaction is totally different from that of poisoning."
The fact is that concentration has a great deal to do with
allergic reactions. Considering the professions of the authors,
however, one must agree that there are remarkably few oppor-
tunities for criticism even when they discuss subjects as difficult
as allergy.

Treating of the danger of dermatitis from hair dyes, the
authors are frank in acknowledging the facts and in warning
of the danger. Particularly in respect fo the exceedingly
dangerous practice of using dyes containing “para” for the
coloring of eyebrows and lashes do they give emphatic warning.
While strongly advising against the attempt, they give minute
directions for minimizing the danger if it is undertaken. British
hair dressers are still playing with this fire.

The book is well written, thorough and easy to understand.
It treats of the structure of the hair, bleaches, dyes of various
kinds and degrees of excellence, “brightening shampoos an
“rinses” and the technics of the various procedures and en >
with a chapter on the causes of gray hair, with some hints o
those who wish to avoid premature grayness.

infections of the Hand: A Guido to the Surgical Treatment of
and Chronic Suppurativo Processes in the Fingers, Hand an •

» -I-- n -- , im ‘.--.n. Seventh edition. Cloth. Trice, i

Philadelphia: Lea & Febiger, 1W9.

Pp. 503, with 229 Illustrations.

Dr. Kanavel, whose tragic death on May 27, 193 , v
great shock to the medical world, has left for posteri 5 . ^
humanity a monumental work on infections of the hand, r
and brought down to date a short time before lus deat .
are four parts to the volume. The first is concerned w
anatomy of the hand with reference to infection, the s
with localized infections and clinical entities, the nr ,
lymphangitis, fascial space and tendon sheal th lnfec lons,^
the fourth with complications, sequelae and after t .
infections of the hand. Special emphasis is placed on
vention of deformities and on treatment with function
in mind. The treatment of sequelae of infections i js
stressed more in this than in preceding editions. I ie ' an j
generously supplied with reproductions of roentgenogr
photographs, diagrams and anatomic illustrations.

A Textbook of Surgery. By American Authors. Edited by Frede ^
Christopher, B.S., M.D., F.A.C.S., Associate Professor o k doth.
Northwestern University Medical School, Chicago. Seco j,onil<> n:

Price, $10. Pp. 1,695, with 1,381 illustrations. Philadelphia A n
IV. B. Saunders Company, 1939. ..

An imposing array of surgeons has been mustered to comp ^
;extbook of surgery of exceptional value and au o -. a*
:onstant state of flux permeating the field of surgua ^

las created in its wake a host of specialists in a .(forts
lighly technical. These specialists have L nda rd

produce in almost seventeen hundred full pag

C III annual acvcmuv,u --- - - . modern

urgery. This would seem to be the ideal way o
extbook on surgery to be written. I he differences

xpresses the opinion of each author and, wi - on the

xpresses me upunuu ur — , . • . L

xist, it is impossible for a reviewer to draw c0,,c with

idividual contributions. He must either concur j inqu ; s !,ed
he mode of presentation, a duty which is rightfu y , this
i the discriminating reader. The comprehensive

er. l ne compi ■ - - ■ cr) ..

ingle volume makes it a genuine OP'*^ 11 ® ^^(Jjjyided and

mgiv- vuiuiiiv, «■ a *

ieneral surgery and the specialties alike are phe

cceivc exposition from a varying number of p J con tain
rief bibliographic lists following many of the topic-

ccent references and further enhance the s “ > The repto-
'here are numerous illustrations of variable \a u ■ . sat j s -

uction of the roentgenograms in general 1S ' 1 °. sort is the
ictory. The great advantage in a book of ew c di-

loroughness with which it can undergo revisto - arl d

on, therefore, will usually contain much r ’ cv - av craE c

ttle floating dead wood. While too adva "“ student of

:udent, this book will serve well the postgraduate^^,
jrgery and the practicing physician, surgeon or

Volume 113
Number 15

BUREAU OF LEGAL MEDICINE AND LEGISLATION

1439 .

Clinical Biochemistry. By Abraham Cuntarow, M.D., Associate Pro-
fessor of Medicine, JciTcrson Medical Collette, Philadelphia, and Max
Trumper, Ph.I)., Clinical Chemist and Toxlcolodst. With a foreword by
Hobart A. ltelmnnn, M.l)., Professor of Medicine, Jefferson Medical
Collette. Second edition. Cloth. Price, $G. Pp. GGG, with 15 Illustra-
tions. Philadelphia & London : W' B. Saunders Company, 1930.

The task of adequately discussing the many biochemical sub-
jects which find important applications in clinical medicine and
surgery in a comparatively short textbook is admittedly difficult.
Under the new title “Clinical Biochemistry” the authors have
extensively revised and supplemented the material presented in
the first edition. Chapters or sections arc devoted to the
metabolism of carbohydrates, proteins, lipids, chloride, calcium,
inorganic phosphorus, magnesium, iron, iodine, sodium and
potassium and to the topics of phosphatase activity', acid-base
balance, respiratory exchange and basal metabolism, vitamins,
renal function, hepatic, gastric and pancreatic function, cerebro-
spinal fluid and water balance. The normal picture is presented
and the abnormal conditions bringing about disturbances are
emphasized. Attention is given principally to changes of the
blood constituents in the various disease conditions. The sum-
mary chapter on the most important chemical changes which
may be utilized in diagnosis and prognosis of various diseases
or conditions should be helpful. Although criticism might be
found for inadequacy of material and citation of the literature
in certain sections, the text, on the whole, should prove of
considerable value to the practicing physician who wants a
review of the various topics to be better able to select bio-
chemical determinations to aid in diagnosis and prognosis. More
attention, however, could have been given with advantage to
the choice of biochemical methods to be employed.

Petite chirurgle et techalque mtdicale couranto. I’ar G. Roux, profes-
seur agrejie a la Faculty do m£(lcclbc do Montpellier. Cloth. Trice, 120
francs. Pp. 591. with 3G1 Illustrations. Tarls: Masson & Clc, 1938.

The objective of this book is the presentation of the principles
of minor surgery and medical technic to advanced students,
interns and young assistants. The author set out to embrace
not only such subjects as preoperative and postoperative care,
emergency treatment of fractures, blood transfusions, minor
surgical procedures and the customary methods of clinical inves-
tigation, e. g. determinations of the blood pressure, gastric lavage
and parenteral administration of drugs, but also heliotherapy,
hydrotherapy and minor otorhinolaryngologic, ophthalmologic,
urologic and gynecologic interventions. The material is divided
into short sections and paragraphs, each with subheadings that
indicate its contents. A fastidious, lengthy description of such
vast material was purposely omitted in an attempt to present
a concise but comprehensive guide to bedside diagnosis and
treatment. Many methods, instruments and apparatus described
in the book and named after French authors are known to the
American student under different names, and in view of the
variance in the terminology this manual would be of little
value to him. The author seems to have taken too big a bite
and as a result many subjects are treated in an inadequate
manner. To be brief but complete, a synopsis must necessarily
limit itself to a relatively narrow field. An attempt to familiar-
ize the young assistant with the popular methods of diagnosis
and with therapeutic technic in all branches of medicine must
result in a superficial, incomplete and therefore less valuable
presentation.

The Patient is the Unit of Practice. By Duane Willard Tropst,
A.B., B.S., .M.l)., Assistant Professor of Medicine, University of Illinois
College of Medicine, Chicago. Cloth. Price, $3.50. Pp. 2t9, with 9
illustrations. Springfield, Illinois, & Baltimore: Charles C. Thomas,
1939.

. The author of this book tries to systematize medicine so that
it can be utilized by the student in a chartlike fashion. He
discusses at length the constitutional potentialities of disease
and the psychogenic factors concerned in the patient’s attitude
toward his problem. A great deal of space is taken up by
the psychosomatic approach. In his “diagnostic or working
hypothesis” he reports a case of numerous functional complaints
associated with delusions and illusions. However, even after
meticulous observations no examination of the spinal fluid is
reported and no diagnosis is made as to the mental aspect of
the patient. He goes at length into the various diagnostic
procedures, which, of course, are -exceedingly elementary. The

charts are not at all inclusive. For instance, the chart on the
etiology of dyspnea is so confusing that it emphasizes the neces-
sity for the student to have a photographic mind. The thera-
peutic principles outlined are divided into rest, diet, symptomatic
treatment and psychotherapy. He emphasizes at great length
the relation of weather conditions to disease. He is particularly
interested in the biosocial classification of mankind. All in all
the book is a philosophic approach to the problems of medicine
from the point of view of both diagnosis and treatment. This
probably represents a hobby of the author and should not be.
taken too seriously as the best method of teaching medical
students the importance of medical facts ; nor does it arouse
the curiosity of the student toward an investigative approach.

Bureau of Legal Medicine
and Legislation

MEDICOLEGAL ABSTRACTS

Hospitals: Liability of Charitable Hospital for Injury
to Pay Patients. — A hospital conducted in the interest of
charity, the Supreme Court of Idaho held in Wilcox v. Idaho
Falls Latter Day Saints Hospital, is not liable to pay patients
injured through the negligence of hospital employees, even
though the hospital may not have exercised due care in the
selection of the negligent employee. The court based its hold-
ing on the ground that one who accepts the benefit of a charity
enters into a relation which exempts the benefactor from lia-
bility for the negligence of his servants in administering the
charity. The articles of incorporation of a hospital, the court
said, are admissible in evidence to establish a disputable pre-
sumption as to the charitable status of the hospital. In this
case a child was taken to the hospital for treatment for pneu-
monia. Her attending physician directed that she be given
diathermy treatment. The treatments were administered by a
hospital nurse during the course of which the child sustained
a severe burn.

In Sisters of the Sorrowful Mother v. Zcidlcr, the Supreme
Court of Oklahoma held that a pay patient in a charitable
hospital.. may recover damages for injuries sustained through
the negligence of a servant, agent or employee of the’hospital.
The doctrine of nonliability, the court said, was “repugnant
and shocking to a sense of fairness and justice to the victim
of what may aptly be termed protected negligence." In this
case, a woman was taken to the hospital in a delirious condi-,
tion. Due, it was alleged, to the negligence of hospital
employees in leaving her unattended, she fell or jumped from
a second story window, death resulting. — Wilcox v, Idaho
Falls Latter Day Saints Hospital (Idaho), 82 P. (2d) 849;
Sisters of the Sorrowful Mother v. Zcidlcr (Ohio.), 82 P.
(2d) 996.

Health Insurance: Impacted Wisdom Teeth Not a
Disease. — The defendant insurance company issued, Sept. 4,
1936, a policy insuring the plaintiff against “loss from disease
contracted during the life of this policy and after it has been
maintained in continuous force for thirty (30) days from its
date.” Within thirty days thereafter the plaintiff’s dentist
informed her that she had four impacted wisdom teeth. She
had suffered no pain or illness from them and was not aware
of the condition. On October S the impacted teeth were
extracted and the plaintiff was unable to do any work for the
succeeding five weeks. She brought suit on the policy. The
trial court overruled motions of the insurance company for a
judgment of nonsuit and entered a judgment in favor of the
plaintiff, and the insurance company appealed to the Supreme
Court of North Carolina.

The sole question before the court was whether or not the
disability of the plaintiff resulted from a disease. The term
“disease,” said the court, has been defined as “an alteration
in the state of the human body ... or of some of its
organs or parts interrupting or disturbing the performance of
the vital functions, or of a particular instance or case of this” ;
as “deviation from the healthy or normal condition of- any of

1440

SOCIETY PROCEEDINGS

Jour. A. M. A
Oct. 7, 1935

the functions or tissues of the body,” and as “a morbid con-
dition of the body.” Black’s Law Dictionary, ed. 3, 18 C. J.
1139. Obviously, then, the impacted teeth did not constitute
a disease. The plaintiff did not know of the condition until
so informed by her dentist; the teeth had given no trouble or
pain; there was no disturbance in the performance of any of
the functions or tissues of the body and no morbid condition
existed. The sickness and disability following the extraction
of the teeth were the results of the extractions to which the
plaintiff voluntarily submitted; she might never have had any
trouble, pain or sickness from the teeth if they had not been
removed. Even if it is conceded that the impacted teeth con-
stituted a disease, the evidence was clear, the court said, that
the condition had existed for a long time prior to the lapse
of thirty days following the issuance of the policy.

The trial court should have sustained the motion of the
insurance company for a judgment of nonsuit. The judgment
for the plaintiff was therefore reversed . — McGregor v. General
Acc. Fire &■ Life Assur. Corporation (N. C.), 198 S. E. 641.

Workmen’s Compensation Acts: Cancer of Tongue
Due to Inhalation of Sulfuric Acid Spray an Occupational
Disease. — Boal, the plaintiff, had been employed for more than
ten years as a “pickier” in one of the pickling rooms in the
defendant company’s storage battery plant. In the process of
pickling used by the defendant, lead plates or “grids” for stor-
age batteries were arranged on wooden racks inside of large
tanks into which was piped a solution of sulfuric acid and
water. After the tank was drained, the picklcrs removed the
lead plates while still damp and placed them on trucks. The
wooden racks were also removed and piled in the same room.
Both the plates and the racks were allowed to dry in the pick-
ling rooms. As a result of this operation, Boal and the other
picklers were constantly exposed to and had to inhale a mist, a
spray or the fumes of sulfuric acid, which commonly caused
coughing, dryness of the mouth and smarting of the skin. A
cancer developed on the right side of Boal's tongue. He
brought suit at common law in the United States district court,
E. D., Pennsylvania, against his employer, claiming that his
cancer had been caused by the inhalation of the mist, spray or
fumes of sulfuric acid. He alleged that the defendant company
had negligently failed to warn him of the danger incident to
his employment and to provide ventilating facilities or other
devices for his safety. From a judgment of nonsuit, Boal
appealed to the United States circuit court of appeals, third
circuit.

Uncontradicted testimony showed that Boal’s cancerous con-
dition was so serious that death would result in a relatively
short time. Expert witnesses testified that the inhalation of or
exposure to the spray of sulfuric acid was the proximate cause
of Boal’s cancer. A pathologist testified that exposure to a mist
of sulfuric acid would cause dehydration and disturbance of
function of the cells of the mouth. A specialist in industrial
toxicology, a chemist, testified that exposure of the cells of the
mouth to .a spray of sulfuric acid would cause physical damage
to them and that the continued irritation or chemical trauma
would eventually give rise to ulceration. Two physicians testi-
fied that such prolonged chemical irritation of the mucous
membranes of Boal’s mouth caused an ulcer to develop and in
turn caused the unhealed ulcer to develop into cancer.

The defendant contended that its failure to provide ventik ting
facilities did not constitute actionable negligence, because the
precautionary measures taken by it for the safety of its employees
came up to the general standards prevailing in the industry.
With this contention the circuit court of appeals was not in
accord. The specialist in industrial toxicology testified that the
defendant’s practice of allowing the lead plates and the wooden
racks to dry in the pickling rooms was “really the vice or error
in the case, or in this working condition,” and that in no pickling
process in any industry was such procedure considered to be
good practice. In fact, as he testified, a common procedure in
the pickling of metal is to transfer the metal directly from the
pickling vat to a conveyor which carries the metal away auto-
matically, an exhaust or warm air system being used to prevent
any mist of sulfuric acid getting into the air.

Neither could the court agree with the defendant’s contention
that it was not negligent in failing to warn the plaintiff of danger

because such danger was not known to it. The evidence showed
that the defendant could have known of the danger if it had
exercised due and proper diligence. General scientific knowledge
existed on this subject which the defendant could have asm-
tamed from various publications and from persons acquainted
with the art, if proper inquiry had been made. One of the
medical witnesses testified that "sulfuric acid is notorious for
causing a type of ulcer which is indurating and doesn't tend to
heal,” and that “even in very low concentrations there would be
definite damage done to the person breathing these fumes." Nor
could the court agree with the defendant’s further claim that it
did not and could not know that cancer would develop from
exposure to sulfuric acid fumes. The fact, as the defendant
pointed out, that there was no record of and none of the expert
witnesses could recall any other case in which the inhalation oi
fumes of sulfuric acid resulted in cancer was not conclusive, for
the effect of such fumes on different persons would vary accord-
ing to individual physical resistance. Where an employer knows
or is presumed to know that a danger exists, it is not necessary
that he should have contemplated the particular consequences, the
form of the accident or the nature of the injury, and the fact
that an accident is unusual, extraordinary or even unheard oi
does not relieve the employer of liability.

In the judgment of the court, the plaintiff was not precluded
by the Pennsylvania workmen’s compensation act 'from main-
taining this common law action in tort. Under that act, diseases
caused or aggravated by accident are compensable, but diseases
of gradual development, or occupational diseases, are not com-
pensable. The court disagreed with the defendant’s claim that
because cancer is not a disease known by common experience to
result from the occupation of pickling metal, Boal was not suf-
fering from an occupational disease. Occupational diseases are
not limited to those diseases which are known by common
experience to have resulted from a certain occupation.

Accordingly, the circuit court of appeals reversed the ju S‘
ment of nonsuit and ordered a new trial . — Boal v. Electric - or
age Battery Co., 98 F. (2d) 815.

Society Proceedings

COMING MEETINGS

American Academv of Ophthalmology and Otc-Laryngology, P^’pvecutirc
8-13. Dr. William P. Wherry, 107 South 17th St., Omaha,
Secretary. - , , J)t.

American Academy of Pediatrics, Cincinnati, November-'
Clifford G. Grulee, 636 Church Street, Evanston, HI., be 5 r< r ^ Y.,
American Clinical and Climatological Association, Saranac a » g os f orI>
Oct. 9-31. Dr. Francis M. Rackemann, 263 Beacon on.

American College of Surgeons, Philadelphia, Oct. 16-20. Vt. ftedc
Besley, 40 East Erie St., Chicago, Secretary. n Reginald

American Public Health Association, Pittsburgh, Oct, 17-^0. ,

M. Atwater, 50 West 50th St., New York, Executive becre Jj ^
American Society of Anesthetists, New York, Oct. 12,

Wood, 745 Fifth Ave., New York, Secretary. nxM. Br*

American Society of Tropical Medicine, Memphis, Tenn., in

E. Harold Hinman, Wilson Dam, Ala., Secretary. _ Br.

Association of American Medical Colleges, Cincinnati, uc-
Fred C. Zapffe, 5 South Wabash Ave., Chicago, Secretary.

Central Association of Obstetricians and Gynecologists,: ka City*

Nov. 2-4. Dr. W. F. Mengert, University Hospitals,

Secretary. , Dr, I*

Central Society for Clinical Research, Chicago, *® v *

Thompson, 4932 Maryland Ave., St. Louis, Secretary. . City,
Clinical Orthopaedic Society, Little Rock, Ark., ana BirfliiflS'

Oct. 13-14. Dr. H. Earle Comvell, 215 Medical Arts Bldg-. *
ham, Ala., Secretary. ^ ^ ^ t n .. p r> John «•

Delaware, Medical Society ' 1 -ii. •

Mullin, 601 Delaware Ave rjr. Clyde C*

Gulf Coast Clinical Society, ‘ "

Rouse, 56 St. Joseph St., 1 jf r , Thon^ 5

Indiana State Medical Association, Fort Wayne, Oct. l - r- <$ ecr< rtary'
A. Hendricks, 23 East Ohio St., Indianapolis, Executive ber JS.
International Society of Medical Health Officers, Pit s „ crc iary.

Dr. Leon Banov, 12 Mill Street, Charleston, S. L., score / Cblaf c.
Inter-State Postgraduate Medical Association of A ' a- ' Free!’ cr1 '
Oct. 30-Nov. 3. Dr. W. B. Peck, 27 East Stephenson at..

111., Managing Director. Vnrk Oct. 2<r^‘

National Society for the Prevention of Blindness, Ne« ’ j Director*

Mr. Lewis H. Carris, 50 West 50th St., New York.

New York State Association of Public Health L- ,\yc., A Ibany.
Nov. 3. Miss Mary B. Kirktmde, New Scotland

JPacffic^Coast Society of Obstetrics and Gl-neeoIogy. fT^Sreret^-
Nor. 8-11. Dr, T. Floyd Bell, 500 29th St., Oakland, ea a p.

Southern Medical Association, Memphis, Tenn., ^ov* ~

Loranz, Empire Bldg., Birmingham, Ala., Secret JK - saS Marshall'
Tri-States Medical Society of Texas, Louisiana and A * Secret^
Texas, Nov. 8-9. Dr. Robert K. Womack, Longview,

Volume 113
Number 15

CURRENT MEDICAL LITERATURE

1441

Current Medical Literature

AMERICAN

The Association library lends periodicals to members of the Association
and to individual subscribers in continental United States and Canada
for a period of three days. Three journals may be borrowed at a time.
Periodicals arc available from 1929 to date. Requests for issues of
earlier date cannot be filled. Requests should be accompanied by
stamps to cover postasc (6 cents if one and 18 cents if three periodicals
are requested). Periodicals published by the American Medical Asso-
ciation arc not available for lending but may be supplied on purchase
order. Reprints as a rule arc the property of authors and can be
obtained for permanent possession only from them.

Titles marked with an asterisk (*) arc abstracted below.

Alabama State Medical Assn. Journal, Montgomery

9:37-68 (Aug.) 1939

Mediastinal Tumors in Children: Report of Case. D. B. Monsky, Mont-

Hjmerinsuliilism Cured by Removal of an Islet Cell Adenoma: Report
of Case. J. F.. Beck and G. O. Segrest, Mobile— p. .40. .

Syphilis in Private Practice: Case Reports Illustrating Problems in Man-
agement. C. K. Weil and W. II. Y. Smith, Montgomery.— p. 43.

Id.: Differential Diagnosis of Venereal Diseases. C. R. Lafferty,

Montgomery. — p. 50. .

Chronic Back Pain. P. W. Shannon, Birmingham.— p. 53.

American Journal of Medical Sciences, Philadelphia

19S: 149-300 (Aug.) 1939. Partial Index
Central Connections of Vestibular Pathways: Experimental Study. VV.

E. Dandy and P. A. Kunkel, Baltimore. — p. 149.

•Value of Colloidal Aluminum Hydroxide in Treatment of Peptic Ulcer:
Review of 407 Consecutive Cases. E. E. Woldman and C. G. Polan,
Cleveland. — p. 155.

Prolongation by Zinc Salts of Water Balance Reaction of Posterior
Hypophysial Extract. E. M. Boyd and K. J. Clark, Kingston, Ont.-

Choice of Technic for Sedimentation Test. A. Hamblcton and R. A.

Christianson, London, Ont. — p. 177.

Note on Erythroblastic Splenomegaly Occurring During Pregnancy.

R. A. Moore and J. B. Pastore, New York. — p. 187.

Sedimentation Rates of Sickled and Nonsickled Cells from Patients with
Sickle Cell Anemia. H. Bunting, Baltimore. — p. 191.

Experimental Production of Vitamin Bi Deficiency in Normal Subjects:
Dependence of Urinary Excretion of Thiamin on Dietary Intake of
Vitamin Bi. N. JollitTe, R. Goodhart, J. Gennis and J. K. Cline,
New York. — p. 198.

•Evaluation of Influence of Overweight on Blood Pressures of Healthy
Men: Study of 3,516 Individuals Applying for Periodic Health
Examination. J. J. Short and H. J. Johnson, New York. — p. 220.
Further Studies on Treatment of Chorea and Rheumatic Infection by
Fever Induction. E. L. Bauer, Philadelphia. — p. 224.

Note on Oral Administration of Potassium Chloride in Treatment of
Hay Fever, Nasal Allergy, Asthma and Sinusitis. A. F. Abt, Chi-
cago. — p. 229.

Lymphogranuloma Venereum: Treatment of 300 Cases, with Special
Reference to Use of Frei Antigen Intravenously. B. A. Kornblith,
New York. — p. 231.

Prognosis in Diabetic Coma: Basic Importance of Mental State. L.
B. Owens and S. S. Rockwern, Cincinnati. — p. 252.

Colloidal Aluminum Hydroxide for Peptic Ulcer. —
Woldman and Polan have now employed the continuous admin-
istration of colloidal aluminum hydroxide for three years in the
treatment of 407 patients with peptic ulcers. The treatment
represents no radical departure from the methods that have been
in use for many years, all of which have been designed to
counteract the effects of excessive acid secretion in the stomach.
The drip treatment with colloidal aluminum hydroxide merely
emphasizes and expands this principle by the use of a more
effective neutralizing agent administered continuously instead
of intermittently. The corrosive action of hydrochloric acid is
the most formidable antagonist to the healing process. If the
factors causing the ulcer are dominant over the natural healing
process, the lesion progresses steadily. On the other hand, if
the factors producing the ulcer are satisfactorily controlled, then
the balance shifts in favor of healing. It follows that treatment,
to be satisfactory, should protect the ulcer from acid corrosion
continuously. Otherwise the accumulation of acid at night may
destroy some of the granulation tissue formed during the day
and thus delay or prevent healing. In addition to its exceptional
neutralizing effect, colloidal aluminum hydroxide appears to
promote healing by coating the lesion with a jelly-like, pro-
tective mass, and by its astringent effect. The most striking
features of this treatment are prompt relief of pain, rapid heal-
ln g of tlie ulcer, healing of refractory ulcers unsuccessfully
treated by other methods and excellent results in bleeding ulcer.

Of 101 patients with massive hemorrhage treated, only three
died. The authors do not claim that this regimen can prevent
the recurrence of ulcers after they have been healed. Never-
theless, thirty patients who have continued to take colloidal
aluminum hydroxide by mouth for two years or more have been
followed closely throughout the entire period, and none of them
have had a recurrence, although previously a number of them
had had exacerbations of ulcer symptoms two or three times
annually for several years. Laboratory studies made on these
patients showed that the drug had no harmful effect.

Influence of Overweight on Blood Pressures. — In
evaluating the effect of overweight on blood pressure, Short and
Johnson determined the systolic and diastolic pressures of 2,858
overweight and, for comparison, 658 normal weight men, all
in supposedly good health. The authors also consider the effect
of both the degree and the duration of obesity on hypertension
and state that it is unfortunate that these contributory factors
have usually been ignored in previous studies on the subject.
All the men were ambulatory, about their usual occupations.
They applied for the periodic health examination provided by
insurance companies carrying their several policies. They have
been unselccted for the study except for the factor of over-
weight. Those having a systolic pressure of 150 mm. or higher
were considered as having systolic hypertension and those having
a diastolic pressure of 90 mm. or higher as having diastolic
hypertension. The subjects were divided into weight groups as
follows : a “normal” weight group whose weights ranged from
5 per cent under to 5 per cent over “ideal” weight, and over-
weight groups of from 6 to 15, 16 to 25, 26 to 40 and 41 or
more per cent above "ideal” weight. For systolic blood pres-
sure there was virtually no increased incidence among those of
normal weight. There was, however, a moderately increased
incidence for each overweight group up to 40 per cent, at which
point the incidence of hypertension was 10 per cent, while in
the group more than 40 per cent overweight there was a sharply
increased incidence of hypertension to more than 30 per cent.
The incidence of diastolic hypertension exceeded that of systolic
hypertension in all ranges of overweight and, in general, showed
a progressive increase to more than 35 per cent in the highest
weight group. The difference in average blood pressures was
greatest in the age group from 50 to 59 years. The incidence
of hypertension in the overweight group was generally lower
than reported by other observers. Average blood pressures were
consistently higher in the overweight group, but not so great
as had been expected. The authors are inclined to agree with
Mosenthal that the influence of overweight on blood pressure
has probably been somewhat exaggerated.

American Journal of Physiology, Baltimore

127: 3-210 (Aug.) 1939. Partial Index

Studies on Estimation of Cardiac Output in Man, and of Abnormalities
m Cardiac Function, from the Heart’s Recoil and the Blood’s Impacts;
the Ballistocardiogram. I. Starr, A. J. Rawson, H. A. Schroeder and
N. R. Joseph, Philadelphia. — p. 1.

•Alterations in Dark Adaptation Under Reduced Oxygen Tensions. R. A.
McFarland and J. N. Evans, Brooklyn.— p. 37.

Leukocytosis Following Parenteral Administration of Liver Extract in
Man. H. D. Bruner, Charleston, S. C. — p. 58.

Respiratory and Vasomotor Effects of Variations in Carotid Body Tem-
perature: Study of Mechanism of Chemoceptor Stimulation. T. Bern-
thal and W. F. Weeks, Ann Arbor, Mich. — p. 94.

Measurement of Blood Flow of Spleen. J. H. Grindtay, J. F. Herrick
and F. C. Mann, Rochester, Minn. — p. 106.

Rhythmicity of Spleen in Relation to Blood Flow. J. H. Grindlay, J. F.
Herrick and E. J. Baldes, Rochester, Minn. — p. 119.

Conduction Velocity and Diameter of Nerve Fibers. J. B. Hursh, New
York. — p. 331.

Properties of Growing Nerve Fibers. J. B. Hursh, New York. — p. 140.

Magnitude, Adequacy and Source of Collateral Blood Flow and Pressure
in Chronically Occluded Coronary Arteries. D. E. Gregg, J. J.
Thornton and F. R. Mautz, Cleveland. — p. 161.

Action of Progesterone on Gonadotropic Activity of Pituitary, E. B.
Astwood and H. L. Fevold, Cambridge, Mass. — p. 192.

Dark Adaptation Under Reduced Oxygen Tensions.—
McFarland and Evans measured the phenomena of the dark-
ening of the visual field under anoxia by the usual procedures
used in studying night blindness. Each of the twenty subjects
(students and physicians) went through a practice period of
two hours, during which time the dark adaptation test was
gi\ en repeatedly. This was sufficient so that each subject's
report was consistent. The dark adaptation curves (plotting
threshold against time) were progressively elevated with

1442

CURRENT MEDICAL LITERATURE

Jour. A. St. A
Oct. 7, ljj)

increasing oxygen deprivation. These effects were counter-
acted within two to three minutes by inhaling oxygen. The
diminution in light sensitivity was statistically significant for
all but five of the eighteen subjects at the first simulated
altitude of 7,400 feet, for all but one at 11,000 feet and for
the entire group at 15,000 feet. The magnitude of these
changes was 0.1, 0.22 and 0.4 of a log unit, respectively.
These effects are probably of no great practical significance
in relation to night blindness in a pilot until altitudes of
approximately from 10,000 to 12,000 feet are attained. In the
authors’ opinion the results obtained in this experiment suggest
that the changes are not concerned with the photochemical
substances of the retina but with the neural elements of both
the retina and the central nervous system.

Am. J. Roentgenol. & Rad. Therapy, Springfield, 111.

42: 161-320 (Aug.) 1939. Partial Index
Diseases of Hypopharyngeal Region Producing Dysphagia: Roentgeno-
logic Consideration. E. H. Shannon and A. II. Veitch, Toronto. — p.
173.

•Multiple Giant Bullae Associated with Antliracosilicosis: Clinicopatho-
logic Study of Case. E. R. Wiese, C. A. Heiken and R. Charr,
White Haven, Pa.- — p. 186.

Hemangioma of Vertebra with Compression Myelopathy. N. S. Sehlez-
inger, Philadelphia, and H. Ungar, Jerusalem, Palestine. — p. 192.
Intervertebral Disk: Involvement in Vertebral Fractures and in Spinal
Pathology: Report of Fifty-Six Cases. H. A. Olin, Chicago. — p, 235.
Ainhum: Its Occurrence in the United States: Report of Three Cases.
E. W. Spinzig, St. Louis. — p. 246.

Cardiac Mensuration Aided by Horizontal Orthodiagraphy. W. R.
Stecher, Easton, Pa. — p. 264.

Roentgen Diagnosis of Meckel’s Diverticulum. B. Ehrenpreis, Brook-
lyn. — p, 2S0.

•Roentgen Therapy in Acute and Chronic Otitis Media. J. P. Brown,
L. L. Titclie and W. E. Lawson, Monroe, La. — p. 2S5.

Giant Bullae and Anthracosilicosis. — A case of multiple
giant bullae of the lung associated with anthracosilicosis, proved
clinically and roentgenologically and substantiated by gross post-
mortem observations and microscopic examination, is reported
by Wiese and his associates. They believe this case to be unique
because of the multiplicity and the size of the bullae, which could
readily have been mistaken for spontaneous pneumothorax.

Roentgen Therapy for Otitis Media — Brown and his
co-workers state that the roentgen treatment of acute and
chronic otitis media is rational because of all the body cells
the lymphocytes are the most sensitive to the rays. Lympho-
cytic infiltration is a major and constant feature of inflammation
and infection of the middle ear, and breaking down these cells
relieves pressure within the cavity and thereby relieves pain.
Roentgen irradiation also promotes phagocytosis, which pro-
gresses rapidly until the lymphocytes are almost entirely
destroyed. The polymorphonuclears and eosinophils undergo
disintegration somewhat less rapidly. In addition to this cel-
lular destruction and phagocytosis, the x-rays are believed to
liberate enzymes, antibodies and other unknown principles which
also aid in the processes of autolysis and liquefaction. The
technic that the authors employed has varied. At present they
are using 85 kilovolts (peak), 5 milliamperes, 10 inch target-
skin distance and 1 mm. of aluminum filter. They do not follow
a hard and fast rule as far as dosage is concerned but take
into consideration the severity or duration of the condition and
the age of the patient. In mild cases in infants they have used
from 50 to 60 roentgens and in young children and adults the
dosage has varied from 60 to 100 roentgens. Their cases of
acute catarrhal otitis media required only one treatment. In
cases of acute purulent otitis from three to seven days elapsed
between treatments, depending on the condition of the ear.
Patients with chronic purulent otitis received treatments about
ten days apart. In acute otitis media if the temperature was
not more than 99.6 F„ with bulging of the drum and obliteration
of the short process, irradiation was not preceded by myringot-
omy. Only one of thirty-one cases of acute catarrhal otitis
media required myringotomy following therapy and in this
instance myringotomy had been refused by the parents and roent-
gen therapy was tried as the only resort. The majority of the
cases were seen within the first twenty-four or forty-eight hours.
The average number of roentgens was 72.9 and the number of
days required for the drum to return to normal was 3.15. Of
eighteen cases of acute purulent otitis media, myringotomy was
performed in twelve, while spontaneous rupture of the drum

membrane occurred in the other six within twenty-four hours
of being seen. The duration of symptoms before the fr-t
examination varied from three days to six hours. These patients
received an average of 1.33 treatments, with an average of
70 roentgens. The ears were dry and the drums were normal
within an average of 8.16 day's. Four patients required two
treatments and one patient three treatments. None of the eight
cases of chronic purulent otitis media, with a history of an
intermittent discharging ear of from four months to eight years,
required myringotomy, the opening in the drum being of suf-
ficient size to afford excellent drainage. Six patients received
only' one treatment, one received two treatments and one received
three treatments. An average of 64.54 roentgens was given
The ears were dry within an average of 11.63 days. In nine of
eleven cases not classified an initial roentgen treatment was
given and the patient did not return for further observation,
one was finally cured and one was afforded considerable relief.
In conclusion the authors state that instead of mastoidectomy
it now seems that not only will a short series of roentgen treat-
ments suffice to cause an ear to become dry and free from pain,
but hearing will be fairly normal in it. None of their cases
have shown any' complication following this mode of therapy.

Archives of Neurology and Psychiatry, Chicago

42 : 373-594 (Sept.) 1939

Partial Thenar Atrophy: Clinical Entity. R. Wartenberg, San Fran
cisco. — p. 373. .. .

Experimental Study of Pathogenesis of Cerebral Changes FwJW s
Prolonged Insulin Hypoglycemia. H. Yannet, with technica a$$i
tance of J. F. Iannucci, New Haven, Conn. — p. 395.

•Recovery of Sympathetic Nerve Function in Skin Transplants. •
Kredel, Charleston, S. C., and D. B. Phemister, Chicago.— P-
Palatal Myoclonus. O. Sittig and V. Haskovec, Prague, Czec
vakia. — p. 413. ... ...

Effect of Pleasant and of Unpleasant Ideas on Respiration m >
neurotic Patients. J. E. Finesinger, Boston. — p. 425. «

•Protective Effect of Cholesterol in Experimental Epilepsy.

Aird and C. Gurchot, San Francisco. — p. 491. , •

Unusual Form of Lymphocytic Choriomeningitis. J. E. Skogan
A. B. Baker, Minneapolis. — p. 507. . n( j

Convulsive and Other Neurologic Phenomena Appearing in s

Arteriosclerotic Psychoses. J. B. Tompkins, Boston. — P* 51J ‘ V i. ^
Objective Technics in Personality Testing. G. C. Booth, Ivew
p. 514.

Recovery of Nerve Function in Skin Transplants-
Kredel and Phemister followed up for periods up to nine 1 ^
eleven patients with skin transplants, chiefly pedicle flaps,
evidence of sympathetic recovery'. Sudomotor, vasomotor, P
motor and sebomotor functions were studied and corre
with the recovery of sensation. The study shows that a c ^
siderable amount of sympathetic nerve function may re urn ^
transplanted pedicle skin flaps. Variability in the ra e
extent of recovery is marked. Adequate return of as *°j 3c(or
sensation, particularly of light touch, seems a necessary
in sympathetic recovery. In case 1, in which there vvas
siderable delay in return of light touch distally, swea ^
not recovered in the lower portion of the skin transplan ^

lower part of the right leg. In case 8 , in which there ^

recovery of touch, there was no sweating twenty-two (0

after the transplantation of a skin flap from the a (0 j

the left forearm. In case 7 delayed and incomplete recov ^, er
touch and of sympathetic functions was shown in 1 ^

portion of the skin flap on the heel. In the tubed pen' 1 ; case 4
planted from the back to the undersurface of the cun 1
sweating was recovered only over the basal area 0
of touch. The presence of deep scarring about a ^ ( 0
sympathetic as well as somatic nerve regeneration 0 ( | on
parts of a flap. Return of sudomotor and sebonio 0
may be of some practical importance in keeping a „ tt ’evcr.
Three patients had some annoy'ance in this regar< . ^

infection was not observed to result from accumu a 10 ^

Inadequate vasomotor function results in variations 1 < _ 0 j n t.

the skin, which are undesirable from a cosmetic s .

Some of these vasomotor disturbances may persis 1 occurrc j.
regeneration of sympathetic nerves to blood vessc s as ^
Some flaps remain hypersensitive to cold. The a> u ^
free grafts to recover skin secretions is explame Echini

that many of the sweat and sebaceous glands are s j s 0 f
as well as by inadequate nerve regeneration due _ n ;iheliuifl
the bed. Apparently', the small amount of uc

Volume II 3
Number 15

CURRENT MEDICAL LITERATURE

1443

included in thin grafts prevents regeneration of functional secret-
ing glands in Thiersch grafts. To what extent sweating may
be recovered in the thicker types of free grafts deserves further
study. Some return of sweating has been observed several years
after lumbar and ccrvicothoracic sympathectomy for Raynaud’s
disease.

Cholesterol in Epilepsy.— Aird and Gurchot studied the
effect of intravenous and parenteral injections of cholesterol on
the convulsive threshold of white mice in which experimental
epilepsy was induced by convulsive doses of cocaine hydro-
chloride. In conclusion they state that direct parenteral injec-
tion of cholesterol resulted in a marked rise in the threshold
for convulsive doses of the cocaine. Both a colloidal suspension
of cholesterol in water and a solution of cholesterol in olive oil
showed this protective effect. After a series of protective injec-
tions of cholesterol, the convulsive effects of cocaine hydro-
chloride were more delayed in onset than the corresponding
effects in control groups. This was interpreted as indicating
delayed absorption of the convulsive agent. The protective
effect likewise was explained on this basis. The results of the
study were interpreted as consistent with the theory that the
vital lipids play a significant part in the permeability of cell
membranes and through this mechanism arc an important factor
in epilepsy.

Archives of Surgery, Chicago

39: 323-512 (Sept.) 1939

Osteochondritis Dissecans of Head of Femur: Partial Idiopathic
Aseptic Necrosis of Femoral Head. E. Freund, I.os Angeles. — p. 323.
•Partial Thoracoplasty Without Deformation. 31. Iselin, Paris, France,
and C. R. Arp, Atlanta, Ga. — p. 353.

•Appendicitis, with Especial Reference to Pathogenesis, Bacteriology and
Healing. W. F. Bowers, Omaha. — p. 362.

Primary Isolated Lymphogranulomatosis (Hodgkin's Disease) of Stomach:

Report of Case. C. II. Avent, Memphis, Tenn. — p. 423.

Circulation During Spinal Anesthesia. W. Goldfarb, B. Provisor and
H. Koster, Brooklyn. — p. 429.

Thyrotoxicosis with Malignant Neoplasms of Thyroid Gland: Clinico-
pathologic Study. II. A. Davis, Memphis, Tenn. — p. 435.

Embryology of Hip Joint: Preliminary Observations. D. A. De Santo,
New York, and I*. C. Colonna, Oklahoma City. — p. 448.

Tender Points in Diseases of Renal Pelvis and of Ureter: Peripheral
Distribution of Unilateral and Bilateral Hyperalgesia and Anatomic
Relations of Spinal Nerves and Muscles Involved. 31. S. Levitas,
Brooklyn. — p. 457.

•Morbidity Caused by Operative Complications. W. C. Beck, Chicago.
— p. 478.

Sixty-Ninth Report of Progress in Orthopedic Surgery. J. G. Kuhns,
S. M. Roberts, R. J. Joplin, W. A. Elliston, G. Bailey. Boston; J.
A. Freiberg, Cincinnati; J. E. Milgram, New York, and F. E. Ilfeld,
Los Angeles. — p. 489.

Partial Thoracoplasty Without Deformation. — Iselin
and Arp state that the deformity resulting from a routine
thoracoplasty is due to three causes; (1) vertical lowering of
the scapula with subsequent fall of the shoulder, (2) sinking
of the scapula into the depth and its lateral projection and
(3) scoliosis, with convexity toward the side on which operation
was done. It is their opinion that from the orthopedic point
of view the removal of the transverse processes of the vertebrae
is a mistake and conclude that, to cause no deformity, thoraco-
plasty should not involve the trapezius muscle, the angular and
rhomboid muscles or the latissimus dorsi muscle, since these
muscles fix the scapula. By modifying the direction of Picot’s
incision and cutting some of the trapezius fibers (the ascending
fibers which play no part in fixation of the shoulder) they were
able to perform thoracoplasties involving as many as six ribs
and to perform extrafascial apicolysis under conditions far more
favorable than those obtained in making the usual incisions
around the scapula. The cutaneous incision is oblique, starting
at the seventh cervical vertebra (the prominent one) and extend-
ing as far as 3 cm. below the angle of the scapula. The upper
part of tile incision does not have to reach the seventh cervical
vertebra but starts at 1 cm. from it; if necessary, its lower
extremity may be prolonged along tire spinal border of the
scapula. This incision allows a favorable approach to the most
difficult point in surgical treatment of pulmonary tuberculosis ;
ablation of the first rib, the key of the thoracoplasty. With
this incision the ribs can be viewed one after the other. Extra-
fascial apicolysis is much more easily performed with this inci-
sion, as the apex of the lung is exactly in the center of the
wound. A set of instruments suitable for the operation is
necessary. The authors describe their use. They consist of

two Semb retractors, two strong double-bent retractors, three
rugines, Brunner’s costostome for costostomy and two spatulas
of the type employed by Semb. The scapula can be easily
retracted in spite of the preservation of its muscles. This is
done by putting the patient flat on his stomach and raising the
arm, which places the bone in the sagittal plane and entirely
disclosed from the thorax. It is maintained in this position by
means of a retractor. Some of the advantages of this incision,
the authors point out, are that it provokes little hemorrhage
and, as the muscle is not cut, it does not cause shock. Recon-
struction is simple : the ascending fibers of the trapezius muscle
which have been cut must be carefully sutured. The dissociated
muscular parts are brought together by means of two sutures,
as in McBurncy’s incision. The results are excellent. For the
last two years the authors have used this incision for all thoraco-
plasties and extrafascial apicolyses.

Appendicitis. — The thesis that appendicitis in the majority
of cases is a form of closed loop obstruction is developed in
this paper. Bowers shows that in 80 per cent of 485 cases in
his series the condition was on an obstructive basis and that
in 67 per cent an impacted fecalith was the obstructing mecha-
nism. He demonstrates that there is a direct correlation between
the presence of a fecalith and subsequent development of obstruc-
tion with closed loop formation, eventuating in perforation and
peritonitis if the obstruction is not overcome by expulsion of
the fecalith or release of the obstruction by other means.

Morbidity from Operative Complications. — Of the 450
patients that Beck observed for operative complications (wound
infections and pulmonary lesions) 332, or 73.8 per cent, had an
uneventful convalescence, whereas 118, or 26.2 per cent, had
some complication during the postoperative course; only “clean”
operations were selected for the study. In no case was more
than one complication reported. This may be due to lack of
observation on the part of the person filling out the report but
is more probably due to the fact that the presenting complica-
tion overshadowed the secondary one. There were five deaths
in the series. Surgical shock and "gas pains” are not being
considered. In the series there were fifty-six wound complica-
tions, most of which resulted from hematomas in the wound.
When the edges of the wound are slightly raised and reddened,
a hypodermic needle inserted into the wound will usually aspirate
a small or moderate amount of old blood or of blood-stained
purulent material ; these are small hematomas rather than infec-
tions. Most of the twenty-eight pulmonary ailments in the
group were classified as bronchitis. Whether or not this minor
bronchitis represented small areas of atelectasis is not in the
province of this discussion. There were eight lesions definitely
classified as atelectatic. There were thirteen patients with
complications referable to the urinary tract. There was usually
mild cystitis, although there was one instance of violent cysto-
pyelitis which resisted therapy. Only six of the patients had
had retention of urine requiring catheterization. The complica-
tion arose most frequently in young persons. Thrombophlebitis
of the femoral vein occurred in only two persons in the entire
series. The other complications were so inconstant that dis-
cussion of them is not indicated. Many factors enter into the
pathogenesis of the complications. To evaluate any one of
them, all of the others must be kept at an absolute or relative
value. However, in reviewing the practical lessons learned from
the study, the author finds that probably the most important is
that an explanation can usually be found for a temperature
which remains over 99.6 F. for more than four days. If one
is alert for this sign, one will be able to “pick up” far more of
the complications which beset the surgical patient. If the com-
plications are faithfully recorded, a cause and a cure for some
of them will undoubtedly be found.

Bulletin New York Academy of Medicine, New York

15: 493-576 (Aug.) 1939

Observations on Pathology of Rickets, with Particular Reference to
Changes at Cartilage Shaft Junctions of Growing Bones. E. A
Park, Baltimore. — p. 495.

Therapeutic Use of Vitamin C. G. Dalldorf, Valhalla, N. Y — p 544

Use of Tetanus Toxoid in Private Practice. R. P. Rogers, Greenwich’
Conn. — p. 553.

Influence of Emotional Factors on Physiologic and Pathologic Proc-
esses, !•. Fremont-Smith, New York. — p. 560.

Role of New York Academy of Medicine in Development of American
Museum of Health. G. Baehr, New York. — p. 570.

1444

CURRENT MEDICAL LITERATURE

Joins. A. 51. A.
Oci. ?, 1939

Georgia Medical Association Journal, Atlanta

28:305-348 (Aug.) 3939

Some Problems of Industrial Practice, with Special Reference to Treat*
ment. R. L. Rhodes, Augusta .— p. 305.

Treatment of Fractures in a Small Community Hospital. C. II. Watt,
Thomasville. — p. 307.

Some Ethical and Legal Aspects of Industrial Practice. J. W. Sim-
mons, Brunswick — p. 312.

Operative Treatment of Inguinal Hernia. L. S. Fallis, Detroit.— p. 316.

Lesions in Spinal Cord in Mental Disease and Defect Recognized by
Myelin Sheath Stain: Report of 600 Unselectcd Cases with an
Appendix on Technic. Myrtelle M. Canavan, Boston. — p. 324.

Prophylaxis Against the Common Cold. H. Joiner, Gainesville.— p. 332.

Illinois Medical Journal, Chicago

76:101-200 (Aug.) 1939. Partial Index

Integration of Personality Factors in Diagnosis and Treatment. L. E.
Parkins, Boston. — p. 119.

Roentgen Consideration of Lesions In and About the Larynx: Diag-
nostic Aspects. A. Hartung, Chicago.* — p. 125.

Id.: Therapy. T. J Wachowski, Chicago. — p. 128.

Suggestive Treatment of Maxillary Sinusitis Subsequent to Dental
Surgery. J. S. Clark, Freeport. — p. 130.

^Current Conceptions in Epilepsy. M. Brown, Chicago. — p. 132.

Measles in 1938: Analysis of 400 Cases: Twenty-Eight Instances of
Encephalitis. A. L. Hoyne, Chicago. — p. 136.

Early Diagnosis and Treatment of Poliomyelitis with Poliomyelitis Anti-
streptococcus Serum. E. C. Rosenow, Rochester, Minn. — p. 144.

Hospital Management of Tuberculosis in the Psychotic. S. A. Leader,
North Chicago. — p. 149.

Differential Diagnosis of Chronic Abdominal Disease. II. P. Miller,
Rock Island. — p. 154.

Some Observations on Cerebral Hemorrhage in the Newborn. H. N.
Sanford, Chicago. — p. 162.

•Sudden Death: Anatomic Findings. B. Markowitz, Bloomington. — p.
170.

Colloidal Mercury Sulfide and Wassermann Fastness. S. J. Zakon and
M. A. Jacobson, Chicago. — p. 172:

Anchoring Elusive Breast Tumor. E. I. Greene and J. M. Greene,
Chicago. — p. 178.

Calcium Therapy in Diseases of Cardiovascular System. E. Podolsky,
Brooklyn. — p. 179.

Current Conceptions in Epilepsy. — Brown states that it
has been clearly demonstrated that epilepsy and other nervous
and mental diseases occur more frequently among the ancestors
and collateral relatives of deteriorated persons with epilepsy
than among the general population. The offspring of persons
with epilepsy are susceptible to it and defective mental develop-
ment or other neuropsychiatric disorders. In a study of the
hereditary factors in epilepsy, in which the records of non-
deteriorated epileptic patients were used, it was found that the
hereditary backgrounds of these patients are tainted with neuro-
pathic disturbances to a significantly less degree than are those
of deteriorated patients. Epilepsy occurred in only one of 342
children born to 163 extramural patients with the same dis-
order. Infantile convulsions occurred in six of these children.
The deteriorated and nondeteriorated patients with epilepsy, it
appears, show a distinct and significant difference in the rela-
tion of hereditary factors to their disorder. There are con-
stitutional or inborn differences between mentally deteriorated
and nondeteriorated epileptic patients. Not only are there
important clinical differences between the mentally normal per-
son with epileptic seizures and the psychotic epileptic, but the
differences in hereditary background and in native or constitu-
tional makeup suggest the existence of a fundamental distinction
between these two groups of patients.

Sudden Death. — Sudden death in an apparently healthy
individual or unexpected death in an individual known to be
chronically ill raises many medical and legal problems. Marko-
witz explains that the primary medical problem is easily solved
if sufficient anatomic changes are found which justify a cause
for sudden death. There are instances, however, in which
necropsy fails to reveal such anatomic justification. Yet testi-
mony is constantly being given by physicians and lay coroners
who have little or no information on the subject. The primary
legal problem depends entirely on the medical observations.
Probably the most common anatomic changes in these cases
refer to the heart. Coronary changes are of extreme importance
in cases of sudden heart death. There are coronary arterial
changes, such as calcified and atheromatous plaques, which cause
narrowing of the lumen but no occlusion ; in these cases it is
difficult to give an anatomic cause for sudden death In syphilis
the coronary arteries are but little involved but the aorta is
puckered to'such a marked degree that it may produce sudden

death by occlusion of the mouth of the coronary artery. Syphilis
as an entity may be blamed for sudden death in other instances
such as rupture of the aorta or cerebral vessel through a syphi-
litic aortitis or rupture of a syphilitic aneurysm. Aneurysm is
one of the most common complications of syphilitic aortitis,
especially in Negroes, in whom it is found twice as often as in
the white race. Next to the heart, the brain is probably the
most frequent seat of anatomic changes which produce sudden
death. Sudden deaths due to pulmonary disturbances or edemi
of the larynx are often encountered but rarely without history'
of some previous disease. Pulmonary embolism, a definite
anatomic observation in explaining sudden death, usually follows
some operative procedure or history of thrombophlebitis, Fat
embolism following fracture may cause sudden death, some-
times occurring many hours after the patient is in apparently
good condition. It is questionable whether air embolism, which
is so often feared, is ever a cause of sudden death. In all cases
of pulmonary and laryngeal deaths the history of the antecedent
illness is of extreme importance. In cases of shock, whether
anaphylactic or surgical, anatomic evidence of death is difficult
to demonstrate. The mechanism of death is unknown; the
theoretical explanation of a neurocirculatory disturbance hears
some weight in view of the minor injuries and even emotional
distress which may precipitate shock. Sudden death may occur
of an individual who has been on a prolonged drinking spree.
The history in these cases usually indicates chronic alcoholism
and anatomically' the essential signs are extreme fatty degenera-
tion of the liver with varying degrees of cerebral edema. Death
is most likely due to hepatic insufficiency.

Journal of Lab. and Clinical Medicine, St. Louis

24: 1119-1226 (Aug.) 3939. Partial Index
"Effect of Vitamin C on Lead Poisoning. H. N. Holmes, Kat I tp
Campbell, Oberlin, Ohio, and E. J. Amberg, Toledo, Ohio. P- '
Comparison of Tests for Insulin Sensitivity. P. H. Burgert, i
Nadler and Ruth Stott, Chicago. — p. 1128. , j

Gluconic Acid as Urinary Acidifying Agent in Man. Ib u°
Helen Civin, with assistance of C. Salzman, New York.— p. '

Staphylococcus Epidermis Albtis: Cultural and Immunologic e
of Large and Small Colony Types. Esther Meyer, Chipago.—p.
Study of Enzymes in Normal and Pathologic Cerebrospinal r ■

Kaplan, D. J. Colin, A. Levinson and B. Stern, Chicago.— P- ■ ,

"Normal Hematologic Standards in the Aged. I. Miller, Staten
N. Y.— p. 3172. „ 1177

Short Cut in Gas Analysis. F. S. Cotton, Sydney, Australia. P-
Detection ot Blood by Means of Chemiluminescence. F- r
San Jose, Calif., and A. M. Moody, San Francisco, p. 1J S ■ ..g a .
Determination of Sulfanilamide in Tissue, Urine and Blood. °
tion of Marshall’s Method. F T. Maher and \V. J. R- Camp,

Method of Isolating Larvae of Trichinella Spiralis for Preparatk^^
Antigen Used for Immunologic Reactions in Trichinosis,
iya, St. Louis. — p. 1207. . . A.

Free Chlorine as Source of Error in Blood Sugar Determma
K. Anderson and I. Zipkin, State College, Pa. — p. 1209.

Vitamin C in Lead Poisoning. — After physical
tion of 400 men exposed daily to lead, Holmes and his eo a
made monthly checks on the basophilic aggregation of ^ e
smear and on the degree of stippling. Records of these nf
tests were kept throughout the year of observation. . j
the last three months of this period weekly tests were r ^
on a cooperative group of thirty-four men, all of W 'j’ ^ cse
symptoms and showed signs of chronic lead poisoning. f

men differentials were also recorded on the Wng - n;
From April 1937 to Nov. IS, 1937, from 80 to
(5.2 to 6.5 Gm.) of the gluconate, lactate and diphospnate

of calcium were given to these thirty-four men.

In addition-

y-lUUl ***'-••. — • afl

vitamin D (940 units) and vitamin A (9,400 units) were
daily. The observation was made that the symptoms a ^
exhibited by these men were similar to those foun ,■],.)

clinical scurvy. Ascorbic acid (100 mg. of vitamin . £nts

oral therapy was instituted in the group of thirty- our . aC j ( ]
with chronic lead poisoning: seventeen were given asc0 . sa |t
alone (at least two months after discontinuing the ca c ^
injections), while the others continued the calcium e . ^
at the same time took tablets of ascorbic acid. In gen j
first group of patients showed a marked improvenicn j e;;
cheerfulness, color of skin and blood picture. In a , v,e , non p 3 l
after beginning the treatment most of the men en) 0 )
sleep, lost the irritability and nervousness so common \
calcium treatment of lead poisoning, enjoyed their casC5

and no longer had tremors (if observed before), c> '

Volume 1 13
Number 15

CURRENT MEDICAL LITERATURE

1445

of leukopenia (probably due to previous prolonged calcium
therapy) were cured by the ascorbic acid treatment. In the
second group the gain was less marked and rather irregular.
There was no gain in the number of mature neutrophils in the
blood, in strange contrast with the rapid gain when ascorbic
a.cid alone was given. In several instances alcohol nullified the
good effects of calcium as well as of ascorbic acid, a complica-
tion that workmen exposed to lead hazards would do well to
avoid.

Normal Hematologic Standards in the Aged. — In deter-
mining the normal hematologic standards of ICO men more than
60 years of age, Miller found that the erythrocytes per cubic
millimeter of blood arc diminished in old age. The average
erythrocyte count is 4,460,000. Chronic low grade infection,
nephrosclerosis and decreased cellularity of the red bone marrow
in old age may be causative factors. Hypertension did not pro-
duce an increase in the erythrocytes. The hemoglobin per
hundred cubic centimeters of blood is decreased in the aged, the
average being 14.3 Gm. The decrease in hemoglobin is propor-
tional to the decrease in the erythrocytes. The leukocytes and
differential counts arc within normal limits.

Maine Medical Association Journal, Portland

30: 189-212 (Auk.) 1939

Medicolegal Problems. A. \V. Stearns, Poston. — p. 189.

Sulfapyridine Therapy in Pneumonia. L. A. Parrella and E. E. Crown,
Lewiston. — p. 196.

The Pneumococcus and Sulfanilamide: Report of Two Cases. IT. I.
Goldman, Freeport. — p. 202.

New England Journal of Medicine, Boston

221: 209-250 (Aug. 10) 1939

Epilepsies: Note on Radical Therapy. W. Penfield, Montreal. — p. 209.
Role of Cervix in Pregnancy and Labor. F. L. Good, Boston. — p. 219.
Acute Gonococcic Tenosynovitis: Report of Seven Cases, E. Hamlin
Jr. and S. P. Sarris, Boston. — p. 228.

Agranulocytosis Caused by Sulfanilamide: Report of Recovered Case,
I. L. Cutler and E. J. Crane, Rutland, Mass. — p. 231.

Allergic Diseases. F. M. Rackcmann, Boston. — p. 234.

221: 251-290 (Aug. 17) 1939

Chronic Organic Arterial Disease. E. A. Edwards, Boston. — p. 251.
Nerve Injuries in Supracondylar Fractures of Humerus in Children.
G, G. Bailey Jr., Boston. — p. 260.

"Treatment of Lobar Pneumonia with Sulfapyridine. hr. Cutts, C. F.

Gormly and A. M. Burgess, Providence, R. I. — p. 263.
Granulocytopenia Following Surgical Sepsis and Treated with Adenine
Sulfate. E. L. Richmond. Worcester, Mass. — p. 267.

Industrial Medicine. W. I. Clark, Worcester, Mass. — p. 269.

Treatment of Lobar Pneumonia with Sulfapyridine. —
Cutts and his associates state that of the eighty-four patients
with lobar pneumonia treated at the Rhode Island Hospital
during the past winter only twenty-two were treated only
with serum, forty-four were treated with sulfapyridine alone,
thirteen with serum and the drug and five, entering the hos-
pital after the fifth day of their disease, received no drug or
serum therapy. Patients given both the drug and serum were
not chosen because of any greater severity of their illness.
Severe pneumonia was present in all groups in about equal
proportions. Analysis of the duration of the disease at the
time of admission showed that those in the serum-treated group
averaged 2.4 days while those treated with the drug alone
averaged 3.2 days. In the group of patients receiving com-
bined treatment the average duration was two days. The
average age of the drug treated patients was 42 and the age
of those who were serum treated was 43, while those receiving
both serum and the drug averaged 50 years. There was one
death among the patients receiving sulfapyridine alone, three
among those treated with serum and the drug, two <5f the
serum treated patients died and three of the five patients
admitted to the hospital after the fifth day of illness and receiv-
In S no treatment died. The authors made an attempt to grade
all cases as to the therapeutic response, taking into considera-
tion the number of lobes involved, the day of the disease when
treated, blood cultures, age of the patient, type of infecting
Organism, temperature response and presence of complications.
According to this classification 90 per cent of the drug treated
cases yielded good results, as compared to 73 per cent of the
serum treated group. From their results the authors infer
“'at at least in the great majority of cases sulfapyridine exerts
uo serious toxic effects if used in the dosage described. How-

ever, nausea and vomiting were quite troublesome. The occur-
rence of both rasli and drug fever in the two patients receiv-
ing more than 40 Gm. of the drug suggests that these large
doses should be used with caution. Agranulocytosis or acute
hemolytic anemia was not encountered, but their known occur-
rence in occasional cases makes frequent blood counts and
close observation essential. In the authors’ experience sulfa-
pyridinc was equally effective in all types of pneumonia, with
the exception of that caused by the type III pneumococcus.

New York State Journal of Medicine, New York

39: 1447-1524 (Aug. 1) 1939

Anxiety in Relationship to Hyperthyroidism. G. M. Reck, Buffalo. —
p. 1453.

Value of Tuberculin Skin Tests in School Program. W. E. Ayling,
Syracuse. — p. 1463.

Studies in Water Metabolism in Relation to Nervous System. R. T.
Bellows, Rochester. — p. 1470.

Limitations of Injection Treatment of Hemorrhoids. S. L>. Manhcim and

L. J. Druckerman, New York. — p. 1473.

Electrolysis: Surgical Procedure. A. C. Cipollaro, New York. — p. 1475.
Value of Irradiation in Cancer of Breast. W. J. Hoffman, New York.
— p. 1481.

Circulation of Joints of Chronic Arthritis. J. W. Ghormley and A.
Silverglade, Albany. — p. 1489.

Allergic Manifestations in Central Nervous System. T. W. Clarke,
Utica. — p. 1498.

Oklahoma State Medical Assn. Journal, McAlester

32: 283-316 (Aug.) 1939

Stricture of Urethra. J. \V. Rogers, Tulsa. — p. 283.

Postoperative Management of Tonsillectomies. G. E. Haslam, Anadarko.
— p. 286.

Bladder Infections in the Female. D. W. Branham, Oklahoma City. —
p. 290.

Examination of Contacts: Factor, in Syphilis Control. M. I. Shan-
holtz, Wcwoka. — p. 292.

Emergency Treatment of Airplane Injuries. R. L. Fisher, Frederick. —
p. 296.

Philippine Islands Med. Association Journal, Manila

19: 337-394 (June) 1939

Studies on Vitamin C: V. Vitamin C Content of Normal Filipino Blood.
I. Concepcion and P. Paulino, with technical assistance of' Solita F.
Camara and Maria Luisa Gargaritano, Manila. — p. 337.

Pathology and Bacteriology of Ileocolitis in Children. B. Barrera,
Manila. — p. 345.

Nature of Causative Agent of Cancer from Standpoint of New Concept of
Bacteriophage, Its Action and Role. J. F. Leyva, Manila. — p. 351.

Review of Gastroenterology, New York

6:281-366 (July-Aug.) 1939

Terminal (Regional) Ileitis: Report of Case. R. L. Waugh, New
Orleans. — p. 281.

Regional Colitis: Report of Two Cases. J. A. Dubins, Boston. — p. 293.
Peptic Ulcer Therapy. M. B. Levin, C. H. Burton, R. Roseman and
H. Eisenberg, Baltimore. — p. 299.

Method of Treating Peptic Ulcer Based on Symptomatology and

Pathology. A. Basslcr, New York. — p. 306.

Report of Some Unusual Gastrointestinal Cases. A. A. Herold, Shreve-
port, La. — p. 312.

Effect of Gastric Hydrochloric Acid and Certain Factors on Number of
Colon Bacilli in Feces. W. B. Rawls and G. H. Chapman, New York.
— p. 317.

•Gastrointestinal Allergy. W. Lintz, Brooklyn. — p. 320.

Modern Concepts of Cardiospasm. N. W. Chaikin, New York. — p. 332.
Studies on Vitamin C Metabolism: New Sursaturation Test.

M. Vauthey, Vichy, France. — p. 337.

Tyrosinemia and Takata-Ara Tests in Cirrhosis of Liver. I. R. Jankei-
son, M. S. Segal and M. Aisner, Boston. — p. 341.

Relation of Liver and Gallbladder Disease to Arthritis. Vera L. Collins,
Yonkers, N. Y. — p. 344.

Gastrointestinal Allergy. — Lintz discusses a class of
patients (472) suffering from various digestive disturbances
who are incapacitated and yet not sick enough to go to bed.
Incompletely digested foreign proteins gain access to the cir-
culation not only in these patients but in almost every one.

These proteins are merely the exciting agents that set off the
patients’ cells which inherently react in an abnormal manner.
For instance, the symptoms of asthma are always the same,
irrespective of the agent producing it. The author is of the
opinion that these patients lack or are deficient in a certain
poison neutralizing ferment, transmitted according to laws of
heredity, which normal people possess. He is convinced that
the only difference between normal people and allergic people
is one of degree. The nonallergic person can simply tolerate
larger doses of the allergens. While 10 per cent of the popu-
lation suffers from major allergy, more than half of us mani-
fest mild and infrequent allergic symptoms at one time or

1446

CURRENT MEDICAL LITERATURE

Jout. A. M. A

On. 7, 1913

another. Who does not know of some food or other substance
that gives him clogged nose, sneezing spells, colds, coughs,
dyspnea, headache, rashes, itching, suggestive mild hay fever,
asthma, migraine and cutaneous allergy? Of all the manifes-
tations of allergy the author states that he finds the gastro-
intestinal form by far the most frequent. This is to be
expected in view of the fact that allergens act mainly on the
unstriped muscle cells, the vascular and the autonomic ner-
vous system and the secretory glands. The history is by far
the most important point in the diagnosis and treatment of
these patients. There are three phases to this factor: ]. The
patient usually presents other allergic manifestations. 2. A
family history of allergy will usually be found. In 70 per
cent of these cases the family history was positive for allergy.
3. History of attacks attributed to allergens is almost always
elicited. The autonomic nervous system plays a most impor-
tant part in the production of gastrointestinal allergy and
explains its apparent vagaries as to why a patient can tolerate
a food at one time and not at another. It is overstimulation
of the vagus that is chiefly concerned with allergy, for the
vagus causes increased secretion, spasticity, excessive mucus
formation, colic, hyperirritability and increased vascular per-
meability, which sequence of events occurs in allergy. The
plurality of digestive complaints and the dominance of the ner-
vous symptoms are suggestive of allergy. It is suggested that
herpes occurring in the stomach and duodenum and its diges-
tion is responsible for certain peptic ulcers. Nonbeneficiai
operations of all sorts should arouse a suspicion of allergy.
The history and symptoms are more reliable than the dermal
tests. Coffee not only produces allergic symptoms but makes
patients more susceptible to other allergens. A spastic intes-
tine is responsible for hemorrhoids. Organic disease should
be ruled out and allergy should be made as the last diagnosis.

Southwestern Medicine, El Paso, Texas

23: 247-280 (Aug.) 1939

Splanchnic Anesthesia. C. II. Arnold and L. V. Gibson, Lincoln, Neb.
— p. 247.

Brachial Block Anesthesia. C. H. Arnold and L. V. Gibson, Lincoln,
Neb. — p. 249.

Artificial Pneumothorax. D. W. Mclick, Madison, Wis. — p. 250.

Differentiation of Parietal and Intra-Abdominal Pain. Z. B. Noon,
Nogales, Ariz. — p. 254.

Common Feeding Difficulties in Pediatric Practice. J. T. Bennett, El
Paso, Texas. — p. 257.

Tuberculosis of Tonsil: Resume of Literature with Report of Case.
E. H. Brown, Tucson, Ariz. — p. 260.

Dermatitis from Cosmetics. L. M. Smith and R. P. Hughes, El Paso,
Texas. — p. 263.

Hematuria and Abdominal Pain Associated with Sulfapyridine. V. M.
Ravel and W. R. Curtis, El Paso, Texas. — p. 264.

Sulfanilamide Therapy in Mastoiditis. L. F. Morrison, San Francisco.
— p. 265.

Surgery, St. Louis

G: 167-326 (Aug.) 1939

Anesthetic Management of Patients .with Hyperactive Carotid Sinus
Reflex. E. A. Rovenstine and S. C. Cullen. New York. — p. 167.

Anesthesia, Anesthetic Agents and Surgeons. E. R. Schmidt and R. M.
Waters, Madison, Wis. — p. 177.

Massive Adenomatous Goiter Successfully Removed: Case Report.
C. E. Rea, Minneapolis. — p. 183.

Carcinoma of Parathyroid Gland. K. A. Meyer, P. A. Rosi and A. B.
Ragins, Chicago. — p. 190.

•Surgical Exploration and Closure of Patent Ductus Arteriosus: Report
of Second Successful Case. R. E. Gross, P. Emerson and H. Green,
Boston.- — p. 201.

•Bleeding Tendency in Obstructive Jaundice and Its Correction by Means
of Vitamin K. K. B. Olson and Hildegard Menzel, New York. —
p. 206.

•Conservative Surgery with Irradiation in Gas Gangrene Infection. R. L.
Sewell, Rochester, N. Y. — p. 221.

Woody Phlegmon of Neck. F. H. Straus, Chicago.— p. 230.

Penetrating Stab Wounds of Abdomen and- Stab Wounds of Abdominal
Wall: Review of 184 Consecutive Cases. L. T. Wright, R. S. Wilkin-
son and J. L. Gas ter, New York. — p. 241.

Spontaneous Hematoma of Abdominal Wall. J. O. Lisenby, Atmore,
Ala. — p. 261.

Muscle Flap Repair of Perforations in Larger Arteries of Dogs. R. M.
Isenberger, with assistance of M. C. Carroll, Kansas City, Kan.- —

Linitkfpiastica of Colon: Case Report.^ J. R. Judd, N. P. Larsen and
I. L. Tilden, Honolulu, Hawaii. — p. 278.

Closure of Patent Ductus Arteriosus. — Gross and his

colleagues report the case of an 11 year old boy who had

typical physical and x-ray signs of a patent ductus arteriosus.

As the child had been followed over a period of several years.

there had been slight but definite hypertrophy (or dilatation)
of the heart, this change being presumably caused by the large
shunt between the aorta and the pulmonary artery. In tie
attempt to reduce the work of the heart imposed by the shunt
and also to lessen the danger of subacute bacterial endarteritis,
surgical exploration was undertaken for obliterating the ductus.
The vessel was found to be from 11 to 12 mm. in diameter
and was successfully ligated. The patient stood the operative
procedure with extremely little reaction. This is the second
case to be reported.

Bleeding Tendency and Vitamin K. — Olson and Menzel
determined the plasma clotting time of twenty-four patients
with obstructive jaundice. Twelve of the patients were con-
sidered to have bleeding tendencies because of abnormally pro-
longed plasma clotting times. The other twelve had normal
plasma clotting times, though three bled after operation and
in two of these cases the plasma clotting time became markedly-
prolonged before bleeding occurred. These fourteen patients
were treated preoperatively with vitamin K concentrates and
bile salts. All but one patient had marked improvement ol
the plasma clotting time. Seventy-five per cent of the patients
with bleeding tendencies, but not treated with vitamin K, bled
postoperatively, whereas only 36 per cent of those treated \yitb
vitamin K had postoperative bleeding complications. No patient
bad serious bleeding while receiving treatment. Since vitamin
K and bile salts decrease the bleeding tendency in obstructive
jaundice, their use is recommended in all cases of jaundice
both preoperatively and postoperatively'.

Conservative Surgery with Irradiation in Gas Gan-
grene. — According to Sewell, in the seven years prior to 19 - 1
twelve cases of clinical gas gangrene of the extremities nere
seen at the Strong Memorial Hospital. In four of these gan
grene developed in the stump following amputations for ot «
causes. In the other eight cases, on recognition -of the in ec-
tion, immediate amputation was advised and performed excep
in one instance, in which it was refused. This patient receive
only a small amount of serum and lived; while, of the reraJ1 “
ing seven, four died on an average of twenty-four hours i*
the therapeutic amputation. In the following eighteen m° n 1
with the introduction of roentgen therapy and sulfam anu ,
of five patients with both clinical gas gangrene and P osl 11
cultures, two died, both aged men. One had severe aa e ^
and lived for three days after a midthigh amputation,
regrettable that more reports concerned with irradiation m
gangrene have not appeared in the general surgical
for, although most roentgenologists are well informed o
merits of this mode of therapy, it has not been brougi
ciently to the eyes of the general surgeon. Since t ie m
duction of irradiation and sulfanilamide, it has been a
shown that the infection can be controlled and cured " ^ ^
amputation and even without surgery in numerous ca ^
which, several years ago, immediate operation would un
edly have been performed.

Tennessee State Medical Assn. Journal, Nashvill

32 : 263-302 (Aug.) 1939 .

Pellagra: Discussion of Diagnosis and Treatment of 263-

and Borderline States. J. B. HcLester, Birmingham, ■ , 1 r.
Metrazol Treatment of Dementia Praecox. H. B. iirac

Different ffl Diagnosis of Diarrheas. T. J. Manson, Chattanoosa'

p. 276.

West Virginia Medical Journal, Charleston

25 : 345-398 (Aug.) 1939

chievements and Responsibilities of Our State Association
Bobbitt, Huntington. — p. 345.

K. M-

.). 345. _ rillette, Tel« ta

fagnosis and Surgery of Traumatic Abdomen, i -
Ohio.— p. 349. „ . ,,, y 7 : nn , Ballta 0 *

ndoscopy: Its Relation to Everyday Practice.

he Discharging Ear. J. H. Moore, Huntington. P- 35 jtartm J r -'
lagedorn Era in Diabetes Mellitus. L. C. McGee and J-

Elkins.— p. 361. ,„„„i„,.emia and J n« n!l!

imultaneous Occurrence of Spontaneous _ H.'P S 3 „ ,

Tabes: Case Report. D. C. Ashton, Becklej . P- ( ' h p clcrsen
reatment of Transcervical Fracture of IIip " l,h s
C. C. Garr, Lexington, Ky.— p. 37L , specific Sera-" -

c“" 0 Re C p C ort M f ’ d!‘ Cota ™u. Clarkshurg.-P- *»'

.Volume 113
Number 15

CURRENT MEDICAL LITERATURE

144 7

FOREIGN

An asterisk (*) before a title indicates that the article is abstracted
below. Single case reports ami trials of new drugs arc usually omitted.

British Medical Journal, London

2: 209-264 (July 29) 1939

Retrospect on Forty Years of Practice T. Fraser.— p. 209.
Pharmacologic Actions and Therapeutic Uses of Some Compounds
Related to Adrenalin. J. A, Gunn. — p. 214.

Causation of Delayed Union and Nonunion of Fractures. R. I. Stir-
ling. — p. 219.

Treatment of Ununited Fractures. N. Dunn. — p. 221.

Foreign Bodies Introduced into Bladder in Attempts to Procure Abor-
tion: Report of Case. A. II. Charles. — p. 224.

Indian Medical Gazette, Calcutta

74: 385-448 (July) 1939. Partial Index
Use of Dyes in Various Fungal Infections. P. A. Mnplcstone and N. C.
Dey. — p. 391.

Malarial Infection in Placenta and Transmission to Fetus. B. M. Das
Gupta. — p. 397.

Abdominal Tumor Caused by Gnnthostoma Spinigerum (Owen, 3836).
S. Daengsvang, — p. 399.

Treatment of Cholera (Note on Results of Treatment by Different
Methods). C. L. Pasricha, A. J. II. deMonte, B. C. Chatterjec and
A. Samad Mian. — p. 400.

Thrombo- Angiitis Obliterans: Report of Case Treated by Lumbar Gan-
glionectomy. M. Sein. — p. 404.

Tumors of Upper Jaw and Its Immediate Neighborhood. V. M. Kaikini.
— p. 406.

Scarabiasis or Presence of Beetles in Intestine. C. Strickland and
D. N. Roy.— p. 416.

Lancet, London

2 : 237-296 (July 29) 1939

Forty Years of Practice: A Retrospect. T. Fraser. — p. 237.

•Acute Hyperparathyroidism. W. A. Oliver. — p. 240.

•Effect of Sulfonamides on Blood Serum. G. A. Scott and O. Mccrapfcl.
— p. 244.

Chloroma: Case I. G. Jones. — p. 246.

Reduction of Potassium Tellurite in Diphtheria and Other Throat
Conditions. K. E, Cooper, B. A. Peters, J. Wiseman and J. M.
Davies. — p. 248.

•Insulin Premedication in Convulsion Therapy. D. E. Sands. — p. 250.
Use of Pentothal Acid in Midwifery. G. C. Steel. — p. 251.

Thrombosis After Injection of Pentothal Sodium. F. Evans. — p. 252.

Acute Hyperparathyroidism. — Oliver suggests that the
clinical syndrome including vomiting, loss of weight, anorexia,
bone pains, constipation and lassitude, all of them recently
exacerbated, with increasing drowsiness, evidence of fever, dis-
proportionate tachycardia and impaired renal function without
hypertension should prompt a careful examination of the neck
for a parathyroid tumor, estimation of the serum calcium and
phosphorus and x-ray study of the kidneys. From the experi-
ments of several investigators it appears clear that the ill
effects may be reversible and that, if suitable fluid and electro-
lyte replacement is carried out and followed by removal of
the tumor, good results may be expected ; therefore recog-
nition of the condition and its speedy confirmation by investi-
gation are of considerable importance. Two cases of parathyroid
chief-cell adenomas are reported and it is believed that they
constitute examples of a clinical syndrome — acute hyperpara-
thyroidism — which, if recognized, is amenable to therapy.

Effect of Sulfonamide Derivatives on Blood Serum. —
Scott and Meerapfel describe two cases in which treatment
with a sulfonamide derivative over a long period and in large
doses (423 grains [27.5 Gm.j of uleron [dimethyl disulfanil-
amide] in one case and 748 grains [48.6 Gm.] of sulfanilamide
in the other) was followed by an alteration in the blood serum
which precluded the finding of a suitable donor for blood trans-
fusion. Normal serum treated in vitro with sulfanilamide for
four days or more agglutinated the red blood cells of donors
of the corresponding blood group and the cells of universal
donors. When these drugs were administered over shorter
periods and in smaller doses to six other patients, such a change
m the blood serum did not take place.

Insulin Premedication in Convulsion Therapy. — The
resistiveness, panic and fear accompanying convulsion therapy
have been eliminated by Sands with insulin premedication of
twenty-two of twenty-three schizophrenic patients. The insulin
premedication has enabled him to complete convulsant treatments
of the twenty-two patients which would otherwise have had
to be terminated prematurely because of resistance and appre-
hension. In the instance in which treatment was stopped it

was done because of the excessive exacerbation of symptoms
on recovery from each convulsion. The patient’s condition
deteriorated and it was considered inadvisable to continue the
treatment. The high proportion of “negative fits” — 30 per cent
— which these resistive patients had without insulin was reduced
to 33 per cent with insulin. There have been but three patients
discharged and one has since relapsed. This is an inferior
figure compared with most of the published statistics and those
of Claybury, the discharge rate being 42 per cent. This use
of insulin, by greatly diminishing the unpleasantness of con-
vulsion treatment to resistive schizophrenic patients, has facili-
tated their nursing and management. The object in insulin
premedication is to give such a quantity as will induce the
patient to cooperate with the injection of a convulsant drug.
The dose may require pushing until drowsiness and languor
supervene. On almost every occasion the induction of the fit
has been sufficient to dispel any lethargy induced by the insulin.
The patients are given sugared tea to drink as soon as the
convulsion is over. In two cases, owing to the development of
insulin sensitivity, recovery was effected with dextrose solution
through the nasal tube on one occasion and with intravenous
dextrose on two other occasions. As with metrazol therapy,
the management of the premedication can be performed by the
ordinary nursing staff of the mental hospital without the usual
special training generally necessary for insulin shock therapy.

Medical Journal of Australia, Sydney

2: 123-154 (July 22) 1939

Anesthesia and Pulmonary Atelectasis. S. V. Marshall. — p. 123.

Massive Collapse of Lung. \V. A. Bye.— p. 129.

Treatment of Some Common Disorders Encountered in Industrial Prac-
tice. N. Little. — p. 135.

Japanese Journal of Experimental Medicine, Tokyo

17: 239-332 (June) 1939

Studies on Influence of Bacilli Designated as N, M or J on M and N
Agglutinogens of Human Blood Corpuscles. K. Sliimada. — p. 239.
Studies on Changes in Blood Sugar Content During Fever. I. Ohtake.
— - p. 249

Bacteriologic and Immunologic Investigations on Type B Salmonella.
S. Tsuchiya — p. 269.

Combined Active Immunization Against Smallpox and Typhoid Fever:

Experimental Studies. H. Yaoi. — p. 295,

-Practicability of Combined Active Immunization Against Smallpox and
Typhoid Fever: Clinical Studies. H. Yaoi, S. Hirose and Y. Sud-
zukl. — p. 305.

Clinical Studies on Disease Caused by Hymenolepis Nana (v. Siebold).
K. Nishio. — p. 319.

Immunization Against Smallpox and Typhoid. — In order
to test the efficacy of the combined active immunization against
smallpox and typhoid, Yaoi and his associates vaccinated at
three weekly intervals 7,054 unselected young adult technicians
of the heavy metal industry and a few office workers with
freshly prepared heat killed phenolized typhoid vaccine. How-
ever, only 74.81 per cent of this number received the three
injections. The main complaints expressed by the evaders was
fever, headache or malaise, besides reddening, swelling and pain,
the severe local reactions. The ill effects which may be caused
by the combined active immunization by means of the purified
vaccine virus and typhoid vaccine were determined in 838
newly admitted technicians. Only the first of the three doses
contained a mixture of purified vaccine virus and typhoid vac-
cine. Ill effects which appeared to be more severe than when
typhoid vaccine alone was used were not observed. It was
confirmed that the two antigens used acted quite independently
in that nodules due to the vaccinia virus appeared on the fourth
or fifth day, after the immediate local reaction subsided. From
a study of the local reactions caused by 'the typhoid vaccine and
the combined immunization the authors find that the allergic
reaction caused by the typhoid vaccine is much more severe
than that caused by the smallpox vaccine. After combined
active immunization, serums drawn on the fifteenth day showed
titers from 1 : 1,600 to 1 : 3,200 and in those drawn on the twenty-
second day the titers ranged from 1 : 3,200 to 1 : 6,400. Thus
it was decidedly confirmed that more rapid and effective
immunization can be obtained by the combined method than
in the case of typhoid vaccination alone. The comparison with
two agglutinin figures after seventy-five days clearly demon-
strated the superiority of the combined method (titers from
1 : 800 to 1 : 1,600) as compared with typhoid vaccine (titers
from 1 : 400 to 1 : 800) with regard to the duration of immunity.

1448

CURRENT MEDICAL LITERATURE

Jour. A. M. A
On. 7, 1!!!

Presse Medicale, Paris

47: 1189-1204 (Aug. 2) 1939

Bt Avitaminosis and Cardiac Insufficiency. L. Langeron. — p. 1189.
‘Interpretation of Examination of Labyrinth in Aviators. W. Salem —
p. 1191.

Examination of Labyrinth in Aviators. — Salem says that
at the otorhinolaryngologic clinic of the school of naval aviation
in Rio de Janeiro they have about 200 records pertaining to
examinations of the labyrinth of aviators. In the course of
these examinations and of continuous control tests on aviators
it was found that life as an aviator rapidly fatigues the organism
and influences the vestibular apparatus. The more active the
man is as a pilot, the weaker become his vestibular reactions.
The rotatory test of Barany is employed by the author only
during the first examination; for experienced aviators he found
the test of little value. He observed that the postrotatory
nystagmus should not be interpreted by algebraic formulas and
he gained the impression that it is advisable to adhere to the
general medical principle that an isolated sign never has absolute

produced some effect in the animals, 200 mg. daily was required
to produce, normal creatine values. The large quantities of
synthetic vitamin E that are required for cure are surprising,
because only small quantities of vitamin E are necessary to
achieve a prophylactic effect. Experiments with synthetic vita-
min E revealed that it effects fixation of creatine but that this
fixation ceases as soon as does the administration. Regarding
the point of attack of vitamin E in the organism, the author
says that in 1930 he advanced the theory that it is in the anterior
lobe of the hypophysis. He summarizes his discussion by stat-
ing that creatinuria is a result of a disturbance of the muscular
metabolism on the one hand and of the reduction o! the
secretions of the anterior lobe of the hypophysis and of the sex
glands on the other hand. The function of these two systems
is impaired in case of deficiency of vitamin E. The adminis-
tration of a synthetic vitamin E counteracts the dysfunction of
both systems as well as their chief symptom, creatinuria, in that
it effects fixation of creatine in the tissues.

value. The falling test, with the head inclined 90 degrees for-
ward, he found of no clinical value, but he regards the caloric
test as the best mode of examination of the labyrinth. He cites
cases of hypo-excitability in experienced pilots and says that
to him such hypo-excitability is of no clinical value. If such
pilots have no other symptoms, they can continue their activity
as aviators. The aviator acquires a sense of equilibrium superior
to the normal. Aside from this, the labyrinthine sensitivity is
nearly always diminished ; this seems to be a phenomenon of
adaptation. By itself hypo-excitability does not reveal a per-
turbation of the labyrinth and has no value in aviation. The
author also mentions a case of labyrinthine hyperexcitability
detected by caloric tests in a stunt flier. This man was per-
mitted to continue ordinary flying but was advised not to do
stunt flying and high altitude flying. On the basis of his
observations the author reaches the following conclusions :
1. There exists a labyrinthine adaptability in aviators which
modifies the reactions in the examinations on the vestibular
apparatus. It is a relative modification and of no pathologic
significance in aviation. 2. The labyrinthine hypo-excitability
or hyperexcitability cannot be given uniform interpretations, but
they must vary relatively in each case and in relation to each
form of flying.

Schweizerische medizinische Wochenschrift, Basel

69! 737-756 (Aug. 19) 1939. Partial Index
"Creatinuria in Deficiency of Vitamin E and Its Cure by dl-Alpha Tocoph-
erol (Synthetic Vitamin E). F. Verzar. — p. 738.

Action of Somnifen on Blood Sugar Regulation of Human Subjects. Z.
Horn. — p. 741.

Therapeutic Significance of Elimination of Calcium Acetyl Salicylate
Which Lasts More Than Twelve Hours. F. Dellamartina.— p. 742.

Experimental Contribution to Blood Transfusion on Battle Fields. H.
Knoll and II. Marki. — p. 744.

Creatinuria in Deficiency of Vitamin E.— Verzar says
that creatine or creatinine originates in the endogenic muscular
metabolism and also is taken in with the food, and that some
investigators maintain that it develops also from arginine.
Creatinuria is observed in different disturbances of the glycogen
metabolism of the musculature but also in some endocrine dis-
turbances. It has been observed in connection with hyperfunc-
tioning of the anterior lobe of the hypophysis, in pregnancy and
in hyperthyroidism. Morever, in animals the administration of
anterior hypophysial and of sex hormones has been known to
produce an increase in the elimination of creatine and a decrease
in that of creatinine. Postclimacteric creatinuria has been sup-
pressed by the administration of androgen. All these observa-
tions indicate that creatinuria may be elicited by reduction in
the production of sex hormones or by disturbances in the
anterior lobe of the hypophysis. New light was thrown on the
problem of muscular dystrophy by the observation that certain
diets elicited muscular dystrophy but that they failed to do so
when they were complemented by wheat germ oil with its high
vitamin E content. The author cites his own observations on
the creatinuria of rats with muscular dystrophy, which were fed
for a number of months with a diet lacking vitamin E. He
further shows that it was possible to counteract the creatinuria
of animals with muscular dystrophy by means of a synthetic
vitamin E (dl-alpha-tocopherol acetate). He found that whereas
the daily administration of SO mg. of this synthetic vitamin E

Bol. de la Soc. Cubana de Pediatria, Havana

XI: 363-442 (July) 1939. Partial Index
Elements of Diagnosis in Tuberculosis of Infants. T. Valledor.— p. 363.
"The Lung in Whooping Cough. R. Mendoza and J. Mir.— p. 399.

The Lung in Whooping Cough. — Mendoza and Mir carried
out a clinical and x-ray study in a group of eleven children
who had whooping cough. They found that, when the con-
dition is benign, fever and physical signs of involvement of the
respiratory tract do not appear and the respiratory tract app®
normal on x-ray study of the chest. When- fever and phys'.'a
signs of involvement of the respiratory tract appear, the respira-
tory tract shows abnormal x-ray shadows of various extra
and intensity, which disappear in about a week as fever allies
and the physical signs of the respiratory tract disappear (un ess
complications occur). The tuberculin tests are (or ‘ jec0 * f J
negative in the course of whooping cough and remain nega ■'
after recovery of the patient. As a rule the abnormal x-r s
shadows are located at the infra-hilus and juxtamediastm
regions. Regularly they are bilateral and triangular, from ^
base (or else diaphragm or mediastinum) to the apex ( or j,
the hilus) and may overshadow the hiliocardial space,
transparency of the pulmonary fields is diminished in some ca •
According to the author, the clinical evolution of the con i>
the physical signs and the roentgenogram show that the a ^
tions of the respiratory tract in whooping cough arc u ^
general inflammation and cellular infiltration of all scgmen
the tract with early involvement of the bronchi, broncnioe ^
lung and the development of a consequent latent exu
pleuropulmonary condition which may evolute to dineren 1 ^
of pneumonia, pleurisy or bronchopneumonia. That the W
tion is not of a tuberculous origin is proved by the M »
facts: (1) The patients do not have a history of hbw j
(2) the tuberculin tests are negative, (3) the symptoms, P ' ^
signs and x-ray alterations are of short duration and w^,..
topography and character of the shadow’s do not show
culosis. The author believes that the role of whooping ^
for the development or else aggravation of tubercuos
been exaggerated. The negativity of the tuberculin tcs s
course of the infection and after it (in cases of previous
tive tests) do not necessarily indicate evolution of til cr - s
He calls attention to the importance of a differentia ’ ^

between whooping cough and certain forms of spasmo i ^
from tuberculous tracheobronchial adenopathies wbic i l
erroneously diagnosed as whooping cough.

Endokrinologie, Leipzig

21: 305-448 (June) 1939 LangtWI

Interrelations of Thyroid and Adrenal Glands. E. Hoen,

and C. Oebme. — p. 305. , , t r. Fareha 5 -'"

Ammonia-Induced Hypertrophy of the Adrenal Glands. * ^

‘Adrenal Cortex and Blood Pressure Regulation. S. . Th J d S _ o’rgaa s cf
Study of Relationship Between Primary and Secondar)

the Rat. R. Baum and B. Cunningham.— -p- 34 . f Thyroid- ^

T-*rr . _ or NWL- of Function at * j

Sanchez-Calvo. — p. 355. #

Blood Pressure Regulation in Addison’s U>sea^ ^
Thaddea reviews the clinical and experiment o r egufo*

other investigators on the blood pressure behavior j rc af

tion of persons with Addison's disease, before an

Volume 113
Number 15

CURRENT MEDICAL LITERATURE

1449

mcnt with adrenal cortex extract. Systolic pressure values as
low as SO mm. of mercury and lower are not uncommonly found
in Addison’s disease, with diastolic values somewhat better.
Persons with tuberculosis of the adrenal glands arc said to show
a somewhat higher pressure than those proved at necropsy to
be without it. Patients with cardiac compensation are not
affected by adrenal cortex extract; those with cardiac decom-
pensation have an increase of systolic and diastolic pressure
range after similar therapy. In Addison’s disease, blood pres-
sure is highly dependent on the position of the body, as tested
with a tilting table and the measurement of patients during
physical exertions such as standing, knee bending and leg rais-
ing;. Patients with Addison’s disease not therapeutically man-
aged have an insufficiency of blood pressure regulation that may
lead to collapse. Dysfunction of the regulatory mechanism
may be due to “hypotonic" or “hypodynamic" disturbance. In
the former, diastolic pressure in the upright position remains
the same or rises ; in the latter, diastolic pressure in the same
position shows a decrease simultaneously with the systolic.
Such “hypodynamic" regulatory disturbances are conditioned by
the fact that vasoconstriction compcnsatorily necessary in the
upright position fails to occur because of the absence of nerve
impulses. “Hypodynamic” dysfunction may occasionally com-
bine with "hypotonic.” The cause of these regulatory fluctua-
tions must be sought in the functional unity of the hypophysis
(anterior lobe) and the adrenal cortices. However, the dys-
function of the “central intercalary areas” may be involved
rather than the varying degree of excitability in the peripheral
pressoreceptor system. Hypodynamic regulatory disturbances
were found to yield to long continued treatment with adrenal
cortex extract and no longer manifested low pressure as before
treatment when put to the test of the physical exertions already
mentioned. The author stresses the significance of the circula-
tory conditions in insulin shock. Insulin intravenously admin-
istered precipitated rise of blood pressure of patients with normal
tone in the second phase of insulin intoxication and is usually
coincident with the lowest level of the blood sugar curve. In
persons with Addison’s disease not under therapeutic supervision
sudden rise of blood pressure was not observed. According to
the author, a further circulatory symptom of adrenal insufficiency
is the almost regular absence of the otherwise demonstrable
pressure increase after administration of epinephrine. This dys-
function, however, is susceptible of correction by adrenal cortex
extract or hydrochlorate cysteine therapy.

Khirurgiya, Moscow

1-132 (No. 4) 1939. Partial Index
Hemotherapy in Practice. Kb. Kit. Vlados and M. S. Dultsin. — p. 5.
Mitogenetic Irradiation of Blood of Patients with Gastric Cancer. V. P.

Nagoryanskaya. — p. II.

Indications for Treatment of Military Gunshot Skull Injuries. I. P.

Dmitriev. — p. 15.

Incidence of Esophageal and Gastric Cancer. L. M. Nisnevich. — p. 27.
Surgical Treatment of Cancer of the Cardia. A. I. Savitskiy. — p. 33.
Intestinal Strangulation in Mesenteric Slits. A. B. Frenkel. — p. 59.
•Removal of an Entire Liver Lobe for Alveolar Echinococcus. I. V,

Danilov.— *-p. 63.

Removal of Liver Lobe for Alveolar Echinococcus. —
According to Danilov the alveolar echinococcus of the liver
bears a certain resemblance to a malignant growth because of
its infiltrating character, its iron hard consistency, adhesions
to neighboring organs, formation of metastases in the brain,
pleura, lungs, endocardium and the lymph nodes of the liver
hilus, and its tendency to recurrence after radical removal. The
alveolar echinococcus develops slowly and as a rule is diagnosed
late. The average duration of life of a patient with this con-
dition is about eight years. There were admitted in the last
two years to the Bashkir Medical Institute fifty-seven cases of
echinococcus of the liver, twenty-five of which were of the
alveolar or multilocular variety. In two of these operation was
refused and in sixteen the intervention was limited to explora-
tion, while in seven a radical removal was performed. In one
case the author removed the entire left lobe of the liver, the
seat of a large echinococcus cyst, together with a growth invad-
ing the right lobe. There was considerable traumatism and
loss of blood leading to shock, requiring two blood transfusions
to combat the shock. The patient recovered.

Geneeskundig Tijdschr. v, Nederl.-Indie, Batavia

79: 1601-1664 (June 27) 1939

Experimental Infection of White Mice with Cholera. R. M. R. Koesoe-
madilaga. — p. 1602.

Cauterization of Adhesions in Pleural Cavity. \V. M. Prays. — p. 1623.
•Allergic Etiology of So-Called Catarrhal Icterus. D. Brouwer.- — p. 1636.

Hereditary Palmar Plantar Keratoma: Case. R. Goenawan. — p. 1647.

Allergic Etiology of Catarrhal Icterus. — Brouwer dis-
cusses the connection between “serous inflammation” and disease
of the liver. He says that Eppinger regards catarrhal icterus
as a serous hepatitis which is closely connected with alimentary
intoxication and that Swedish physicians assume that it is an
infectious disease. This infectious theory is corroborated by
the occasional epidemic appearance which the author was able
to observe in Batavia. However, the demonstration of a specific
causal factor has not been successful as yet and recently an
allergic etiology has been considered. The author describes
two cases of catarrhal icterus in which the prodromal symptoms
were of the allergic type; in one case the catarrhal icterus was
preceded by the cutaneorheumatismal syndrome and in the other
case by severe attacks of migraine. He thinks that the eosino-
philia which existed in both cases indicates the allergic character
and that the migraine as well as the urticaria and articular
disturbances can be regarded as equivalents of gastro-enteritis.
They indicate humoral disturbances of the type existing in serum
disease which first involve the skin, the joints and nervous
system and which secondarily involve the liver. The author
cites several other investigators who suggested a connection
between anaphylaxis and icterus.

Maandschrift voor Kindergeneeskunde, Leyden

8: 379-426 (July) 1939

•Postvaccinal Encephalomyelitis. B. Brouwer. — p, 379.

Epidemiology of Scarlet Fever. Helene M. Brouwer-Frommann. — p, 393,

Albers-Schdnberg Disease in a Newborn Infant. N. I. Heybroek. —
p. 416.

Postvaccinal Encephalomyelitis.— Brouwer demonstrates
that the incidence of postvaccinal encephalomyelitis is decreas-
ing in the Netherlands because the frequency of vaccination has
decreased. In 1938 three cases of encephalomyelitis were
accepted by the Governmental Committee for Encephalitis as
postvaccinal in origin. Two of these were studied microscopi-
cally. Typical areas of demyelinization with perivascular increase
of microglia cells were found scattered through the entire central
nervous system. These histologic changes are a constant mani-
festation in tlie postvaccinal form of encephalomyelitis but they
do not exclude other forms of encephalitis, because they can be
found also in other postinfectious encephalitides. The author
emphasizes that the formerly widely accepted belief that patients
with postvaccinal encephalitis either succumb or recover with-
out residual defects is not correct in that cases have been
observed in which tetraplegia or other forms of invalidism
persisted many years later. As regards the pathogenesis, the
author does not accept the theory of activation of a virus already
present in the central nervous system before vaccination. He
believes that the encephalitis is caused by the vaccinia virus
itself but that an endogenous factor is to be considered.

Acta Paediatrica, Stockholm

23: 405-574 (June 30) 1939

Vitamin D and Bone Formation in Hats. R. Nicolaysen and J. Jansen.
— p. 405.

Mental Development in Congenital Myxedema. L. F. Schaeffer. p. 434.

♦Pulmonary Tuberculosis in Children with Special View to Prognosis*
S. Holm. — p. 455.

Pathogenic Mechanism of Early Acquired Hydrocephalus. O. Elo and
E. Otila. — p. 503.

Congenital Anodontia with Abnormalities of the Dermal System. R.
Rinvik and A. Syrrist. — p. 548.

Prognosis of Pulmonary Tuberculosis in Children.—
Holm reports a study of the prognosis of active pulmonary
tuberculosis in children. Of 267 children, fifty-one died. In
forty-six of these tuberculous meningitis or miliary tuberculosis
was the direct cause of death; the other five died as the result
of the pulmonary process. In /orty-eight of the fifty-one fata!

1450

CURRENT MEDICAL LITERATURE

Jour. A. M. A.
Oct. 7, 1939

cases, death resulted within one year after the admission to the
hospital. Thus it seems that, if the children outlive the first
year of illness, they have a good chance of surviving. The
prognosis differs greatly in the various age groups. Of fifty-
five children under 1 year, twenty-four died ; of fifty-six chil-
dren aged from 1 to 2 years, fourteen died ; of forty-one children
aged from 2 to 3 years, five died ; of eighty-five children aged
from 3 to 7 years, seven died, and of thirty children aged from
7 to 14 years, one died. On reexamination of 216 survivors,
only nine were found who were still ill. This indicates that
if the children survive the first year of illness they stand a
good chance of recovering completely. As roentgenography is
considered the most important method of examination, particular
efforts were made to elucidate what prognostic conclusions may
be drawn from the roentgenogram at the onset of treatment.
Tables indicate that the extension of the tuberculous processes
in the lungs is decisive in the prognosis, while the location of
the processes has no demonstrable significance. Nineteen
patients had miliary dissemination in both lungs ; seventeen of
these patients died while two recovered completely. Thus cases
of this form of tuberculosis are not to be considered altogether
hopeless. Exudative pleurisy was found in fifteen children ; none
of them died. All children were tuberculin positive. The
sedimentation test proved to be of but slight prognostic value.
Auscultation and the subjective symptoms provided no informa-
tion that was of prognostic value. * Extrapulmonary complica-
tions were rare and they appear not to aggravate the prognosis.
In 167 cases it was possible to establish the source of infection,
and it was intrafamilial in 120 of these cases. For children
over the age of 1 year the prognosis appears not to be less
favorable in those cases in which the source of infection is
known or even intrafamilial.

Nordisk Medicin, Helsingfors

2: 3723-1802 (June 10) 3939. Partial Index
Finska Lakaresallskapets Handlingar
-New Experiences with Hemorrhagic Diatheses. E. A. von Wiliebrand
and J. Olin. — p. 1743.

Three Cases of Transitory Myopia. R. Mattsson. — p. 1751.

Principles for Determination of Hemeralopia as Symptom of Vitamin A
Deficiency. C. E. Nylund.— p. 1754.

Hemorrhagic Diatheses.— Von Wiliebrand and Olin state
that in true hemorrhagic diathesis the hemorrhages are the
expression of injuries which affect the whole organism or a
certain organ in its entire extent and that they seem to occur
spontaneously or after insignificant traumas without establish-
able more marked exogenic injuries. Etiologically the following
types are distinguished: avitaminosis, hemorrhagic diathesis in
general, disturbances in nutrition, heredofamilial types, infec-
tious types, toxic types and hemorrhagic diathesis in diseases
of the blood. In the origin of hemorrhagic diathesis a number
of different factors are important, namely the blood chemistry,
the form elements, especially the thrombocytes, together with
the mechanism of bleeding and arrest of bleeding of the vas-
cular walls. In the group of pseudohemophilic disorders four
different types have been differentiated: hereditary hemorrhagic
thrombasthenia (Glanzmann), constitutional thrombopathy (von
Willebrand-Jurgens), the Naegeli type (Switzerland) and the
Jurgens type (central Germany). These four types are united
in a group termed hereditary thrombopathies. Common to the
«roup are heredity, dominant transmission and deficiency of the
thrombocytes together with the vascular weakness found in all
hemorrhagic diatheses. To aid in diagnosis, six different types
(Jurgens) may be set up : the avitaminotic the hemophilic, the
thrombopathic, the thrombopemc, the capillary toxic and the
hormonal type of hemorrhage.

Norsk Magasin for Laegevidenskapen
2 : 1803-1886 (June 17) 1939. Partial Index
•Osteosclerosis in Tuberculous Spondylitis. ^ JA«h-p 1831.

Thymus Cancer and Aplast.c Anemia. R. Opsahl. p.

Osteosclerosis in Tuberculous Spondylitis.— To make
clear the relation between the development of osteosclerosis and
destructive changes- in the course of tuberculous spondylitis,

Scheel studied seventy-seven cases of certain tuberculous spondy-
litis. In all the active cases the roentgenograms showed sclerotic
changes ; furthermore, the sclerosis was most marked in the
recent forms and was least marked in those of older date. In
increasing sclerosis there were simultaneous signs of activity in
the form of increased destruction, while in decreasing sclerosis
activity could not be established. The author says that accord-
ing to his results sclerosis, far from being a sign of healing,
points to activity'.

2: 1887-1962 (June 24) 1939. Partial Index
Hygiea

•Serologic Studies in Acute Pneumonia. G. Lofstrom. — p. 1927.

Serologic Studies in Acute Pneumonia. — Lofstrom says
that by the use of mixed vaccines and a slide agglutination
method the specific agglutinins against the thirty types of pneu-
mococci can be studied easily. His material comprises eighty-
seven cases (thirteen serum-treated cases of lobar pneumonia,
twenty-eight additional cases of lobar pneumonia, thirty-eight
of bronchial pneumonia, seven of acute infections of the upper
respiratory’ passages and one case of acute tuberculous pneu-
monia). In eighty-two cases pneumococci were established and
type determined and in fourteen cases streptococci were
demonstrated, which in eleven cases occurred together wit
pneumococci. In two cases examination of the sputum was
bacteriologically negative. In forty-two of the seventy-four non-
serum treated cases agglutinins appeared, occurring with grea
regularity in lobar pneumonia and with less regularity m
bronchopneumonia and infections of the upper respiratory pas
sages. In about two thirds of the cases only one type o
pneumococcus was found, and homologous agglutinins deve op
in the majority of these. Agglutinins not corresponding to e
pneumococci occurred in four cases. In about one third o e
material more than one pneumococcus type was present, n a
these cases there were agglutinins against only one type,
three cases there were specific agglutinins without any es a
lished pneumococci. Specific agglutinins against pneuinococ
are not found in the population in general. During a barra
epidemic agglutinins were established in nine of twenty-
carriers (Gard and Lofstrom). In acute pneumonia, agg" 11
develop between the fifth and the twelfth day. In five o
six fatal cases, agglutinins did not develop.. In cases trea
with sulfapyridine, agglutinins developed as in untreatc « •

In the thirteen cases of pneumonia in which serum trea
was given, the highest titer was usually established on ,c
after the treatment; in the ten cases treated during e ,
days of the disease the titer rapidly diminished and disapp
In the nine bacillary carriers with positive agglutinins an ^
five of the seven type I pneumonias and one of two yp ^
pneumonias, agglutinins were still present after ' rom r . ,| lC
four months. Under certain conditions antibodies occur "j
blood serum which cause swelling of the capsu es o
XXVII and XXVIII, sometimes also of types IX, A * ’
XVII, XVIII, XXI and XXIII. They are best studied oy
use of a dilution of the vaccines about twenty times 8
than in the regular slide method. Agglutination occurs
the swelling is most pronounced. Unspecific capsu ® - n f ec .

tne swelling is most pronounteu. ^ ^ . . • ; n f ec -

seems to occur regularly in pneumonias, less regu ar y ■ ^

tions of the upper respiratory passages. '

positive in 120 healthy young recruits,
acute respiratory infection the reaction became posi iv

The reaction was ;
During an epidemic ot
in about

te respiratory lniecuun u.c

one third of 157 soldiers. Complications developed c
the cases with positive capsule swelling reaction. twelve

with fever above 39 C. (102.2 F.) complications occurredt^
times in the 36 per cent with positive reaction as ag of

in the 64 per cent with negative reaction. In eig ; n

lobar and bronchial pneumonia the reaction was ps ^
the first blood specimen, that is on the first o e was

of the infection. In the twelve cases m which the c J ^
uneventful the reaction became negative between [ion

the twelfth day; in the other cases, in which ^

remained positive, pleuritic exudate and serum ^ no(

oped and four of the cases were fatal. The "“ ‘ f Aberncthy
seem to be identical with the intracutaneous tes
and Francis.

The Journal of the
American Medical Association

Published Under the Auspices of tho Board of Trustees

Vol. 113, No. 16

CorVRioiiT, 1939, nv Americas Medical Association

Chicago, Illinois

October 14, 1939

THE POSTOPERATIVE CARE OF THE
URINARY BLADDER

J. DONALD WOODRUFF, M.D.

AND

RICHARD W. TE LINDE, M.D.

BALTIMORE

Ever}' one with any surgical experience will agree
that difficulties in voiding play a major role in post-
operative discomfort. The closer the field of operation
approaches the bladder region, the greater the difficulty
in voiding spontaneously and the greater the discomfort
from overdistention. Hence, the postoperative care of
the bladder concerns the gynecologist more than any
other surgeon. In recounting their hospital experi-
ences, patients frequently mention the discomfort from
overdistention or from catheterization among their
most unpleasant memories. There is, however, an even
more important reason than the patient’s comfort for
the proper handling of the bladder after operation.
Many chronic and serious urinary tract lesions have
their origin in mismanagement of the bladder at this
time. In our experience in female urologic conditions
we have been struck with the frequency with which
patients date their illnesses from trouble in emptying
the bladder after operation.

In 1925 a routine was established in the gynecologic
service of the Johns Hopkins Hospital which had for
its purposes the promoting of postoperative voiding
and minimizing the use of the catheter. The procedure
consists of the instillation into the bladder of 1 ounce
(30 cc.) of 0.5 per cent aqueous solution of mercuro-
chrome at the conclusion of the operation, while the
patient is still on the operating table. Here sterile
technic should be at its best as well as easiest. At the
same time the patient is given rectally 1 liter of 2 per
cent sodium bicarbonate solution containing 60 cc. of
liquid petrolatum. This rectal instillation of fluids was
borrowed from the clinic of the late John G. Clark
of Philadelphia. It has for its purpose the insurance of
a good alkaline fluid intake during the early postopera-
tive period and the softening of the fecal material in
the lower part of the bowel, which it is hoped will
facilitate early defecation. It was also thought that an
adequate early fluid intake would give the bladder
‘‘something to work on” in its early attempts at empty-
ing itself. Whether the giving of this fluid by rectum
has any beneficial effect in bringing about early mictu-
rition will be discussed later in considering the results
of our experience. The originator of the idea that a

From the Gynecological Department, Johns Hopkins University.

Read before the Section on Obstetrics and Gynecology at the Ismetieth
ioVr. ua Session of the American Medical Association, St. Louis, May lo,

bladder instillation of mercurochrome might facilitate
postoperative voiding is not known to us.

The favorable results of our early experiences were
reported by Craig 1 in a western journal in 1930. As a
result of this there has been an adoption of the pro-
cedure in some clinics on the West Coast, but generally
it is little used. Our results over a long period have
been so satisfactory in cases of pelvic laparotomy that
we believe they should be brought to the attention of
the general profession.

In 1914 Taussig 2 concluded from his study that the
danger of infection from catheterization lay less in
the technic than in urinary stagnation. Curtis 3 has
repeatedly emphasized that simple catheterization at
times other than in the postoperative period is relatively
harmless. Our experience confirms the views of both
of these men. In our outpatient department and in
private practice we pass catheters several times a day
to obtain urine for diagnostic reasons. We have never
had any reason to believe that this procedure has been
responsible for a urinary tract infection. Our technic
in the outpatient department is simply to swab the
urethral meatus with two successive toothpick swabs
dipped in 5 per cent mercurochrome. Because of the
undesirable staining qualities of mercurochrome, we
have substituted an aqueous solution of 1 : 1.000 mer-
thiolate in the office with equally satisfactory results.
With this technic the bacterial flora about the meatus
is reduced, but we do not claim for it complete sterili-
zation of the meatus and certainly not of the outer
urethra. Undoubtedly some bacteria are introduced
into the bladder, but in spite of this we have never seen
cystitis occur. The ability of the patient to empty her
bladder completely at subsequent voidings apparently
prevents the development of cystitis. In dealing with
the bladder postoperatively, one is confronted with the
additional factor of residual urine. That there is prac-
tically always residual urine postoperatively, even when
the patient voids from the beginning, has been well
demonstrated by Taussig. 2 He compared the total
amount of urine voided in a given time in a group of
thirty who voided spontaneously with the total amount
obtained by catheter in a group of thirty over an equal
period. An average of 5 ounces (150 cc.) more of urine
was obtained by catheter from each patient. That there
is residual urine for a time in those patients who have
required one or more catheterizations has been demon-
strated innumerable times by all who practice catheteri-

1. Craig, Robert G.: Bladder Care After Abdominal Operations.
California & West. Med. 32:162 (March) 1930.

2. Taussig, Fred J.: Bladder Function After Confinement and After
Gynecological Operations, Tr. Am. Gynec. Soc. 40: 351, 1915.

3. Curtjs, Arthur H.: The Bladder of Women After Operation: A

Consideration of Postoperative Bladder Disturbances, with Special Regard
to Treatment, Based on a Study of This Subject in the Care -of 465
Ca? e s Operated Within the Last Eighteen Months, Am. J. Obst. 78:
lla inVc 8 ' A R c S . ld V al Ripe in Women, Surg., Gynec. & Obst. 50:

689 (May) 1925; A Study of Bladder Function, ibid. 29: 24 (July) 1919.

1452

CARE OF BLADDER— WOODRUFF AND TE LINDE

Jour. A. J[. A.
Oct. H, 1939

zation _ for residua! urine after the resumption of
micturition. Once one has catheterized a patient post-
operative^ and presumably introduced a few bacteria, it
becomes important to prevent stasis of residual urine on
resumption of voiding. We watch the patient carefully
after catheterization ; if the frequent voiding of small
amounts or quickly recurring bladder discomfort after
voiding of even larger amounts suggests residual urine
we catheterize at least once daily until the residue is
reduced to 50 cc. or less. Our experience in reducing the
incidence of urinary tract infections by this routine has
convinced us of its importance. However, all students
of this subject admit the desirability of doing away with
the catheter entirely if possible. Any procedure which
makes a real advancement toward this end is worthy
of consideration.

Most reports on methods of promoting voiding are
concerned with inducing the bladder to empty itself
after postoperative retention has occurred. The usual
procedures of running water, putting warm water in
the bedpan, giving enemas, irrigating the perineum and
elevating the patient to a partial sitting position are
known to all surgical nurses and physicians. They
undoubtedly are of value, especially in those cases in
which the psyche plays a large role. Drugs have been
used extensively. Several years ago some rather enthusi-
astic reports appeared on the use of solution of poste-
rior ..pituitary, but subsequent experience has proved
disappointing. The parasympathetic stimulators dorvl
(carbaminolcholine chloride) and mecholyl (acetylbeta-
methylcholine chloride) have been used widely with
some success. Doryl was first used clinically by Schulze, '
who noted success in 80 per cent of a large series of
patients with urinary retention after childbirth and
gynecologic operations. Subsequently the drug has
been used in England 5 and in this country with con-
siderable success. Constitutional disturbances such as
sweating, fainting, salivation, vomiting and a drop in
blood pressure are noted in about one third of the cases.
The writers on the subject do not consider these symp-
toms alarming. In our clinic we have had a limited
experience with mecholyl administered by mouth in a
dose of 25 mg. and we have had some success. We
have seen no serious constitutional effects. Administered
hypodermically, however, we feel that it is dangerous
and the alarming constitutional effects far outweigh the
beneficial effects in promoting voiding. In two instances
we have been greatly alarmed by the sudden onset of
profuse sweating, salivation, fainting, involuntary urina-
tion and defecation and a marked drop in blood pressure.
In another institution in this city the hypodermic
administration of 25 mg. of mecholyl resulted in death
before the antidote of atropine could be adnunisteied.

The injection of irritants into the full bladder has
been used to induce voiding. Baisch 6 advised the injec-
tion of 20 cc. of 2 per cent boroglycerm solution into
the full bladder, but Taussig 3 thought that this was
responsible for cystitis in certain cases. Taussig - noted
on doing air cystoscopy the not infrequent tendency of
the bladder to contract as the air rushed in. He there-
fore tried the injection of several ounces of air into the
full bladder as a mild vesical irritant and reported suc-
cess in nine of eleven cases.

4 . Schulze, Eberhy ' 1 7 .-\ Ti " " '\ r ..

Wochenbett und nac . ;■ ■. ■ ■

Wrhnschr. 82! 135S . .* 11 • •

11 WU &? ». JTBfjS te-

Use of Poo-J 'in Postoperative and Postpartum

ibid 1:261 (Jan- 30) 1937.

6, Baisch, cited by Taussig:. 2

HarnverhaJtung im
, Munchen. med.

c- .dive Retention of
Moir, Cbassar: The
Retention of Urine,

The method under discussion in this paper approaches
the problem from a different angle. Our procedure is
an attempt not to empty the distended bladder but
rather to prevent distention by inducing the patient to
void early.

In our series there were 500 pelvic laparotomy
patients who were given the mercurochrome bladder
instillation and the fluid by rectum in the operating
room. Six and six-tenths per cent of these patients -
required one or more catheterizations. In a control
series of 257 patients with pelvic laparotomies, done at
another hospital, 51 per cent required catheterization.
In this institution the routine postoperative order was
for eight hour catheterization if necessary, whereas in
our group the order was for catheterization twelve hours
after the operation, if necessary, and after this every
eight hours. This difference in orders, however, affected
the time of first catheterization very little, for in the
control group the average time after operation at which
the first catheterization was done was ten hours and
twenty-four minutes, whereas in our group it was ten
hours and fifty-three minutes. The percentage of cathe-
terizations in the control group is considerably higher
than in many series reported in the literature, but both
of our groups represent, for the most part, extensive
pelvic laparotomies. The conclusion seems to be justi-
fied that catheterization has been reduced in our series
to almost one eighth by this simple procedure.

We attempted to determine what effect the adniinis-
tration of fluid by rectum had on postoperative voiding.
We were able to collect records on only fifty-four cases
of laparotomy in which the bladder instillation v' as
given but the fluid by rectum omitted. Five and six-
tenths per cent of the patients required catheterization.
Although this series is small we believe that it indicates
that the essential part of our procedure is the bladder
instillation ; although we feel that the fluid by rectum
is desirable for other reasons, we do not believe that it
facilitates voiding.

The time and amount of first voiding in our lapa-
rotomies are interesting and instructive. For 551 lapa-
rotomy patients who received our routine treatmen ,
the average time of the first voiding was five hours ant
thirty minutes. For the control series of 132 patients,
who did not receive this postoperative treatment, tie
average time of first voiding was nine hours ant
twenty-six minutes. For a series of 495 patien s
receiving routine treatment, the average amount of t ie
first voiding was 194 cc. whereas for a control senes
of 125 patients, who voided without catheterization
and without treatment, the average amount was loo c c -
These data seem to show that by means of this ro u m
the patients more completely emptied their bladder >
for in five and one-half hours more urine was obtaine
than was voided in almost double the time by a con r ^
series. Considering the importance of complete emp}
ing of the bladder in relation to the prevention o
urinary infection, we believe that this accomphslime
is a strong point in favor of our procedure.

The mode of action of the mercurochrome in pr
moting voiding has interested us; we believe it is
to a temporary' chemical irritation of the bladder,
sionalft a little microscopic blood can be noted m
first specimen, but in only one case in our senes w
there gross hematuria. Often the patient calls 0
bedpan as she is arousing from the anesthetic an
plains of a marked desire to void before sufncici
has elapsed after operation to allow an Jjppr c
amount of urine to collect in the bladder. The

Volume 113
Number 16

CARE OF BLADDER— WOODRUFF AND TE LINDE

1453

irritation usually disappears in twenty-four" hours.
Although the average first voiding is 194 cc., the
amounts of subsequent voidings rapidly increase and
we believe it is a reasonable assumption that complete
emptying of the bladder is soon obtained.

The influence of the duration of the anesthetic con-
firms an impression which, we are sure, has been noted
by most surgeons. We arbitrarily divided our lapa-
rotomy patients into two groups. In the first group,
containing 227, the duration of anesthesia was less than
one and one-half hours; 4.4 per cent of these required
catheterization. In the second group, of 272. the dura-
tion of anesthesia was more than one and one-half
hours and 7.4 per cent required catheterization. We
were also interested in noting the effect on voiding
of avert in with amylene hydrate as a basal anesthetic.
In 280 cases in which this was used, supplemented by
ether, 8.2 per cent of the patients required catheteri-
zation. In 217 cases gas, oxygen and ether were used
and only 3.7 per cent required catheterization. It seems
reasonable to suppose that the latter group recover
more quickly from the anesthetic and hence are more
acutely sensitive to the impulse to void. On the other
hand, the avertin group are lethargic for most of the
day of operation and hence less aware of their full
bladders, which therefore require catheterization in a
larger percentage of cases.

Although the postoperative comfort of the patient is
of great importance to her, the avoidance of a persistent
urinary tract infection is even more essential in the
long run. We therefore made a study of our cases from
that point of view. We sought to determine how many
of our patients had evidence of cystitis on discharge
from the hospital. In only one of the 500 cases was a
bladder symptom present on discharge, and this con-
sisted of only slight frequency but no burning. It was
noted in the patient’s history that she had had an
attack of frequency and burning several years prior
to admission, but her urine on admission was normal
microscopically. Despite the symptoms just noted, the
urine culture was negative on discharge.

Among the 500 patients who received our treatment,
two developed pyelitis postoperatively, but in both cases
there was a history of previous urinary tract infection.
A short summary of these two cases follows :

Case 1. — The patient complained of nocturia, having voided
three to four times per night for two years, and of dysuria
for three months before admission. The urine, however, was
clear microscopically on admission, but no culture was made.
On the third postoperative day the patient had a temperature
of 103.2 F. and on the fourth day Bacillus coli was cultured from
the bladder urine, which contained many white blood cells.
On the fifteenth postoperative day the urine culture again showed
B. coli but the patient had no symptoms. She was discharged
on the twentieth postoperative day, still with a low grade fever.
Twenty days later she returned to the hospital with typical
acute pyelitis. She was treated with sulfanilamide and the
urine became sterile. On discharge, after ten days of therapy,
the patient was symptom free.

Case 2. — On admission the patient gave a history of nocturia,
voiding twice a night, and catheterized urine showed occasional
clumps of white blood cells. The postoperative course was
not remarkable and she had been allowed to walk. On the
twentieth da}' she had a chill and a temperature of 104 F. The
urine was loaded with white cells, and B. coli was cultured.
I he temperature became normal on the twenty-eighth day but
the culture was still positive. Subsequent follow-up study in the
dispensary revealed no residual urinary disturbance.

Here, then, are two cases of postoperative pyelitis
and one of mild bladder symptoms in our series of 500

cases, but all three patients had histories of previous
urinary tract infection. Let us compare these results
with those of our control series of 249 laparotomy
patients from another hospital. The postoperative his-
tory notes were less complete than in our series, so
details such as notes on cultures and catheterized speci-
mens were often lacking. However, in this group there
were five cases of clinical cystitis and two of pyelitis.
In none of these was there an}' evidence of preexisting
urinary tract infection, but as before mentioned the
histories were not as complete as those in our own
series. Comparing these results with those of our own,
we believe that we are justified in concluding that
urinary tract infections are less frequent in patients
treated according to our routine. In fact there was no
postoperative infection in any patient who did not have
a previous history of infection.

Our results with this procedure after the vaginal
plastic operations were less successful. In fact our study
shows that the procedure is of no value in promoting
voiding after extensive vaginal operations. In our
series of fifty-nine vaginal plastic cases, which includes
twenty-five interposition operations, 58 per cent of the
patients required catheterization. In our control series,
in which patients did not receive our treatment, there
were sixty-two cases, including twenty-eight inter-
position operations. Exactly the same percentage (58)
of the patients required catheterization. Our clinical
impression has been that the Watkins interposition
operation offers the greatest difficulty with postopera-
tive voiding. Our statistics bear out this impression,
for after a total of fifty-three interposition operations
in both series 72 per cent of the patients required
catheterization.

Since there is nothing in our statistics to indicate
that our procedure is of any value in promoting void-
ing after extensive vaginal plastic operations, we have
returned to the use of an indwelling male catheter for
the first week. Certainly with the interposition operation
this is the logical procedure, as only 28 per cent of the
patients voided spontaneously. There is little doubt
that infection travels into the bladder via the indwelling
catheter, but this is apparently of little significance since
few of these patients have bladder symptoms following
removal of the catheter. When it is removed at the
end of a week the bladder has generally so regained its
tone that spontaneous and complete micturition follows.
If there is any indication of residual urine the patient
should be catheterized until it has been proved that
such a residue no longer exists.

The importance of avoiding overdistention of the
bladder was well illustrated in one of our interposition
cases. _ The patient began to void spontaneously post-
operatively but voided frequently and in small amounts
without relief. She was finally catheterized on the third
day, and 700 cc. of urine was obtained. In the next
twenty-four hours she was catheterized for great dis-
tress three times, and 800 cc., 700 cc. and 450 cc. of
urine were obtained successively. On the fourth post-
operative day her temperature rose to 103 F. and she
had costovertebral tenderness on the right. On the fifth
day an indwelling catheter was inserted, and the tem-
perature became normal in twenty-four hours. This
case also indicates that a routine order for catheteri-
zation every eight hours if the patient voids less than
100 cc. at one time is not entirely satisfactory. This
patient voided as much as 200 cc. at a time but appar-
ently only as an overflow. She should have been cathe-
terized for bladder distress long before her bladder

1454

CARE OF BLADDER— WOODRUFF AND TE LINDE jonuuu

Oct. H, 1935

became so distended, but the nurse, adhering literally
to the 100 cc. rule, failed to pay proper attention to the
patient’s distress. With such severe bladder discomfort
the nurse should have called the intern, who undoubtedly
would have ordered catheterization earlier.

SUMMARY

A special technic to promote postoperative voiding
consists of instilling into the bladder 1 ounce of 0.5 per
cent aqueous solution of mercurochrome in the operating
room. The results after pelvic laparotomies have been
very gratifying, the incidence of catheterization having
been reduced from 51 per cent in a control series to
6.5 per cent in a series of 500 cases in which this pro-
cedure was used. An instillation of a liter of fluid by
rectum at the same time was found to be of no value
in reducing the incidence of catheterization. Evidence
has been presented to show that the patients in whom
the instillation was used voided earlier and in greater
amounts, thus more completely emptying the bladder
than the patients in the control series. It has been
shown that the shorter the anesthesia the greater the
likelihood of spontaneous postoperative micturition.
The patients receiving a basal anesthesia of avertin
with amylene hydrate required catheterization in 8.2 per
cent while those given straight gas, oxygen and ether
required catheterization in only 3.7 per cent. Post-
operative urinary tract infection, as judged by symp-
toms of cystitis on discharge and pyelitis, did not occur
after any of the 500 laparotomies in which the pro-
cedure was carried out, with the exception of three
cases. In each of these there was a definite history of
urinary tract infection preoperatively. The procedure
has been shown to be of no value in case of extensive
plastic operation, in which an indwelling male catheter
is considered the most satisfactory procedure.

ABSTRACT OF DISCUSSION
Dr. George H. Gardner, Chicago: An idea! method of
managing the bladder after gynecologic operations should be
equally effective after all types of operations, cause the patient
a minimum of discomfort, safeguard the integrity of sutures
that have been placed near the bladder, and finally not only
eliminate acute complications of the upper urinary tract from
postoperative problems but also obviate chronic conditions in
the lower urinary tract as permanent sequelae of gynecologic
surgery. The technic which Dr. Arthur H. Curtis described
and° which has been the routine in our service at Passavant
Memorial Hospital for ten years is a close approach to the ideal.
Our patients are subjected to intermittent catheterization; they
do not have indwelling catheters. They are catheterized for
distress, not after any specified number of hours, but for any
marked’ discomfort which may be ascribable to a distended
bladder We endeavor to avoid- overdistention and consider the
accumulation of more than 350 cc. of urine as being potentially
harmful After a woman has been catheterized two or more
times or has worn an indwelling catheter, her bladder is infected.
Such an infection rarely attains significant proportions, if the
physician and his staff are residual urme conscious. Conse-
quently, after our patients start to void they are catheterized
once or twice daily for residual urine until that residual is
persistently less than 15 cc. in amount and is grossly clear. I
prefer intermittent catheterization with routine check for resid-
ual urine, because this method is equally applicable to all patients
and we realize that simplicity in hospital routine makes for
more efficient care of patients. We do not favor retention
catheters, either male or de Pezzer, because they give one a
false sense of security; indwelling catheters do not always drain
the bladder completely, as they tend to become ffisplaced and
Dlu^ced After a retention catheter has been removed it is
vital that the patient be checked in a routine way for residual

Dr. William T. Kennedy, New York: Nature has to
overcome obstacles to restore the bladder to normal following
pelvic or vaginal operations. First, some patients come lor
operation having been below , par physically ; • they have very
mild, low grade infections of the upper urinary tract, .with some
desquamation. This at operation suddenly becomes more active
and for the first few postoperative days the sediment in the
bladder is increased; this with the associated loss of musdc
tone of the bladder permits the accumulation of a precipitate
which on standing breaks down, into the alkaline ammonia salts
to irritate the base of the bladder. Only part of this precipitate
passes out when the patient voids. ■ Nature has two resources:
one, to increase the flush from the kidneys ; the other, to send
bacteria in to clean up this mixture of mucus, desquamated
cells, and so on. The colon bacilli are those elected. Hoiv
they get in I do not know, but I doubt that it is through the
urethra. Here is our opportunity to help nature. The first
catheterization for residual urine is done and it is allowed to
stand for a couple of hours for sedimentation. If sediment is
present, the bladder is irrigated with boric acid solution and
an ounce of 10 per' cent solution of caroid or papain instilled
into the bladder. This will materially aid in clearing up the
base of the bladder. This is repeated daily for three or four
times. Instillation of antiseptics at this time would only inhibit
nature’s bacterial processes. With the recent advent of neo-
prontosil, I feel that much could be accomplished in preventing
this complication by giving the drug three or four days before
operation. Second, the next obstacle to overcome is the dimin-
ished function of the kidneys. This is best activated bj
clysis or intravenous saline solution or dextrose, as well as all
the fluids which can be tolerated by mouth. Drs. Woodruff
and Te Linde found that the recta! instillation had little effect
on the bladder. Most fluids are used by the body in counter-
acting dehydration. The return of the urine flow 'to "t> r ™
may roughly be estimated by the excretion of 400, 500, lA
and 1,600 cc. on the first four successive days. Third, tie
next obstacle nature has to overcome is ■ the loss of Had cr
muscle tone either when the -bladder structures have been
unmolested or considerably disturbed by operative procedures.
Comparing the treated cases with the untreated controls or
the time of first voiding and the amount voided, one is amaze
that the treated bladder voids more urine than the. untreate
one and almost twice as soon. The kidneys were .either more
active or there was less residua! urine, and I am force
believe there was less residual urine. The authors have ma
definite progress in eliminating this worst offender (resi u
urine). In the care of the bladder after operation I usc
indwelling male catheter for about a week, watch me un
carefully for sediment and, if it. appears, irrigate the ba
and instil caroid or papain solution into it. After the cat c
has been removed I catheterize the patient twice a da> ,m *
diately after voiding until the residual urine is one-half ou
or less.

Greater Mortality Among Males. — About one <3 ua 0 ;
the known pregnancies result in stillbirths. Great nurT * . - n
these aborted babies have been examined, and some sur
data obtained. In embryos aborted when they are a ou ^
months old, specialists can already distinguish sex, an >
early mortalities they have found that the males ou
the females almost four to one. These, however, are 11 .

percentage of the total stillbirths. In those in the four 1 ^

aborted males are double those of females, in the U . n
145 males to 100 females, in the next few months the P r ’ . (
drops further, but just before birth there is a rise . °„ nr) thcr
140 males aborted to every 100 females. All this leads 0 att
conclusion : That before birth, certainly, males as a c
not only not stronger than females but, quite on t ie ^
are weaker. - If we. look beyond birth we find, more. ' > ^
at almost every stage of life, males drop out at a . is v atu fe
than, females. It may very’ well be, then, that a ca n nj ; n
enters more males than females at the start ot > c e j n f e I(f,
order to counterbalance the difference in mortality. c.npes
Amram: You and Heredity, New York, Frederick
Company, 1939.

Volume 113
Number 16

PRIMARY PERITONITIS— LADD ET AL.

1455

PRIMARY PERITONITIS IN INFANTS
AND CHILDREN

A MORE EFFECTIVE TREATMENT

WILLIAM E. LADD, M.D.

THOMAS W. BOTSFORD, M.D.

ANI)

EDWARD C. CURNEN, M.D.

The types of pneumococci isolated in peritonitis have
not been noted in the majority of publications on the
subject, but those reported show a preponderance of
the type I pneumococcus. 3 In the present series of
cases there were five of type I, four of type VI, two of
type V and one each of types IV, VIII, X, XI, XVIII
and XXII. No conclusions can be drawn from the
available material as to the relation of the type of
pneumococcus to the severity of the peritonitis.

ROSTOV

Primary, idiopathic or metastatic peritonitis has
always been associated with a very high mortality rate
in infants and children. In recent years, with the use
of sulfanilamide and antipneumococcus serum, we have
markedly lowered the mortality rate in this disease
and have revised our therapeutic approach. It is our
purpose in this paper to present an effective treatment
of the disease and the information gained from sixty-
seven cases of primary peritonitis observed in the ten
year period 1929-1939 at the Children’s Hospital.

ETIOLOGY

The offending organism in primary peritonitis is
usually the pneumococcus or the hemolytic streptococ-
cus. Three patients with primary peritonitis, not
included in this series, were encountered in whom no
organisms were demonstrable by direct smear or culture
of the peritoneal exudate. The streptococcus was found
more than twice as frequently as the pneumococcus,
since there were forty-seven cases attributable to the
former and twenty cases to the latter.

The pathways by which the organism may enter the
peritoneal cavity have received detailed consideration
in previous reports. 1 The possible inodes of entry are
by way of (1) the blood stream, (2) the vagina and
fallopian tubes in females, (3) the gastrointestinal tract
and (4) the transdiaphragmatic lymphatics.

In the present series blood cultures were made on
twelve patients with pueumococcic peritonitis, and ten
of these were positive. Similar cultures were made on
eighteen patients with streptococcic peritonitis, and four
were positive. Cultures of material from the vagina
were taken of three patients with pueumococcic peri-
tonitis, and one yielded the same type of pneumococcus
as that isolated from the peritoneal cavity. Vaginal
cultures were taken of six patients in the streptococcus
group, and three were positive for hemolytic strepto-
cocci. Cultures of material taken from the throat of
five patients with pneumococcic peritonitis failed to
reveal the offending organism, although in each other
types of pneumococci were isolated. In the strepto-
coccus group, four throat cultures were made and two
of these were positive for hemolytic streptococci.

Of the forty-one patients who died, twenty came to
autopsy, including eight females. In no instance was
there evidence of an ascending infection along the
genital tract. 2 In the 'absence of more convincing evi-
dence concerning the other possible routes, we feel that
the probable mode of entry is by way of the blood
stream.

From the Departments of Surgery and Pediatrics of the Children’s
Hospital and the Harvard Medical School.

1. McCartney, J. B., and Fraser, J.: Pneumococcus Peritonitis, Brit.
J- burg. 9 : 479.489 (April) 1932. Obadelek, W. : Die Friihoperation der
1 1 A m ^Peritonitis im Kindesalter, Zentraibl. f. Chir. 58: 1250-

*448 (May 16) 1931. Rischbiatli, H. : On Pneumococcus Peritonitis,
yuan. J. Med. 4 : 205-231, 1910. Glazier, M. M.; Goldberg, B. I., and
rmvrm, A. A.: Primary Pneumococcic Peritonitis: Recovery of the
Acme Serous Type Following Type I Serum Treatment Without Surgical
intervention, Ann. Int. Med. 10: 1042-1049 (Jan.) 1937.

4. barber, Sidney; Personal communication to the authors.

AGE AND SEX

The disease is much more common in the first four
years of life, as shown in the accompanying chart.
Streptococcic peritonitis has its highest incidence dur-
ing infancy, whereas pneumococcic peritonitis predomi-
nates between the ages of 2 and 7 years. The latter
observation is in accord with the observations of
McCartney and Fraser. 1

There were no appreciable differences in the sexes
in the total group or when they were divided into their
etiologic groups (table 1). However, it is to be noted
that six of the male patients in the pneumococcic group
had nephrosis whereas only two females of the same
group had nephrosis. Excluding the patients with

AGE IN YEARS

Incidence of primary peritonitis according to age.

nephrosis, there would be a definite preponderance of
females in the pneumococcic group, an observation that
has been emphasized repeatedly. 4

CLINICAL FEATURES AND DIAGNOSIS

Primary peritonitis was preceded by an infection of
the upper respiratory tract, mild or severe, in more than
one half of the cases. In several cases there had been
a previous otitis media or a cervical adenitis. The
onset was acute and was associated with fever, abdomi-
nal pain, nausea and vomiting. The abdominal pain
may be difficult to localize in infants and children, but
in a large number of instances it appeared to be peri-
umbilical. Diarrhea was a common symptom and at
times was profuse. The diarrhea, if present, usually
appeared in the first thirty-six hours of the disease.
Some of the common symptoms and their incidence
are listed in table 2.

On physical examination, patients with primary peri-
tonitis appear severely ill and are frequently prostrated.
Signs of infection of the upper respiratory tract may
be present. The temperature is elevated between 103
and 105 F. and the pulse is correspondingly rapid. The
abdomen is diffusely tender throughout and the general-

j. .Leonardo,

00 . 4,1 pneumococcus Peritonitis, Ann. Surg.

S»*. 413-416 (March) 1926. Donovan, E. J. : Surgical Aspects of
(Nw a ) r> 'l934 eUmOC ° CCUS PentQmtxS ’ Atn< J* Bis. Child. 48; 1170-1173

1456

PRIMARY PERITONITIS— LADD ET AL.

Jovg. A. M. A.
Oct. 14, 1939

ized involuntary spasm may be boardlike. In infants
up to 2 years of age, however, the abdomen may be
“doughy” rather than spastic to palpation. Abdominal
distention of varying degree may be present. Rectal
examination reveals diffuse tenderness, although occa-
sionally a pelvic abscess is detected. The remainder
of the physical examination is remarkable in that it
reveals nothing severe enough to account for the “toxic”
picture. The leukocyte count varies between 20,000 and
50,000, with more than SO per cent polymorphonuclear
leukocytes. Urinalysis usually reveals the presence of
acetone.

It is impossible to differentiate between streptococcic
and pneumococcic peritonitis clinically', but we feel that
primary peritonitis can usually be distinguished from

Table 1 . — Incidence of Primary Peritonitis According to Sex

Primary Peritonitis Males Females

All cases 33 34

Pneumococcic 9 11

Streptococcic 24 23

secondary peritonitis. In the present series the correct
diagnosis of primary peritonitis was made in 64 per
cent of the cases on entry. We do not agree with the
statement of Leopold and Kaufman 1 that “a definite
clinical diagnosis of peritonitis cannot be made without
operation or abdominal tap.”

The condition most likely to be confused in diagnosis
is acute perforated appendicitis with generalized peri-
tonitis. However, in primary peritonitis there often
has been a preceding infection of the upper respiratory
tract. The age is important, as appendicitis is infre-
quent in the first two years of life. The patient is sicker
from the onset, which may be initiated by a chill, and
diarrhea is more likely to be associated with primary
peritonitis than with appendicitis. Furthermore, the
abdominal signs are more generalized and the fever is
higher. The leukocyte count is usually higher than
in peritonitis of appendical origin. It is obvious that
in some instances the diagnosis between primary and
secondary peritonitis will not be clear until the character
of the peritoneal exudate is studied.

TREATMENT

sick patients. 2. The results are never equivocal.
3. Drainage is established, which we feel is of consider-
able value, although we realize that it is impossible to
drain the entire peritoneal cavity. 4. The procedure is
not shocking and does not upset the patient. 5. If the
peritonitis is due to appendicitis, the incision is easily
enlarged for an appendectomy. Abdominal paracentesis
lias been advocated 5 as the procedure of choice for
recovering organisms from the peritoneal cavity. We
do not recommend it because, (1) if the results are
negative, primary peritonitis has not been ruled out;
(2) if the peritonitis is of appendical origin, appendec-
tomy' cannot be performed, and (3) the needle may
enter a loop of bowel, which may' do no harm but is
undesirable.

The gross appearance of the peritoneal exudate is
important. In pneumococcic peritonitis the exudate is
odorless, fibrinous and soapy, while in streptococcic
peritonitis it is odorless and thin and contains small
flecks of fibrin. As soon as' the exudate is obtained it
is stained by' Gram’s method and cultured on blood
plates, beef broth and human ascitic fluid. If the pneu-
mococcus is present it will usually' grow out in the
human ascitic fluid within three hours and then can
be ty'ped. The stained smear gives an immediate clue
as to the identity' of the organism. It is apparent from
the foregoing that the specific therapy' can be instituted
within several hours after the patient enters the hos-
pital. The administration of the specific therapy; vnll
be discussed later.

The after-care of the patient is very important. B ,e
patient is placed in a high Fowler’s position and given
morphine sulfate subcutaneously every four hours bj
the dock for the first thirty-six to forty-eight hours.
Hot flaxseed poultices are applied to the abdomen every
three hours. The water balance is maintained by intra-
venous injections of 10 per cent dextrose solution an
hypodermoclyses of physiologic solution of sodium
chloride. Blood transfusions are liberally employed o
anemia or hypoproteinemia. If the patient does no
vomit and there is no distention, water and dilute ru
juices are given by mouth several hours aftei oper

Table 2. — Common Symptoms: Incidence

Cafes

As soon as the clinical diagnosis of primary peritonitis
is made, the organism responsible must be recovered
in the quickest possible manner in order that specific
therapy can be instituted. Our method of choice for
recovering the organism is operative. The patient is
given parenteral fluids if indicated and then taken to
the operating room, where under local or cyclopropane
anesthesia a 1 inch muscle-splitting incision is made in
the right lower quadrant. The peritoneum is merely
nicked, and sufficient exudate for smear and culture is
obtained by swab or gentle aspiration through a rubber
catheter. A Penrose drain is inserted and the wound
is closed to the drain with two or three sutures. It is
important to point out that no exploration is performed
and that the purpose of the procedure is to recover
peritoneal exudate and incidentally' to insert a drain.
The advantages of this method for recovering the organ-
ism are that: 1. It is a minor operation and can be
performed under local anesthesia in infants and very'

4. Leopold, J. S., and Kaufman R. E- : 7 Acu \TrL'nnP-
Peritonitis, J. Fed. 10:45-65 (Jan.) 1937. McCartnej
Glazier, Goldberg and Weinstein.

Streptococcus
and Fraser. 1

Fever

Abdominal pain

Nausea and vomiting..

preceding respiratory infection

Diarrhea

Constipation

Vagina] discharge (34 females)..

66

66

31

41

35

•23

4

on. Fluid by mouth is increased gradually an
miisoiid diet is readied by the third or fourt i P
perative day. If there is vomiting or distention,
rant gastric siphonage is employed. We have t
le high concentration of oxygen as advocated >
nd his associates 0 to be a valuable addition ^
■eatment of distention in patients with primary p
>nitis. The wound is dressed frequently enoug ,

;ep it dry. The sutures are removed from the " . .
i the seventh postoperative day, and the ab oi_ _ — __

5. Neahoff, H., and Cohen, J.: Abdominal Puncture^" tbc

Acute Intraperitoneal Disease, Ann. Surg. w > /jfarcb)

>le, W. E.: Pneumococcus Peritonitis, Surgery Xi M _
3/1 Leopold and Kaufman. 4 . p ur ther CI»n ,c £

6. Fine, J.; Hermanson, L. t and Frehlmg. S.. from

cperiences with 95 per Cent Oxygen for Absorption of A
ssues, Ann. Surg. 1071 1*13 (Jan.) 1938.

Volume 113
Number 16

PRIMARY PERITONITIS— LADD ET AL.

1457

drain is removed between the seventh and tenth post-
operative days. It is of interest that only two patients
in this scries required an enterostomy for intestinal
obstruction following primary peritonitis.

SPECIFIC THERAPY IN STREPTOCOCCIC
PERITONITIS

The dosage and method of administering sulfanil-
amide in use at the Children’s Hospital have been
reported previously by Carey. 7 In primary peritonitis,
treatment with sulfanilamide may be instituted as soon
as the patient lias returned to the ward from the operat-
ing room, even before the results of the peritoneal
culture are known. If a pneumococcus is isolated,
sulfapyridine may be substituted and continued in con-
junction with specific serum therapy. The initial dose
of sulfanilamide may be given by hypodermoclysis of
an 0.8 per cent solution in physiologic solution of sodium

to have symptoms of acute appendicitis and an explora-
tion was performed immediately. Operation revealed
the true nature of the disease and pathologic examina-
tion of the appendix showed only periappendicitis. In
all cases the bacteriologic diagnosis was established by
cultures of the peritoneal cavity obtained at operation.
Early operation was performed in all but two of the
cases (cases 2 and 3). In case 3 the operation was
deferred four days, and not until then was specific treat-
ment started. Recovery followed a prolonged and
stormy course. In case 2, in which the illness termi-
nated fatally, incision of the abdomen was deferred for
about eighteen hours. None of the patients \Vith strep-
tococcic infection who recovered had positive blood
cultures, although all of them were critically ill.

The first two patients (1 and 2) who were treated
with sulfanilamide received very small amounts of the
drug and died. The other five patients received doses

Table 3. — Patients with Primary Streptococcic Peritonitis Treated with Sulfanilamide

Sulfanilamide

Organism First , * ,

Day of Recovered Operation Day of Blood

Month

Age

Disease

, *—

r

• - ■ —

\

Disea

ISC

Level,

Pa-

and

, >

1 *

On

Day of Bacter-

Day of

, A-

\

Mg. per

Compli-

tient

Year

Yr.

Mo.

Sex

Entry

Source

Disease

cm la

Nature

Disease

Dose

First

Last

100 Cc.

cations

Results

1

Nov.

1

4

9

G

Abdomen

G

Yes

Incision

G

ProntoslI

G

7

None

Died

1936

and

33 cc. of

taken

drainage

total dose

2

March

9

9

3

Abdomen

4

Yes

Incision

4

0.025 Gm.

4

11

None

Died

1937

and

per pound

taken

drainage

3

June

3

0

<3

5

Abdomen

9

No

Incision

9

O.OG Gm.

9

13

None

Fecal fistula;

Recovered

1937

and

per pound

taken

broncho-

drainage

pneumonia

4

Nov.

5

8

S

3

Abdomen

3

No

Incision

3

0.1 Gm.

3

4

None

None

Recovered

3937

and

per pound

taken

drainage

O.OG Gm.

4

12

per pound

5

Dec.

9

d

o

Abdomen

o

No

Incision

2

0.1 Gm.'

2

5

22.0

None

Recovered

1938

and

per pound

6.2

drainage

6

Dec.

6

5

9

1

Abdomen

2

No

Incision

3 .

0.00 Gm.

1

2

None

None

Recovered

1938

and drain-

per pound

taken

age, appen

dectomy

7

Feb.

1

7

9

2

Abdomen

2

No

Incision

o

O.OG Gm.

2

10

14.8

14th post-

1939

and

per pound

S.3

operative day

drainage

0.03 Gm.

10

12

0.0

intestinal

per pound obstruction,

enterostomy

chloride and maintained by oral administration of
crushed tablets as soon as the patient is able to tolerate
fluids by mouth. During the first two or three days
of treatment, doses of from 0.1 to 0.15 Gm. per pound
of body weight in twenty-four hours will usually be
sufficient to establish an optimal blood level of from
10 to 20 mg. per hundred cubic centimeters as esti-
mated according to the method of Marshall. 8 The dose
may be reduced by one half when definite clinical
improvement is in evidence and discontinued about one
week later, according to the indications in the individual
case. In several of the cases reported here, administra-
tion was discontinued earlier than would seem advisable.

Seven patients with primary peritonitis due to the
hemolytic streptococcus received sulfanilamide (table 3).
fn six of the cases the diagnosis of primary peritonitis
was made at entry. One patient (case 6) was thought

I, T O r fy, B- W., Jr.: The Use of Para-Aminobenzenesulfonamide and
cnee er u at,ons \ n *ke Treatment of Infections Due to the Beta Strepto-
o « orwi “ aeir, olyticus, the Meningococcus, and the Gonococcus, J. Pediat.
202-214 (A U g.) 1937.

■ -Marshall, E. K-, Jr.; Emerson, Kendall, Jr., and Cutting, W. C. :
1937' Amin0ben2enesu,fonaTTlide - T A - M - A - 108 = 953-957 (March 20)

of from 0.06 to 0.1 Gm. per pound for periods which
varied from one to twelve days. In most of the cases
the blood levels were not recorded, and the drug was
administei ed and discontinued arbitrarily according to
the clinical appearance. Satisfactory concentrations of
sulfanilamide were obtained in the blood of two patients
who responded to treatment by a prompt drop in tem-
perature and early clinical improvement. Patient 6,
who made an uneventful recovery, received a dose of
0.06 Gm. per pound for only twenty-four hours, at which
time the drug was discontinued because of marked
nausea. While under treatment, all the patients
appeared cyanotic and in all moderate anemia developed
which was treated by blood transfusions.

SPECIFIC THERAPY IN PNEUMOCOCCIC PERITONITIS
Before treatment with specific antipneumococcus
serum, precautions are taken in each case to determine
the presence or absence of sensitivity. This includes
a careful inquiry into the past history for previous injec-
tions of serum or manifestations of allergy and the usual
intradermal and ophthalmic tests with a 1 ; 10 dilution

1458

Jour. A..M, A
Oct. 14, 191}

PRIMARY PERITONITIS— LADD ET AL.

of the animal serum to be used. During the testing and
administration of serum, epinephrine solution should
always be available for immediate use. Serum treatment
is deferred postoperatively until the patient’s circula-
tion and general condition are sufficiently restored to
minimize the danger of precipitatory collapse.

Serum was given exclusively by the intravenous
route. The schedule of administration, gradually for-
mulated, consisted of an initial injection of 1 cc. followed
at frequent intervals of at least two hours by larger
injections of from 3 to 10 cc. To minimize reactions,
slowness of injection was deemed of great importance.
This was facilitated by diluting each dose of serum in
from 5 to 10 volumes of physiologic solution of sodium
chloride. Small quantities were delivered from a stand-
ard syringe; large amounts were given as an infusion
or injected through the rubber tubing of a constant

showed no growth. The blood stream of one bacteremic
patient (5) was temporarily sterilized by the adminis-
tration of specific antibody but reinvasion occurred and,
despite continued treatment, persisted until death.
Another patient (8) whose blood culture before opera-
tion was positive had a remission of symptoms and nega-
tive blood cultures postoperatively, even before specific
antipneumococcic treatment was started.

Surgical incision and drainage of the abdomen was
performed in seven of the eight cases. In six cases
this was carried out at the earliest possible opportunity;
that is, on the day of onset or admission to the hospital.
Early conservatism in the policy of treating one patient
(3) resulted in a considerable, although fortunately not
a fatal, delay in operating and establishing the bacterio-
logic diagnosis. Administration of serum was started
in this case prior to surgical drainage on the evidence

Table 4. Patients with Primary Pncuinococcic Peritonitis Treated with Serum

Pa-

tient

Month

and

Year

Age

V ay of
Disease
nt

Time

of

Yr.

Mo.

Sex

Entry

Type

1

Nov.

1934

11

6

9

1

I

2

June

1936

7

6

9

2

I

3

May

1937

7

3

9

1

I

4

Nov.

1937

5

10

9

4

r

5

Aug.

1938

11

9

Onset in
hospital

IV

6

Sept.

1938

3

11

<S

1

VI

7

Nov.

1938

17

9

5

V

8

Feb.

1939

2

7

9

Onset in
hospital

IV

Organism First

Recovered Operation

Day of Bnctcr-

Day of

Source

Disease

cm in

Nature

Disease

Abdomen

2

+

Exploratory 1

laparotomy,

nppendcctomy

Blood

5

Incision and
drainage of
abdomen

C

Abdomen

1

Incision nnd
drainage of
abdomen

1

Abdomen

4

-

Incision nnd
drainage of
abdomen

4

Blood

2

+

None (pnrn-
centesis of
abdomen)

2

Abdomen

1

4-

Incision nnd
drainage of
abdomen

1

Abdomen

1

+

Incision nnd
drainage of
abdomen;
appendectomy

G

Abdomen

2

+

Incision and
drainage of
abdomen

1

Scrum Treatment*

* * Fres-

Day of ence

Disease of

Total

,

No-

Results

Units

First

Last phrosis Complications

Horse

170,000

2

4

—

Pneumonia,
empyema,
serum sickness

Recovered

Horse
ISO, 000

5

G

—

pneumonia.

empyema

RCCOVeied

Horse
ISO, 000

2

4

—

Pneumonia, Recover^
abscess o!
abdominal wall,
fecal fistula

Horse

150,000

5

G

—

Pneumonia, .
pelvic abscess

Recovered

Rabbit

3SO,000

2

6

+

Intestinal
obstruction,
renal failure

Died

Rabbit

800,000

1

4

+

0

Recovered

Rabbit

900,000

5

7

-

Serum sick'
ness

Recovered

Rabbit

60,000

2

2

+

0

Recovered

* The rabbit serum used in the last four patients from Lederle*s Laboratories.

intravenous drip. When the anticubital veins were
inaccessible, 24 gage needles were used and the serum
was injected into small veins of the extremities or scalp.

Eight patients with proved pneumococcic peritonitis
were treated more or less according to the method
advocated (table 4). In every case a clinical diagnosis
of primary peritonitis was promptly made from the his-
tory and physical examinations, and the bacteriologic
diagnosis was established on the basis of cultures
obtained from the peritoneal cavity. In six of the eight
cases early operation on the day of entry to the hos-
pital facilitated identification of the responsible pneu-
mococcus within a few hours. In two cases (3 and 5)
the invading organism was not sought immediately in
the peritoneal cavity and was first detected in the blood

cultures. . ...

Bacteremia was present prior to specific serum ther-
any in six of the eight cases. In each instance the
organism obtained from the blood stream was identical
with that from the peritoneal cavity. In five of the cases
all blood cultures taken subsequent to serum treatment

of a positive blood culture. At operation the appe”.^
was removed from two patients (1 and 3) because mj
tion and fibrin deposits on the serosal surface sugges ^
the possibility of primary appendical involvemen
the patient’s condition warranted this manipulai
Subsequent pathologic examination, however, rev
only periappendicitis. Abdominal paracentesis was ^
stituted for surgical drainage in case 5, nephrosi ,
which the illness terminated fatally. .

The amount of antibody required appeared to
with individual cases, and the number reporte
are too few to warrant definite conclusions. ® « ,,
nature of the infection is severe, highly fatal and us i
accompanied by bacteremia, serum was admirus e ^
large doses during the first twenty-four to tor y ^ »
hours and continued until the blood stream was ‘
and definite clinical improvement was in ev ^
Immunologic studies were carried out m some ^
more recent cases, but the data available 0 t j )e
present offer a more accurate basis of cstuna fc j n
antibody requirement. Reactions to serum oc

Volume 113
Number 16

PRIMARY PERITONITIS— LADD ET AL.

1459

three cases but in no instance proved alarming. Serum
sickness appeared during convalescence in two cases.

Because the bacteriostatic action of sulfanilamide
against the pneumococcus has been demonstrated in
vitro and applied successfully in the treatment of pneu-
niococcic meningitis,® this drug was included in the
therapy of three patients (5, 6 and 7), but in only
one (case 6) was a satisfactory concentration of this
drug in the blood achieved and maintained. Recent
reports 9 10 on the efficacy of sulfapyridine in the treat-
ment of pneumococcic peritonitis encouraged the admin-
istration of this drug in case 8. Clinical improvement,
however, seemed to occur and the patient became non-
bacteremic before the administration of sulfapyridine or
serum, so that no definite conclusions can be derived
in this case as to the benefit of either.

Complications attributable to the offending pneumo-
coccus occurred in five cases, in three of which bac-
teremia was proved.' In the four cases of type I
infection pneumonia developed as a secondary disorder
and was followed in two cases by empyema requiring
surgical drainage (cases 1 and 3). In one case an',
abscess of the abdominal wall developed together with
a fecal fistula, which healed slowly without surgical
intervention. In case 4 a pelvic abscess developed and
resolved gradually. In the case of type IV infection,
the complications were incident to a fatal termination.
The patient was a boy with lipoid nephrosis, whose
symptoms were initiated by a chill and a sudden rise
in fever while under treatment for nephrosis in this
hospital. Type IV pneumococci were identified in a
blood culture fourteen hours later. An abdominal para-,
centesis done at this time yielded the same organism.
No operation was performed. Serum was administered
in daily doses of 180,000, 80,000, 40,000, 40,000 and
40,000 units, starting on the second day, or about fifteen
hours after onset. On the first day of treatment the

Table S. — Mortality Rates in Pncttmocaccic and
Streptococcic Peritonitis

Pneumococcic Peritonitis Streptococcic Peritonitis
Mor- -Mor-

is' o. of tnlity, No. of taiity.

Author Tear Cases per Cent Tear Cases per Cent

LIpshutz, B., and Low*
enberg, H.: J. A. M. A.

M0, 1926 1926 13 100 1020 0 100

Ladd, W. E.: Pennsyl-
vania M. J. 34 : 153,

1030 1930 15 66 1930 SO 65

Donovan 3 1934 12 75 1936 42 7S

c °l e 5 1937 20 54

Leopold and Kaufman * . . 1937 12 91

blood cultures were negative and agglutinins were dem-
onstrated in the patient’s serum. Improvement in the
patient’s condition lasted for four days and then bac-
teremia recurred; the patient’s condition declined until
the eighth day, when he died.

MORTALITY

. A characteristic feature of primary peritonitis is that
4 has been universally accepted that it has a high mor-
tality rate (table 5). However, when the present series

9. Finland, Maxwell; Brown, J. W., and Rauh, H. E. ; Treatment of
23) eU 193S OCCiC Meni,,sitis ’ New England J. Med. SIS: 1033-1044 (June

,, 10 u Barnett, H. L.; Hartmann, A. F.; Perley, A, M., and Reuhoff,
a ’ u -\ The Treatment of Pneumococcic Infections in Infants and Chil-
dren With Sulfapyridine, J. A. M. A. 112: 518-527 (Feb. II) 1939.

of cases is divided into those in which specific therapy
was and was not given, there is a striking difference in
the mortality rates (table 6). It is. at once evident that
the total rate has been lowered more than 50 per cent.
In the pneumococcic group with early operation and
specific therapy there is only 12.5 per cent mortality, in
contrast to 83.3 per cent in those without the advocated
therapy. On the other hand the streptococcic group

Table 6. — Mortality Rates in Pneumococcic and Streptococcic
Peritonitis With and Without Specific Therapy

Without Specific Therapy With Specific Therapy

Children’s Hospital/ * , * »

Primary Peritonitis Total mortality. Total Mortality,

1929-1939 Cases Deaths per Cent Cases Deaths per Cent

All primary eases... 52 38 73.0 15 3 20.0

Pneumococcic 12 10 83.3 8 1 12.5

Streptococcic 40 28 72.0 7 2 28.5

presents a less striking but significant drop in the mor-
tality of 72 per cent to 28.5 per cent in the correspond-
ing groups. As pointed out previously in this paper,
the one patient with pneumococcic peritonitis and the
two with streptococcic peritonitis who were given spe-
cific therapy and died were not given adequate specific
treatment.

COMMENT

In the present clinical study of primary peritonitis,
the benefits of early operation and adequate specific
therapy have been reflected by a significant reduction
in the mortality. The details of treatment remain some-
what elastic and, as pointed out elsewhere, not all of
the patients were treated according to our present con-
cept of the most effective procedure. The virulence of
the organism and the resistance of the patient are two
factors in primary peritonitis which always play an
important role, which is difficult to evaluate in discuss-
ing the results of any type of treatment. Several cases
of pneumococcic peritonitis successfully treated with
sulfapyridine have been reported 10 recently. This may
prove a valuable adjunct to the serum therapy of the
disease.

The present program of treatment of primary peri-
tonitis that we advocate following is as follows :

1. Early incision and drainage of the peritoneal cavity
with minimal manipulation.

2. Identification as rapidly as possible of the offend-
ing organism obtained from the peritoneal cavity.

3. Immediate postoperative institution of sulfanil-
amide therapy by hypodermoclysis, continued by oral
administration when fluids can be taken by mouth.

4. If a pneumococcus is obtained, substitution of
sulfapyridine for sulfanilamide therapy and intravenous
administration of type specific antipneumococcus serum.

5. (a) Use of high concentration oxygen and gastric
siphonage to relieve abdominal distention; (b) main-
tenance of adequate fluid intake by parenteral and
enteral routes; (c) repeated small blood transfusions
to combat anemia and hypoproteinemia.

CONCLUSION

The high mortality rate in primary peritonitis can be
strikingly reduced by early operation for recovery of
the offending organism and drainage followed by ade-
quate treatment with sulfanilamide in the streptococcic
group and with type specific serum in the pneumococcic
group.

300 Longvood Avenue.

1460

RECURRENCE OF CALCULI— HIGGINS

Jour. A. M. A
Oct. 14, 1919

FACTORS IN RECURRENCE OF
RENAL CALCULI

CHARLES C. HIGGINS, M.D.

CLEVELAND

The recurrent formation of renal calculi following
the surgical removal of a stone from the kidney con-
stitutes a major problem in the management of patients
with renal lithiasis. That formation of secondary cal-
culi will frequently occur unless adequate preventive
measures are instituted seems plausible when it is
obvious that, in the majority of instances, the under-
lying factors associated with the production of the pri-
mary calculus are not corrected or eradicated by the
surgical procedure.

From experimental and clinical observation, it appears
evident that no one etiologic agent is entirely responsible
for the formation of all kidney stones. This emphasizes
the necessity for an intensive preoperative investigation
to ascertain the causative factors in each individual case.
This facilitates correction o’f these factors at the time
of surgical treatment or during the postoperative regi-
men. Certainly the operative procedure per se con-
stitutes but one phase in the management of this group
of patients, and to neglect an exacting preoperative
investigation and adequate postoperative supervision
will be attended by an unwarranted high incidence of
recurrences. It is also evident that, while an investi-
gation of the etiologic factors is essential during the
preoperative period, additional factors known to be
associated with the formation of calculi may be intro-
duced or be directly attributed to surgical intervention,

reported that "recurrence” took place in 56 per cent
of patients treated by nephrotomy and in 51 per cent
of those treated by pyelotomy.

Barney-’ in 1922 again studied a series of cases from
the Massachusetts General Hospital and stated that
the incidence of recurrence was 32 per cent following
the removal of a calculus from the kidney; however.it
is interesting to note that postoperative roentgenograms
revealed that stones were still present in the kidney
in nine of twenty cases, or 45 per cent.

Braasch and Foulds 3 in 1924 stated that calculi
recurred in 10.79 per cent of the patients who were
operated on at the Mayo Clinic. Herbst 4 has noted
the incidence of recurrence as 15 per cent, while Hun-
ner 5 in 1927 gave the incidence as 9.5 per cent follow-
ing operations for renal stones and as 4.4 per cent
following operations for ureteral calculi.

Oppenheimer 0 in 1937 cited true recurrences follow-
ing pyelolithotomy, pyelonephrolithotomy and nephrot-
omy in 14.9 per cent, 32.0 per cent and 29.4 per cent,
respectively, of his cases.

f^Twinem ' in 1937 reviewed 314 operations for stone
performed at the New York Hospital and stated that
there were 28 per cent recurrences following nephrot-
omy and 20.9 per cent following pyelotomy. During
I the preceding year and a half, however, he stated that
■ recurrences had been reduced to 5.3 per cent. At the
Cleveland Clinic the incidence of recurrence prior to
1933 was 16.4 per cent. Between the years 1933 and
^1939 this has been reduced to 4.9 per cent by adding
Vthe high vitamin A acid ash or alkaline ash diet to the
'other postoperative measures, thereby controlling the
j/>H of the urine.

*** INFECTION

namely, trauma, infection and conditions conducive to
the production of stasis.

Recurrent renal calculi may be of either one of the
following two types :

1. True recurrence or the formation of a calculus after com-
plete removal of the original stone.

2. False recurrence, or a persistence of stones or fragments
of a calculus overlooked at the time of operation.

A knowledge of the true incidence of these recurrences
is influenced by the frequency with which postopera-
tive roentgenograms are secured. Misinterpretation of
end results cannot be avoided unless roentgen study
is made as a routine procedure after the operation.
A small calculus may be overlooked at the time of
operation, especially if multiple stones are being
removed. Unless a roentgenogram is secured before
the patient is dismissed from the hospital a recurrence,
either asymptomatic in type or productive of renal
colic, and which is noted by roentgen studies months
later, may be misconstrued as a true recurrence or a
stone that formed de novo, whereas it is really a false
recurrence. When multiple calculi are being removed,
I believe that a roentgenogram of the exposed kidney
should be secured at the time of operation in order to
avoid overlooking a small stone.

It is evident from the contributions of several authors
that a progressive decrease iruthe incidence of recurrent
renal calculi is taking place^In 1915 Cabot and Crab-
tree 1 in reviewing the results secured in the treatment
of renal calculi at the Massachusetts General Hospital,

Read bcfoS'S^s’ecSon'on Urology at the Ninetieth Annual Session
_ e .u American Medical Association, St- Louis, May 19, 1 939.

1. Cabot, Hugh, and Crabtree, E- G.: Fre -S u ^ y of 2*3*

Stone in the Kidney After Operation, Surg-, Gynec. Obst. 21. 2-3-

Stone in the Kidney
225, 1915.

The relationship between infection and the formation
of primary or recurrent calculi has been stressed tor a
long time. Brongersma’s 8 statistics illustrate the re a
tionship between infection and recurrent renal Iitinasis-
In the absence of infection the incidence of recurrence
was between 3 and 6 per cent, but it was approxima e )
27 per cent when the infection was slight and 50 pe

cent when severe.

Rovsing 9 found that 68.18 per cent of all recurrences
occurred when renal infection, either primary or
ondary, was due to urea-splitting organisms. How c ' e ;
in 15.91 per cent of his cases the recurrences deve |
in the presence of sterile urine. Ten examples o bp
stone due to the staphylococcus were reported by 0
hamer 10 in 1932. The formation of these ealeu i
probably due to the ability of certain members o
group to split the urea in the urine with the r< j sU
formation of ammonia, a reaction favorable to the P
cipitation of the alkaline salts in the urine, m
Runeberg 11 stressed the importance of anaerobic or{,<

isms in the genesis of calculi. . — —

VzP Barney, J. D.: Recurrent Renal Calculi, Surg., Gynec. & 0h
So: 743-748 (Dec.) 1922. _ _ , Results

3. Braasch, W. F., and Foulds, G. S.: Postoperative

Nephrolithiasis, J. Urol. 11: 525 -537 (June) 1924. Pause and

4. Herbst, R. H.: Recurrent Renal Calculus: Its c.i in-
vention, Am. J. Surg. 12 : 58-62 (April) 1931. Treated t : . v Ne*

5. HunneriG. L.: Calculus of Upper Urinary Tract Treated
Methods; End Results, Tr. South. S. A. -10: 1-17. ‘93/- Opera" 09

6. Oppenheimer, G. D.: Nephrectomy versus Consenaii Cynee .
in Unilateral Calculous Disease of the Upper Urinary i ract, a

& Obst. 65: 829-836 (Dec.) 1937. . operations

7. Tivinem, F. P.: Study of Recurrence Following OP
Nephrolithiasis, J. Urol. 37 : 259-2 67 (Feb.) 193 / .

8. Brongersma, cited by Jo)y. !S Infection ot

9. Rovsing, C. M.. cited by Fowler, H. A.: Cococaj* l Cu0r .
Kidney, Its Role in Formation and Recurrence of Stone, ut

Rev. 38: 594-605 (Aug.) 1934. . ... „ n MSnc hen. r“ cd -

10. Boshamer, K. : Staphyfokokkensterne der Meren, .1

Wchnschr. 79 : 1951-1953 (Dec.- 2) 1932. _ Urinary Calculi.

11. Runeberg, B.: Anaerobic Bacteria in Urine and
Finska Iak.-sallsk. handl. 77 : 737-746 (Dec.) 1935.

Volume 113
Number 16

RECURRENCE OF CALCULI— HIGGINS

1461

A study of a series of 200 patients with recurrent
renal calculi made at the Cleveland Clinic showed a
coexisting renal infection in 81.5 per cent of the cases
(figs. 1, 2 and 3), while the urine was sterile in 18.5
per cent (fig. 4). It was noted tiiat when the stones
were large an infection was usually present, while the
urine was more frequently sterile in the presence of
smaller calculi.

Determination of the chemical constituents of stones
formed in the presence of sterile urine showed them
usually to he composed of uric acid, cystine or oxalates,
while the recurrent stones associated with renal infec-
tion were generally composed of phosphates, carbonates
or mixtures of these salts with occasional traces of
oxalates.

In considering the relationship of infection to recur-
rence, two types of infection must be considered. If
the organisms possess the power of splitting urea, such
as Bacillus proteus, there is a greater tendency for a
recurrent calculus to develop than when the infection
is due to Bacillus coli, an acid-forming organism which
does not possess this power. This requires further
elucidation, however, since the reports of Brown and
Earlam 11 in 1933. These authors stated that 18 per
cent of the bacilli which infect the urinary tract possess
the power of splitting urea and that 40 per cent of
Staphylococcus albus have similar properties. These
organisms split the urea in the urine with the resultant
formation of ammonia and carbon dioxide. This shifts
the />„ of the urine to the alkaline side, enhancing the
precipitation of the alkaline salts, i. e. phosphates and
carbonates.

Fig. 1. — Recurrent renal calculi associated with proteus infection.

In the present series of cases, 9 per cent of the bacilli
and 18 per cent of the staphylococci possessed this
power. It was also noted that infection of the kidneys
was much more frequent in the patients with bilateral
recurrent renal calculi than in those with unilateral
stones. The predominant organism cultured was
Staphylococcus albus. It was found most frequently

12. Brown, R. K. L., and Earlam, M. S. S. : Relation of Prolonged
immobilization and Urinary Tract Infection to Renal Calculous Forma-
tion, Australian & New Zealand J. Surg. 3:157-171 (Oct.) 1933.

in pure culture and usually was present in the mixed
infections. Bacillus proteus in pure culture was the
second chief offender, although other bacilli and strep-
tococci in mixed cultures were often observed.

As the selection of medication employed to eradicate
the renal infection may be influenced by knowledge as
to whether the organisms split urea — and, in fact, cer-
tain drugs such as ammonium chloride may be contra-

Fig. 2. — Recurrent renal calculi associated with colon bacillus infection,
the organism having the power of splitting urea.

indicated in the presence of a proteus infection — it
should be a routine part of one’s bacteriologic stud}'
to determine whether the offending organisms have the
power of splitting urea. Similarly, in addition to a
culture, a stained smear of the urinary sediment should
be made in each case. While it appears true that infec-
tion plays a major role in the production of recurrent
renal calculi, in view of the clinical observation that
many recurrences develop in the presence of sterile
urine, further search for etiologic factors is essential.

FOCAL INFECTION

In 1921 Rosenow and Meisser 13 presented their
experimental data which indicated the role of focal
infection in the formation of renal calculi. They inocu-
lated the pulps of the teeth of dogs with streptococci
isolated from the urine of patients with renal lithiasis.
Following this, calculi developed in the dogs and strep-
tococci were again isolated from the urine.

In reviewing the present series of 200 recurrent renal
calculi, definite foci of infection could be demonstrated
in many instances, but there was no apparent relation-
ship between the organisms cultured from these sites
and those isolated from the urine. In view of the work
of Rosenow and Meisser, however, I believe that foci
present in the teeth, tonsils, cervix and prostate should
be eliminated.

STASIS

Urostasis in many instances seems definitely to be
associated with the formation of recurrent renal calculi,
and its presence is conducive to shifting the p H of the

13. Rosenow, E. C., and Meisser, J. G.t
After Experimental Production of Chronic
Papers of Mayo Clinic 13 : 253-257, 1921.

Nephritis and Urinary Calculi
Foci of Infection, Collected

Joui. ‘\}\L
Oct. M. h! ’

RECURRENCE of C vious conm*"*""'* Vm!' ren”S c “ u W, ,‘

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lag^*

Volume 113
Number 16

RECURRENCE OF CALCULI— HIGGINS

1463

on a simple, stable diet which is rich in vitamin A, high
in acid-ash base and extremely low in calcium.

I believe therefore that a biophotometer test to deter-
mine the absence or presence of vitamin A deficiency
should be a part of the examination of every patient
with calculous disease (fig. 7). Furthermore, my asso-
ciates and I prescribe vitamin A as a routine in the
postoperative course for two reasons: first, to correct
vitamin A deficiency if it is present and, second, for
its effect on the epithelial structures.

HYPERPARATHYROIDISM

Albright and Bloomberg, 21 Barney and Mintz 22 and
others have stressed the relationship between hyper-
parathyroidism and renal lithiasis. Barney and Mintz
in 1934 reported a series of eighteen cases in which
a diagnosis of hyperparathyroidism had been made and
verified by surgical intervention. In eleven (61.1 per
cent) calculi were present in the urinary tract. The
youngest patient was 13 years of age and the oldest
was 62. Involvement of the bones to varying degrees
was present in twelve cases, while in six others urinary
calculi and changes in the bones were found to coexist.
The renal calculi were bilateral in four (36 per cent)
of the eleven cases. Barney and Mintz conclude that
hyperparathyroidism is responsible for from 4 to 5 per
cent of the cases of renal calculi. In almost 70 per cent
of cases of hyperparathyroidism stones may be present,
while in approximately 38 per cent the patients have

Fig. 5. — Stricture of right ureter following ureterolithotomy. Note stasis
demonstrable by intravenous urogram.

changes in the bones and urinary tract. Barney and
Mintz state and Albright and Bloomberg concur that
hyperparathyroidism is so frequently a cause of renal
lithiasis that in every patient with this condition it
must be determined whether or not it is present. There-
fore a careful study of the calcium and phosphorus
content of the blood should be made in all patients with
renal stones.

21. Albright, Fuller, and Bloomberg, Esther: Hyperparathyroidism and
Ken al Disease, with Note as to Formation of Calcium Casts in This Dis-
Tr. Am, A. Genito-Urin. Surgeons 27: 195-202 (May 15) 1934.

-J. Barney, J. D„ and Mintz, E. R. : Some Newer Conceptions of
Ormary Stone Formation, J. A. M. A. 103: 741-743 (Sept. 8) 1934.

Griffin, Osterberg and Braasch, 23 in reviewing cases
of urinary lithiasis at the Mayo Clinic, state that hyper-
parathyroidism was found to be an etiologic factor in
less than 0.2 per cent of their cases. At the Cleveland
Clinic, hyperparathyroidism has been associated with
renal lithiasis in about 0.1 per cent of the cases. In
one case in this series the presence of hyperparathy-
roidism was overlooked when the primary calculus was

Fig. 6. — Format/on of renal calculus on tbe same side two years inter.

removed. When the patient returned with a recurrent
renal calculus a diagnosis of hyperparathyroidism was
established and verified by blood studies. A tumor of
the parathyroid glands was removed at the time of
operation. Further recurrences have not developed.

Gilmour and Martin 24 have emphasized the relation-
ship between the condition of the parathyroid glands
and renal disease. Fowweather and Pyrah 25 in 1938
also studied the relationship between hyperparathyroid-
ism and renal lithiasis. They noted the absence of any
marked preponderance of high levels of blood calcium
among cases of recurrent calculi as compared with those
without recurrence. They state: “Hence the raised
blood calcium which may be found in association with
renal calculi is in general the result of renal damage,
and the previous suggestions that it is not evidence of
a primary hyperparathyroidism, which is the cause of
the formation of calculi, is confirmed.”

They state further that in the early stages of renal
disease the response of the parathyroid glands to this
stimulus may result, in a certain proportion of cases
and for a certain length of time, in an enhanced activity
of these glands, which is rather more than sufficient
to counteract the tendency arising from renal disease,
so that a raised blood calcium and to a less extent a
reduced blood phosphorus make their appearance. As
the renal disease progresses, the tendency toward a low

43. Grinin, Miles; Osterberg, A. E., and Braasch, W. F.: Blood Cal-
cium, Phosphorus _ and Phosphatase in Urinary Lithiasis; Parathyroid
Di |T S ?"? S Et ' ol »e' c Tact” J. A. M. A. 1X1: 683-685 (Aug. 20) 1938.

<=>ands,

25. Fowweather, F. S., and Pyrah, L. N.: Renal Calculi, Renal Dis-
(April) n i938 IyPerParathyr °' d,Sm ' Pr ° C ' R ° y ‘ SoC- Med - 31 = 59 3-604

1464

RECURRENCE OF CALCULI— HIGGINS

Jour. A. M. A
Oct. 14, 191)

blood calcium and a high blood phosphorus appears
to increase to a point beyond which it is impossible
for the parathyroids to neutralize it, and thus the blood
changes of advanced renal disease are evident. Thus
careful selection must he made of patients in whom
exploratory operation on the parathyroid glands is
advised. It is true, however, that the possibility of
hyperparathyroidism must he considered in all patients
with renal lithiasis, and no preoperative investigation
is complete without due consideration of this disease.

METABOLIC FACTORS

Cystinuria . — This is a familial disease which results
from derangement of the intermediate protein metabo-
lism of the body. In normal persons cystine is oxidized
completely and the sulfur is excreted as a sulfate. It
is stated that calculi develop in about 2.5 per cent of
patients suffering from cystinuria (fig. 8). However,
Seeger and Kearns 20 in 1925 collected 181 cases of

were administered.

cystinuria, 124 of which were complicated by stone
formation. Cystine may be found in the urine partly
in solution and partly as a crystalline_ deposit. A
diagnosis of cystinuria is made in the majority of cases
by a microscopic examination of the urinary sediment.
Treatment consists of increasing the solubility of the
cystine in the urine by the administration of alkalis
and by restriction of the protein intake. Maintenance
of an alkaline reaction of the urine diminishes definitely
the possibility of the formation of a calculus.

Q ou t. Gout is another metabolic disease in which

excessive amounts of crystalloids appear in the urine,
microscopic examination of the sediment revealing the
presence of uric acid crystals and urates. Not only
may calculi composed of uric acid be produced, but
the patient may experience attacks of colic as showers
of uric acid crystals are passed. Other clinical mani-
festations of gout need not be present for uric acid
calculi to form. Normally, in man, from 0.3 to 1.2 Gm.
of uric acid is excreted daily. The amount excreted is

~26 See uer S J., and Kearns, W. M.: Cvstinuric Lithiasis, J. A.
M A. S5: 4-7 (jily 4) 1923.

influenced by the diet of the individual. Postopera-
tively, a low purine diet in conjunction with the high
vitamin A alkaline ash diet assists in minimizing the
incidence of recurrent formation of this type of calculus.

Oxaluria . — Oxaluria has been stated by Neville :: to
be associated with a deficiency of vitamin B. Oxalic
acid, which has both an exogenous and an endogenous
source, is excreted in the urine in amounts of approxi-
mately 15 to 20 mg. daily. Experiments have indicated
that, if an animal is maintained on a diet containing a
fixed amount of calcium oxalate, the amount of the
urinary oxalate can be increased by the administration
of acids and decreased by alkalis. If the calculus is
found to be composed of oxalates, the foods having a
high oxalic acid content should be restricted in the
postoperative regimen.

Xanthine . — Urinary calculi composed of xanthine
are of rare occurrence. Kretschmer 23 in 1937 collected
a series of fifteen cases and added one of his own.
Mathews 29 states that the most important purine found
in the human urine is uric acid, but there are present
also from 30 to 50 mg. of purine bases — xanthine, hypo-
xanthine, guanine and adenine. He estimates that from
16 to 60 mg. of purine bases are eliminated in the urine
daily as the purines are the end products of the metabo-
lism of the nucleins. Postoperatively, foods with a high
purine content should be restricted if the calculus is
composed of xanthine.

Phosphaturia . — The type of phosphaturia present
must be determined. Temporary phosphaturia may e
caused by eating foods containing an excess of alkaline
ash. Permanent, infected phosphaturia is associate
with the presence of an organism that has the power o
splitting urea. In this type the urea is transfornie
into ammonium carbonate, the ammonia then coni
billing with the magnesium and phosphoric acid to t on
triple phosphate, while the carbonate combines with 1
calcium, forming calcium carbonate. Permanent, non
infected phosphaturia is stated to be due to alteration!
function of the gastrointestinal tract. , .

Snapper 30 believes that all factors which ten
stabilize the labile colloids must help prevent the tom
tion of stones. The presence of salicydates, mande a ->
hippurates and other organic salts in the urine nia b •
increasing the stability of the urinary colloids, exer -
a prophylactic influence against the formation ot s
He states: .

Factors which may have a preventive or even a cUra
effect on the formation of renal calculi are: . _ re3S cs

1. Administration of foods with an acid-ash ivhic in
the acidity of the urine and the solubility of the ca ciu _

2. Artificial acidosis by ingestion of ammonium c
ammonium nitrate, or other compounds.

3 . Large supply of vitamin A.

Residues of kidney stones and urinary gra' e ^
be prevented by the use of these measures. , . eS
evident that the presence of hippurates, _ sa i ) ^

mandelates and other organic salts in the urine
of great importance in the prevention ot rena

trauma e5

A review of the literature indicates that mV

following nephrolithotomy and nephropelyio •
are mofe frequent than when pelyiohtho

_ __ . ■ — ; — ~CZ j £ Cu t2r "

->7 Xeville, D. W.: Constitutional Factor in Oxaluria. ro .

Rev. 39: 32-33 (Jan.) 1935. f and R' r,t °

28. Kretschmer. H. L. : Xanthin Calculi, Report ot .

of Literature, J. Urol. 3S: 183-193 (Aug.) 1937. y or k, m 11 ’ 3

59. Mathews, A. P.: Physiological Chemistry, ed. a.

Wood & Co., 1930, pp. 764, 1175. . Secretion of Urine,

30. Snapper, I.: Pathological Physiology Secretion
Intemat. Cong. Urol., 1936, pp. 575-61/.

Volume 113
Number 16

RECURRENCE OF CALCULI— HIGGINS

1465

employed. In nine cases in tin's series a blood clot
was found to be the nucleus for a recurrent stone.
Braasch and Foulds 3 in 1924 estimated a recurrence of
10.79 per cent, a recurrence of 11.85 per cent follow-
ing pyelotomy and 24.03 per cent following nephro-
lithotomy. Certainly a minimum of trauma should be
inflicted during the surgical procedure, and a pelvio-
iithotomy should be performed whenever possible.

TYPE OE STONES

The surgical removal of a branched stone extending
into the calices is more likely to be followed by a recur-
rence than when a smaller stone is removed which is
confined to the pelvis of the kidney. This may be due
to injury of the calix or infundibulum, allowing blood
clots to remain behind, subsequent development of stric-
ture of the infundibulum which is conducive to stasis in
the calix and later infection, or a small stone or frag-
ment of a stone may be overlooked in one of the calices.

It is apparent that the removal of multiple calculi
from the kidney is attended by a greater increase of
recurrence than when a solitary stone is removed.
Frequently a small calculus or a fragment which may
not even be discernible on the roentgenogram has been
removed by a suction apparatus which we employ as
a routine following the removal of a stone from the
kidney. Similarly, if a coexisting infection is present
in the kidney, especially of a staphylococcus or proteits
bacilli, the incidence of recurrence following operation
is more than when culture of the urine is sterile.

In a similar manner, stones of soft consistency are
more prone to be followed by a recurrence, possibly
because sand remains to act as a nucleus for secondary
formation. After removal of a calculus from the
kidney, thorough lavage of the calices and pelvis
followed by suction with the apparatus I have previ-
ously described will minimize the incidence of recurrent
stone formation.

SURGICAL ASPECTS OF PREVENTION
There is little doubt that the surgical procedure which
is accompanied by a minimum degree of trauma to the
kidney is preferable. I do not believe that as a routine
the kidney should be manhandled, traumatized and
delivered into the incision in removing a stone from its
pelvis. Rather, the operative procedure should be
carried down to the pelvis of the kidney and adequate
exposure secured by use of flexible retractors without
delivering the kidney. In instances in which there is
no coexisting renal infection or, if it is not pronounced,
the incision in the pelvis should be closed with triple 0
catgut sutures passing only through the outer coats of
the pelvis and not through the mucosa, where it might
be retained and act as a nucleus for a recurrent calculus.

Joly 31 has stated that even temporary leakage of
urine increases the risk of recurrence of stone and
should be avoided if possible. He likewise believes
that if the kidney has been drained it is usually found
to be infected with Staphylococcus albus. Similarly,
Rovsing 10 has stated that urinary leakage of only a few
days duration is sufficient to infect the kidney. In cases,
however, in which a pronounced infection is present, it
may be advisable to perform a nephrostomy, or a
catheter may be left directly in the pelvis to permit
lavage and facilitate adequate drainage.

Nephrolithotomy is employed only when pelvio-
lithotomy does not seem feasible. In all cases it should

t oly, J. S.: Stone and Calculous Disease of the Urinary Organs,
ht. Louis, c. V. Mosby Company, 1929.

be as conservative as possible. When a calculus is
confined to a calix and the infundibulum is too narrow
to permit its extraction through the pelvis, a localized
nephrolithotomy is advisable. Again, in the removal of
staghorn stones, nephrolithotomy may be necessary, and
I believe that adequate drainage should be instituted in
these cases.

A pelvionephrolithotomy, in my experience, is seldom
necessary, and only if technical difficulties arise.

A heminephrectomy may be the preferable operative
procedure in some instances in which a calculus is con-
fined to a large, dilated calix. In the presence of a
stricture of the infundibulum and infection of the calix,
the latter can be eradicated only' by this procedure, and
fewer recurrences will follow this method than if a
localized nephrotomy is done. Likewise, the remaining
portion of the kidney is saved from the ravages of
infection.

Fig. 8. — Recurrent renal and bladder calculi in a patient with cysttnuria.

Again I wish to stress the importance of thoroughly
lavaging the pelvis and calices followed by the use of
a suction tube again placed in the pelvis and calices to
remove clots, debris, fragments of stones or minute
stones and sand that might be overlooked.

CONCLUSIONS

It is apparent that many factors may be associated
with the formation of recurrent renal calculi. An
intensive preoperative investigation is required in each
individual case to ascertain the factor or factors instru-
mental in the production of the primary calculus. Their
correction and eradication at the time of operation or
in the postoperative routine is rewarded by a reduction
in the incidence of recurrence. In addition to eradica-
tion of the various etiologic agents, control of the />„
of the urine by the high vitamin A acid ash or alkaline
ash diet, depending on the chemical constituents of the
stone removed at the time of operation, has been
attended by a pronounced decrease in the incidence of
recurrent formation of calculus in our hands.

2020 East Ninety-Third Street.

1466

RENAL CALCULI— FLOCKS

Joint. A. SI. A
Oci. H, ISM

CALCIUM AND PHOSPHORUS EXCRE-
TION IN THE URINE

OF PATIENTS WITH RENAL OR URETERAL CALCULI
R. H. FLOCKS, M.D,

IOWA CITY

Many workers have indicated the possibility'' that the
increased urinary concentration of calcium and phos-
phorus associated with certain generalized conditions
such as hyperparathyroidism, 1 bone disease and
fractures 2 may be an important factor in calcium
urolithiasis. However, little quantitative work on this
concentration in patients with urinary calculi is avail-
able.

Since on theoretical, experimental 3 and clinical
grounds it would seem that increased urinary concen-
tration of calcium and phosphorus should be an impor-
tant factor in the formation of stone, it was felt that a
quantitative study of the urinary calcium and phos-
phorus in all types of patients with calcium urolithiasis
and the quantitative differences in this factor as the
result of treatment would be of significance from an
etiologic, prognostic and therapeutic point of view. It
is my purpose in this paper to present the results of
such a study in a series of thirty-five consecutively
admitted patients with renal or ureteral calculi.

SUBJECTS

Thirty-five consecutively admitted patients with cal-
cium stones in the kidneys or ureters form the basis of
this study. Their ages ranged from 19 to 70 years, but
the vast majority were from 20 to 40 years of age.
Twenty-two of them were men and thirteen were

the late stages of Paget’s bone disease. Only one
presented vitamin A deficiency, although twenty of
them were studied by means of the Jeans biophotometer
test. This deficiency was speedily rectified by the
administration of vitamin A. Two patients presented
hyperparathyroidism, as evidenced by increased serum
calcium, decreased serum phosphorus and increased
urinary calcium. Neither 'had bone changes. A para-
thyroid adenoma was subsequently removed from one
of them. Four months after operation this patient con-
tinued to excrete large quantities of calcium in the

Urimry

Calcium
Mgm*.

nr™, q

□

Average

Retpons«

Rmpork
in l hi*
Individual

BLOOD

a-Szt'

r.JzF-

I

Low Intake

High Intake

Urinary

Pfioiphortu

a

Average

Response

Rejpotue
m this
Individual

BLOOD,,

u£zl '

HI

Urinary

Calcium

Mgmi.

per

24 hr*.

a

Average

Reiponi*

Response ,.

in this
Individual

BLOOD

Low Intake

High Intake

Low Intake

High Intake

i Urinary excretion of calcium and phosphorus by a white man
aged 21 With a calcium oxalate stone in the nght

excretion! of ^caldum^on^hath lmv and bjnF^ihtakes.^ Jjk e{ jjy CI ^s

8? crfei™! ,P Compare Ate response to the fixed diets with that illustrated
in figure 2.

women. All of them except one, who had generalized
atrophic arthritis, were ambulatory during the course
of the studi es. Of the ambulatory patients, one was m

From the Department of Urology, State University of Iowa College of

Me Read'before the Section on. Urology at the Ninetieth Annual Session
of the Assgmuo^ S t - an( J Dr Kate Damn

Dr. h>. G. AIcock or tu i state University of Iowa College

of Med°me a ga« the author valuable aid and discussed this subject with
him during the course of this stu 5% The ReIat ; on of the Parathyroid

Glands^to^rjnaB^LUlfiasi^ jAUrol.^3<3 Q^^^j^Juecalcffication, and

Fig. 2 . — Urinary excretion of calcium and Pj“ s P ho A“? JjV h*t-
woman aged <13 with left renal stone. There was > adroiss'en-

thyroidism with subtotal thyroidectomy eleven years io " 0 [ calcium
At present the patient has essentially normal urinan excr that illns-
and phosphorus. Compare this response to the fixed diets
trated in figure 1.

urine, although the blood calcium and phosphorus letch,
which had returned to normal immediately alter up
ation, were still normal. The other patient re
operation, so that direct proof of parathyroid
was lacking. All the patients suffered from some
infection of the urinary tract, as evidenced by ^
ing of an occasional pus cell in the urine, bit
them had outspoken urinary sepsis. 0r £ a " is ~ t hv i 0 .
found in the urines of all patients. These ■» c0 |j
coccus albus and aureus, Bacillus proteus, B of

and Staphylococcus haemolyticus . e ‘ t ^’\. reut j n f e c-
together. No fevers, colds or other interc ; t j,_

tions were noted. In addition, twelve vo u« 1 wet£

out any evidence of stone or other abnormal
used as controls.

METHODS AND RESULTS _ , ^

Metabolic studies including accurate w e 'g marine
analysis of all food and water ingested and ot a ^
excreted were carried out on each P at j ent " iuc j; v idual
different methods of attack were use , section-

methods will be described in the appropriate

EFFECT OF DIETS WITH HIGH AND

CALCIUM AND PHOSPHORUS CONTENT

WITH NEUTRAL ASH _

In order to ascertain whether or not there « ^ l0ru5
sively high concentration of cakimu i and/ o /\ hc \ hir ty-
in the urine of patients with calculus, v0 ]unteer=

five subjects as well as the twelve normal
was placed successively on (a) a dietlm^m ^ g G|J1
and phosphorus, with a daily intake of 0- , ^ a

respectively and producing 3 , neut ™ a gaily intake
die high in calcium and phosphorus w* th at *
of 2.5 Gm. of each and producing a neutral ^ f
diet was fed identically to each Pf 3 ^ 3 waS identical

S P m n Fonowing Fmcrnre of the Vertebrae, South. M. J. 2 , : 22S-233 ^ ^ ^ ^

Wl D.: Reimrrent Urolith^asisj^Etiologm^Factors and for eadl subject and Control

Clinical Management, J. A. M. A. XU* •

diet
a six

was tec! identically to identic

s day period. The daily fluid mt . ak N , * 2 000 cc.
»rh subject and control and was limited to 4

Volume 113
Number 16

RENAL CALCULI— FLOCKS

1467

Repeated studies of seven patients were made at inter-
vals of several months and in each instance the results
were essentially the same.

In eleven of the control group of twelve volunteers
the average calcium excretion, as might he expected,
varied with the diet, being from 100 to 150 mg. a day
on the low intake and from 250 to 300 mg. a day on
the high intake. One of the “normal” controls showed
an excretion of 220 mg. of calcium a day on the low
intake and 460 mg. on the high intake.

The thirty-five patients with stone, however, very
definitely divided themselves into two groups (figs. 1
and 2) : Group 1, a large one consisting of twenty-three
of the thirty-five patients, showed an increased or high
urinary excretion of calcium ; group 2, a comparatively
small one consisting of twelve of the thirty-five patients,
showed either a normal or a low urinary excretion of
calcium. The phosphorus excretion in all the patients,
with one exception, was essentially normal for each diet.
The one exception showed a high phosphorus excretion
associated with a high calcium excretion.

All of the first group of twenty-three patients
excreted more than 420 mg. of calcium a day on the
diets rich in calcium and phosphorus, and a daily cal-

Urinary
Calcium *

Mgmi.

per

24 hr*.

□ ■
Average
Response

Rrrponse

in l hi*
Individual

BLOOD
r. 9~//

Low Intake High Intake

+- VtT. D.

Fir. 3. — P»-5r.ofv r f calcium by a white man aged 28 with

■ . : ■ ,! • . . -rent renal calculi on the right. No

■ ■ *. ■ ■ ■ The stones were calcium phosphate.

Urinary calciums were studied repeatedly over a period of eighteen months
and remained persistently high, while urinary phosphorus remained normal.
Note the marked increase in urinary calcium when vitamin D in moderate
doses was added to the neutral ash diet low in calcium and phosphorus.

cium excretion of more than 600 mg. was not uncom-
mon. These values are comparable to those seen in
hyperparathyroidism. Twenty-one of these patients
excreted more than 200 mg. a day, but the remaining
two excreted less than 200 mg. on the low intake diets.
Both of the patients with hyperparathyroidism were in
this group of subjects with excessive output of urinary
calcium. Moreover, it is of especial interest that all
those patients (ten of the thirty-five) with rapidly
developing stones or with rapid formation of new stones
fell into this group.

Of the group of twelve patients with normal or sub-
normal urinary excretion of calcium three presented a
history which suggested that at the time when the
urinary calculi originated there was probably an
increased urinary excretion of calcium or phosphorus.
3 here was neither a history nor indications in the
remaining nine cases to suggest such a contingency.
However, in none of these cases at the time these
studies were made was there evidence of rapid growth
of stones or of new formation of stones, and in three
of them kidney stone had been known to be present and
quiescent over a period of years.

To review, then, in a group of thirty-five patients
with urinary calculi twenty-three showed excessive
excretion of calcium in the urine. Because the excess
over normal was exaggerated on the high intake, this
excessive excretion could be demonstrated most readily
by noting the response of the urinary calcium to the

Fig. 4. — Appearance of plain x-ray film in a case of right renal stone
in a white man aged 64.

high calcium and phosphorus intake. Only two of these
twenty-three had hyperparathyroidism. In the other
twenty-one no definite reason for the excessive urinary
calcium was to be found. Moreover, all patients show-
ing rapidly forming stones or new stone formation while
under observation showed high urinary calcium excre-
tion. Also of the twelve patients with a low urinary

Fig. 5. — Excretory pyelograms of same patient as in figure 4. Note
that there is good renal function bilaterally^ with practically no distortion
of the right pelvis. The calcium concentrations in the kidney urines were
36 mg. per hundred cubic centimeters on the right and 18 mg. on the left.
The phosphorus concentrations were 76 mg. on the right and 43 mg. on

calcium three gave a history of a condition associated
with increased urinary calcium at the time when the
urinary calculi probably originated. Thus a marked
increase in excretion of urinary calcium was demon-
strable at one time or another in twenty-six of the
thirty-five subjects with urolithiasis.

1468

RENAL CALCULI— FLOCKS

Jour. A. M. A
Oct. 14, 1S33

THE EFFECT OF DIETS WITH AN ACID ASIT
The fact that calcium phosphate does not precipitate
readily at a low urinary /> H has caused many workers 4
to emphasize the necessity of keeping the urinary p n
low in these patients in order to prevent recurrence of
renal calculi and possibly dissolve a certain number of
them. For this reason diets with a high acid ash sup-
plemented by substances such as ammonium chloride
and ammonium nitrate have been advocated. However,
Albright 5 and others 0 have emphasized the fact that
the ingestion of acid-forming substances usually is asso-
ciated with an increased calcium excretion in the urine.
This, of course, would tend to neutralize the effect of
the lower p a . Therefore, in order to estimate this rela-
tionship quantitatively we studied the effect of an acid
ash diet and ammonium chloride in both groups of
patients, i. e. in the group with excessive urinary cal-
cium excretion and in the group with the essentially
normal or low urinary excretion of calcium. When the
group with the high urinary calcium excretion was
placed on an acid ash diet supplemented by 4 Gm. of
ammonium chloride daily, a marked increase in urinary
calcium was obtained. Thus on an acid ash diet con-
taining 0.8 Gm. of calcium daily urinary excretions of
from 400 to 450 mg. of calcium a day were obtained.
In contradistinction, the group presenting the low
urinary calcium showed low responses to the same diet

Fig. 6.— Appearance of plain x-ray film
gSTsJrictu“at tbl 'uret’erovesicular junction in a white man aged 24.

and medication. Values of from 200 to 2o0 mg. of
calcium in the urine per twenty-four hours we e
obtained. This is of considerable import m the treat-

4 Higgins, C. C.: Production and Solution of Urinary Calculi, J. A.
M ' 5 A A^C 29 |u ( ,fc?r'Ba 3 ^ Pi C.= Co^O^r.^ Bloomberg.

Am - J - M - Sc - 18 7 : 49 ' 65 (Jan - )
1934. t tt and Sulkowitch. H. W-: Progress in Management of

Uri 6 na^£UU- J D 'Urllt:°746.r62 (June) 4937.

ment of patients with renal stones by means of the acid
ash diet. In the first group, the group showing high
urinary calcium, relatively little or no beneficial effect
is to be expected from the acid ash diet. Moreover, if
urea-splitting organisms are present in the urine or the
slightest amount of stasis is present harmful effects,

■ figur£ 6.

Fig. 7.— Retrograde pyelogram of same patient as m w fttre »
that_ there is present a gradually, enlarging Jrft ^ rem j. i( j ne} . onto

good function bilaterally. The calcium concentrations >n ^ on t

were 8 mg. per hundred cubic centimeters on the rig . . , an j 9 OS-
left. The phosphorus concentrations were 8 mg. on me

on the left.

ucli as were obtained by Oppenheimer an ^,^° t i en tS(
nay result. In contrast, in the second S r ° u P,°J ', r ; nar v

lay result. In contrast, in me sau.m ‘ j na ry

lose showing a low urinary calcium and a ^ c p e ;

iiusc anuwmg ci 1 . , . , _

alcium response to the acid ash diet, tn!S }P
3 ideal if the desired urinary pn can be obtain

EFFECT OF DIETS SUPPLEMENTED BY VITAM

. r fi.nsiri r\

brru.v m . — . ’nA

A great many of the P re P.^5^.i° n ^ of j^^perimentally

present combined with vitamin D.

itanffn” D is known to produce an increased lir ! na £

- r 1 _ 4.1. .*,-1 f /i

itamm id is miuwu w — — -tnHied the

xcretion of calcium. I have, therefore, norfll al
rinary calcium and phosphorus excre 10 , j ^
ersons and also some of the patients w bfir 0 {
irrpa dprl tirinarv calcium output me , t j|j

.1 CH5CU uiiiimj - J. .node IS - 1

tients in whom complete studies wer increa sed
:ite small. However, all the patien s vi placed

inary calcium excretion and renal calcu eXCeS sive
moderate doses of vitamin D showed a nlUcll
inary calcium response. This . r “f° n , a i volun;
ire marked than that obtained ,n , the !° va tions of
:rs. This finding is similar to the obs ca , ciun ,
awson, 8 who studied the urinary ^cretw helio*

iwson, who sruuieu u c j --- ■

a group of tuberculous patients
erapy (fig. 3).

7. Oppenheimer. G. D„ and Pollack, Herbert^ Attcmptc^Sol^ j;)

uni Calculi by Dietetic Measures. J. A. M- Of

's. Mawson, E. E.: A Consideration of Some.

8. Mawson, E. E.: A Cotisiaera.mn ^children.
Tied in the Development of Urolithiasis in c

ir. J. (pt. 2) 40: 99-133, 1932.

Volume 113
Number 16

RENAL CALCULI— FLOCKS

1469

These significant quantitative differences in urinary
calcium following the administration of high acid ash
and vitamin D intakes illustrate the necessity of study-
ing in each individual patient that patient’s response
to the therapy that is being instituted.

EFFECT OF URINARY STASIS
In order to ascertain the effects of urinary stasis and

■ of other diseases of the urinary tract on the urinary
excretion of calcium, studies were made on urine
obtained by simultaneous catheterization of each ureter
(figs. 4-9). In this way the normal kidney acted as a
control for the pathologic one. Fourteen patients were

| studied in this manner. Although it is difficult to draw
• i conclusions from so small a group, the trend is definite,
j Apparently a slight or intermittent obstruction or a
slight to moderate pathologic process in the urinary
•' j tract, such as the presence of a small stone in the kidney
- j pelvis, was associated with a significantly higher cal-
■i cium concentration in the urine from that kidney than
S in the urine from the normal kidney. At times this
I concentration of calcium in the urine was twice that
| found in the normal mate. In contrast, complete
?i obstruction or marked destruction of the kidney sub-
:i stance was always associated with a reduced calcium
id concentration. These observations are consistent with
j those of Hunner n and others as to the relation of stasis
i to urinary stones. Moreover, they emphasize the danger

■ that a new nucleus may be formed in the kidney sub-
stance during the time consumed while waiting for a
kidney stone to pass spontaneously. Also they may
account for unilateral stone formation in the group of

| patients with a tendency to excessively high urinary
calcium.

EFFECT OF VARIATION OF FLUID INTAKE
Corresponding to the results obtained by Albright,
we found that the total daily urinary calcium excretion

-■ Fig. g, — Appearance of plain x-ray film in a case of one large and
several small right renal calculi in a white man aged 45.

r.

was quite independent of the water excretion, so that
* increased output of water merely diluted but did not
change the calcium and phosphorus output. Therefore,
the most satisfactory method for decreasing urinary
y calcium and phosphorus concentration is the intake of
krge quantities of water.

, r 9 \ Hunner, G. L. : Calculus of the Upper Urinary Tract, with Special
f' operation of Recurring Stone Formation, Tr. West. Branch, Am.

' Hrol. A. 2: 65-86, 1933.

COMMENT

Two groups of factors may be considered as funda-
mental in the pathogenesis of renal stone: (1) those
factors which so change the nature of the renal sub-
stance as to favor precipitation of the crystalloids within
it and (2) those factors which favor the precipitation

Fig. 9. — Retrograde pyelogram of same patient as in figure 8. Note
that renal function was very much decreased on the right side. The con-
centrations of calcium in the kidney urines were 6 mg. per hundred cubic
centimeters on the right and 16 mg. on the left. The concentrations of
phosphorus were a trace on the right and 10 mg. on the left.

of crystalloids in the urinary passageway. In any indi-
vidual patient either or both groups of factors may be
operating at the same time or at different times.

Damage to the kidney substance predisposing to the
precipitation of crystalloids is of importance in many
cases. However, the exact factors that produce this
type of damage with the associated precipitation of cal-
cium salts are not known. Randall 10 has demonstrated
subepithelial plaques of precipitated calcium which
formed a nucleus for stone formation. Hellstrom, Hug-
gins 11 and others 12 have demonstrated similar lesions
and precipitations within and about the tubules and
so-called microliths in kidneys associated with renal
calculi. Precipitations of this sort appear experimen-
tally and clinically in vitamin D “poisoning” and in
hyperparathyroidism. 13 In both these conditions there
is an increased urinary calcium excretion. This exces-
sive excretion may be the underlying factor, or at least
a very important factor, in the formation of these cal-
cium deposits. Higgins 4 and others have established
the fact that there is a definite relationship between
vitamin A deficiency and stone formation. Vitamin A
deficiency may act by destroying the vitality of the renal
epithelium, thus permitting precipitation of calcium
and phosphorus within it. Infection in the renal pelvis
itself and obstruction to the outflow of urine from the
pelvis may likewise damage the kidney substance. In
this clinic twenty-one of a series of fifty-three kidneys
in which renal stone was or had been present were
found to have microscopic deposits of calcium within
the tubules or the tubular epithelium, or microliths as

10. Randall, Alexander: Surg., Gynec. & Obst. 64:201 (Feb.) 1937

11. Huggins, C. B.: Bone and Calculi in the Collecting Tubules of
the Kidney, Arch Surg. 27: 203-215 (Julv) 1933.

12. Crabtree, E. D.: Calcification Within Tubules of Kidney in Asso-

ciation with Urinary Tract Lithiasis, Tr. Am. A. Genito-Urin. Surgeons
23: 17. 19.:tV *"

13. Albright, Fuller, and Bloomberg, Esther: Hyperparathyroidism and
Renal Disease, J. Urol. 3-i: 1-7 (July) 1935.

1470

RENAL CALCULI— FLOCKS

Joes. A. M. A
0a 14, d;j

described by Randall, Hellstrom, Huggins and others.
These lesions are strikingly similar to the lesions
described in hyperparathyroidism, vitamin D “poison-
ing” and experimental stone production by hyperexcre-
tion of crystalloids ( Keyset' 14 ). Thus precipitations of
crystalloids in the kidney substance of each individual
patient may be produced by any one or any combination
of the following factors: toxins, vitamin A deficiency,
vitamin D poisoning, hyperparathyroidism, increased
urinary calcium and phosphorus due to other causes,
infection in the renal pelvis or urinary tract obstruction.

The two fundamental factors determining the precipi-
tation or solution of calcium and phosphorus in the
urinary passageways are the urinary p n and the urinary
concentration of calcium and phosphorus. Certain
accessory factors may also be of importance: the col-
loids of the urine, the surface tension of the urine, the
presence of stasis and the presence of bodies that might
act as nuclei for the precipitation of crystalloids. The
importance of the hydrogen ion concentration and the
ease with which this concentration can be changed to
the alkaline side by urea-splitting organisms, together
with the marked frequency with which these organisms
occur in patients with renal calculi, has been demon-

Urinary
Calcium

Mgtni'
per

24 hr*.

□ 4

Average
Re«pon»e

Rejponte
in thfa
Individual

BLOOD
CL2 z!/.

High intake

Fig. 10. — Urinary excretion of calcium and phosphorus by a patient
with a fracture of the left femur of a week’s duration. The patient is
bedridden with the left lower extremity immobilized. Note the high
urinary calcium response to the low intake.

strated by many workers. Experimentally the impor-
tance of the increased concentration of crystalloids in
the urine has been emphasized by Keyser. The high
incidence of urinary stone in hyperparathyroidism, in
which increased urinary excretion of calcium and phos-
phorus occurs, has been emphasized by Albright and
Barney. The high incidence of urinary calculi in
patients with bone disease, in whom presumably there
is some alteration in calcium metabolism probably asso-
ciated with increased calcium excretion, has been
emphasized by Holmes and Coplan and by Jones and
Roberts and others. Steiner 15 has demonstrated that
the epithelial desquamation which occurred in vitamin A
deficiency may act as a nucleus for the precipitation of
crystalloids. Again there is a multiplicity of factors
one or more of which may be present in each patient.

There are, then, two groups of factors in the patho-
genesis of renal stone : first, those factors which are
associated with the precipitation of crystalloids in the
kidney substance and, second, those which are asso-
ciated with the precipitation of the crystalloids in the
urinary passageway. Moreover, as discussed in the

- 14 Keyset, L. D.: The Mechanism of the Formation of Urinary Cal-

:uh. 4fA„? r Urg Morris- _I Zug^r! Bernard, and Kramer, Benjamin: Pro-

* Die ‘ DrfCiCnt

previous paragraphs, increased excretion of calcium and
phosphorus in the urine may be of importance in both
groups of factors. .

The high incidence of increased urinary calcium in
the thirty-five cases of calcium urolithiasis described in
this report emphasizes the relationship between urinan
calcium and the pathogenesis of renal calcium stones.
Moreover, the fact that twenty-one of these patients
showed no evidences of hyperthyroidism, hyperparathy-
roidism or bone disease emphasizes the fact that high
urinary calcium may be present in these patients and
must be considered in their prognosis and treatment
even though conditions usually associated with increased
urinary calcium are absent.

It would seem that, although the high concentration
of the calcium in the urine of itself is not enough to
bring about precipitation in the kidney substance w
in the urinary 7 passageway 7 , it would predispose these
patients to this occurrence. Therefore, given a patient
or an otherwise normal person with a high urinary
calcium, other factors being equal, he would be more
likely 7 to form stone than one with a low urinary calcium
For example, given two persons with infection o! the
urinary 7 tract presenting urea-splitting organisms, the
question as to the one who will form stone may depend
on the urinary 7 concentration of calcium. Similarly m
deciding which patient will have a recurrence of stone
following operative removal of urinary calculus, other
factors being equal, urinary 7 concentration of calcium
will be the deciding factor.

Moreover, because of this relationship between un
nary calcium excretion and urolithiasis, conditions t«
are associated with increased urinary calcium need co
plete quantitative study from this angle. 'H'en 7
the increased urinary calcium occur? How can i
modified? (fig. 10). In this way information may «
obtained which will be of importance in the preven
of the occurrence and recurrence of calcium stone
the urinary tract. . , f m

The urinary calcium is of importance not ° nI ) .
an etiologic point of view but also from a P r0 »
and therapeutic point of view. The results o
studies emphasize the necessity 7 of studying 4® (
tively 7 the calcium excretion in the urine under i
ty'pes of therapy 7 instituted. They 7 show via
increased urinary calcium is found the prognosis is l .
and that acid ash diets and vitamin D shou d
with care. Marked dilution of the urine si
sought for and all possible sources of this Iugi ^
calcium searched for and eliminated. In c ? n - s fetter
patients with low urinary calcium the prognosis i ^
and beneficial effects may be expected from .

diets. Moreover, in considering the problem
rence of stone in a particular kidney 7 , the p ^
of altered urinary 7 excretion of calcium thro t,
particular kidney is of importance.

SUMMARY AND CONCLUSIONS

1. A study was made of the urinary excre ?
:alcium and phosphorus under fixed conai i j n
jroup of tbirty 7 -five patients with _ renal ca
:wenty-three patients of this series high urinary ^
:xcretion was found. In three of the twe'C ,i n2
irinary calciums there was a history w )jen
ncreased urinary 7 excretion of calcium at a

:he calculi probably 7 started. Only 7 two of t ie

lad clinical evidences of hyperparathyroi i= • 0 >

2. All the patients with rapidly growing

lew stone formation during observation v ca i c p!ni-
jroup presenting the high urinary 7 excretion

Volume 113
Number 16

KIDNEY STONES— KRETSCHMER AND BROWN

1471

3. The patients with high urinary calciums responded
to an acid ash diet with an excessively increased urinary
calcium as compared to the patients with low urinary
calciums.

4. The patients with high urinary calcium responded
to a moderate vitamin D intake with an excessively
increased urinary excretion of calcium as compared to
normal, volunteers.

5. ' A study of the effect of pathologic changes in the
•kidney on the urinary excretion of calcium through that
kidney was made in fourteen patients. A slight patho-
logic change was usually associated with definitely
increased urinary calcium as compared with the normal
mate ; marked pathologic change was usually associated
with definitely lowered urinary calcium as compared
to the normal mate.

6. Increased fluid intake resulting in increased uri-
nary output merely seemed to dilute the urine and thus
reduce calcium concentration per unit volume. It did
not alter significantly the total daily amount of calcium
excreted.

7. Consequently, in the management of patients with
urinary calculi it is important to consider not only such
factors as -vitamin A deficiency, infection of the urinary
tract, hyperparathyroidism and stasis but also the quan-
titative urinary concentration of calcium and the
quantitative influence on this concentration of any
treatment instituted.

' DO ALKALIS USED IN THE TREAT-
MENT OF PEPTIC ULCER CAUSE
KIDNEY STONES?

A STUDY OF 1,940 CASES
HERMAN L. KRETSCHMER, M.D.

AND

RALPH C. BROWN, M.D.

CHICAGO

The occurrence of urinary calculus in a patient who
for a period of time has been taking alkalis in the treat-
ment of peptic ulcer may arouse suspicion that the stone
has formed as a result of the use of the alkalis. This
idea appears to exist not only in the minds of the public
but in the minds of some members of the medical pro-
fession as well.

The present study was undertaken with a view of
securing data from which conclusions might be drawn
as to the etiologic relationship, if any, between the use
of alkalis in the treatment of peptic ulcer and kidney
and ureteral stone formation.

The data that we present were obtained by an exami-
nation of the records of 2,210 cases, of which 1,260
cases were seen bv one of us (IT. L. K.) and 950 by
the other (R. C. B.).

HISTORY

Calculous disease dates back to the very beginning of
civilization. According to Joly, 1 the earliest specimen
pf a vesical stone was discovered by Prof. Elliott Smith
in the grave of an Egyptian and was estimated to be
about 7,000 years old. It was composed of a central
nucleus of uric acid surrounded by a thick layer of

From the Presbyterian Hospital and the A. D. Thomson Fund, Rush
•‘leihcal College, University of Chicago.

Read before the Section on Urology at the Ninetieth Annual Session
Qt the American Medical Association, St. Louis, May 19, 1939.

Q V J* S. : Stone and Calculous Disease of the Urinary Organs,

Louis, C. V. Mosby Company, 1929.

calcium oxalate and ammonium-magnesium phosphate.
He also described another stone which was found lying
close to the second lumbar vertebra of a skeleton in
a tomb, dating from the second dynasty about 4100 B. C.
It was composed of carbonate, phosphate and oxalate
of lime. From its appearance and the position in which
it was found it was supposed to be a renal calculus.

The chemical composition of these stones bears a
striking resemblance to the composition of kidney and
ureteral stones that occur today, and one may say that
through the past 7,000 years there has been no great
change in the chemical composition of these calculi.

Randall 2 has recently published the results of the
chemical examinations of a large series of kidney and
ureteral stones. Attention may be called to the large
number of kidney stones that were composed of pure
calcium-magnesium phosphate, thirty-nine of seventy-
one, or 54 per cent. We wish also to direct attention
to the fact that of 100 cases of stone in the ureter in
which the stones occurred in pure salts, forty-nine of
them consisted of pure calcium-magnesium phosphate.

Before entering into a discussion of the question of
the possible relationship between the use of alkalis in
the treatment of peptic ulcer and the formation of kidney
stones, it might be well to present briefly the various
theories as to the origin of these stones. At the outset
it might be well to call attention to the statement of
Hinman, who says “No more is known of what starts
the mechanisms of formation of stone than of the mecha-
nism itself.” Attention may also he called to the state-
ment of Howard Kelley: “No stretch of chemical or
physiological imagination will permit so heterogeneous
a group of compounds to be ascribed to a common
origin, or their deposition, in kidney, ureter or bladder,
to be uniformly charged to an identical cause.”

Since the treatment of peptic ulcer is intimately asso-
ciated with a definite dietary regimen, it might he well
to state at the outset that all patients are on a program
designed to exclude the possibility of vitamin deficiency,
so that avitaminosis as a factor can be excluded.

Experimental studies have been presented demon-
strating a relation between deficiency of. vitamin A and
the production of urinary calculi in animals. ‘ Contribu-
tions on this subject have been furnished by McCarri-
son, 3 Fujimaki, 4 van Leersum, Perlman, Higgins, 5
Steiner, Zuger and Kramer 0 and many others. They
agree that the vitamin A deficiency is often the cause
of urinary calculi in experimental animals.

Furthermore, attention may be called to the fact
that the incidence of urinary stone in children, espe-
cially bladder stone, has almost disappeared since the
institution of modern diets which prevent avitaminosis.

During the past ten years a good deal of attention
has been given to disturbance in the function of the
parathyroids. Although renal calculi are found in
hyperparathyroidism, it is doubtful whether it plays a
role in the production of renal calculi as seen in practice.

Albright, Baird, Cope and Bloomberg ' reported that
27 per cent of a series of eighty-three patients with
hyperparathyroidism had renal calculi. On the other

2. RandalJ, Alexander: Ann. Surg. 105: 1009-1027 (June) 1937

3. McCarrison, R.: Brit. M. J. 2:159 (July 30) 1927.

4. Fujimaki; League of Nations Health Organization, Geneva, 1926.
p. 369.

5. Higgins , C. G: Production and Solution of Urinary Calculi. X A
M. A. 104: 1296-1298 (April 13) 1935; J. Urol. 29: 157 (Feb.) 1933.

6. Sterner, Morris; Zuger, Bernard, and Kramer, Benjamin: Pro-
duction of Renal Calculi in Guinea Pigs by Feeding Them a Diet Deficient
in Vitamin A, Arch. Path. 27: 104 (Jan.) 1939.

7. Albright, Fuller; Baird, P. C.; Cope. Oliver, and Bloomberg, Esther,

J. Am. M. Sc. 1S7 : 49 (Jan.) 1934. *

1472

KIDNEY STONES— KRETSCHMER AND BROWN

hand, Braasch, Griffin and Osterburg in a study of
1,206 consecutive cases of urolithiasis found hyperpara-
thyroidism as an etiologic factor in less than 0.2 per
cent.

Albright and Bloomberg 8 concluded that formation
of urinary calculus in hyperparathyroidism belongs to
that etiologic group in which the predisposing abnormal
factor is an excess of crystalloids in the urine.

Disturbance in the colloid-crystalloid balance as a
cause of renal stone was proposed many years ago. It
is based on the assumption that the urine is a super-
saturated solution and that the crystalloids are held
in solution because of the presence of protective colloids.
Precipitation of crystalloids may occur if they' are pres-
ent in so excessive an amount that the normal colloid
cannot hold them in solution or if they are present in
normal amount and there is a diminished amount of
colloids present.

Interesting in this connection is the fact that some
patients have an excessive amount of crystalloids in the
urine and yet stone never develops. As examples, cysti-
nuria, oxaluria and phosphaturia may be mentioned.

The theory that interference with urinary drainage
results in stasis and hence predisposes to stone is an
old one. In cases of hydronephrosis with stone forma-
tion one is always confronted with the question of

Table

1 . — Location

of Stone

in Seven Cases

Case

Age

Sox

X-ocatlon of Stone

1

43

$

Kidney

2

40

d

Ureter

3

40

d

Kidney and ureter

4

47

d

Ureter

5

43

d

Kidney

G

47

d

Ureter

7

4S

d

Kidney

whether the stone made the hydronephrosis or vice
versa. Although stasis may play a role in some cases,
it can hardly be called on as a factor in the very large
number of cases in which stasis is absent.

There can be no doubt that infection plays an impor-
tant role in a certain number of cases. On the other
hand, the large number of cases of stone without infec-
tion immediately raises the question of the role played
by infection in each case. Furthermore, the common
cause of renal infection is the colon bacillus ; the largest
number of infections are not associated with stone.

The recent work of Randall is extremely interesting
in this connection. According to him, renal calculous
formation is dependent on a preexisting renal lesion,
and this lesion consists of the deposition of calcium in
the walls and intertubular spaces of the renal papillae.
He believes that these calcium plaques appear to be
a natural reparative process to some form of tubular
damage. He was able with seven specimens to show a
calculus attached to the calcium plaque.

THE RATIONALE OF ULCER TREATMENT

The use of alkaline substances in the treatment of
peptic ulcer is more ancient than our knowledge of the
lesion. Long before Baillie’s description of the_ morbid
anatomy and symptoms of gastric ulcer in 1793 and
Cruveilhier’s classic work some years later, sufferers
with ulcer had learned that relief from the gnawing
pains of ulcer could be had by taking chalk, magnesium
and sodium bica rbonate. When the early standard

8. Albright, Fuller, and Bloomberg, Esther: Tr. Am. A. Genito-Urin.
Surgeons 27 J 195, 193*1.

Jour. A. M. A.
Oct. 14, 1939

types of treatment, such as Leube’s and Lenhartz’s,
came into vogue, the employment of alkalis was a
definite part of the regimen.

In 1914 Sippy proposed the use of acid neutralizing
substances, chiefly alkalis and milk, to be taken with
a frequency and in amounts sufficient to effect complete
neutralization of the free hydrochloric acid in the gastric
content from morning until night. The validity of the
basic principle of the Sippy treatment, namely, freeing
the exposed surface of the peptic ulcer from the tissue
digesting action of the gastric juice by inhibiting its
proteolytic action, as can be done by total neutralization
of hydrochloric acid, has been well established in the
intervening years.

As is true with most useful chemical therapeutic
agents, alkalis must be used with a certain amount of
discretion. Persons differ in their tolerance of various
types of alkalis just as they differ in their tolerance
of belladonna and other substances. In general, older
persons tolerate them less well than the young and the
middle aged. Many different alkaline substances have
been employed, chiefly sodium bicarbonate, calcium
carbonate, magnesium oxide and the tribasic phosphates
of calcium and magnesium, and of these the latter three
are apparently' the least likely to cause an acid-base
imbalance.

In the ulcer cases covered by this survey the group m
the earlier y'ears was treated with sodium bicarbonate
and calcium carbonate. In the last ten years the tribasic
phosphates of calcium and magnesium have been most
commonly used in the treatment of ulcer at the Presn-
terian Hospital. The amount required in the individua
case is determined by' aspiration of gastric contents an
titration. The total daily amount of the tribasic phos
phates used varies from 25 to 30 Gm. for periods Aar)
ing from two to six months. If any symptoms indica ■'
of disturbance of the acid-base ratio develop, the fur i
use of alkaline salts is governed by estimation o '
carbon dioxide of the blood plasma. Special attcn 10
is given to the vitamin requirements of these patten '

It has been claimed that the administration of a '3 '
in the treatment of peptic ulcer may cause ceitain
turbances in the calcium and inorganic phosp 1(> |
content in the blood serum. In order to dcterm
whether or not there is any disturbance of the ca cj
phosphorus blood level, twenty'-five cases of peptic u
under thorough alkalization were studied to detenu^
the serum calcium and serum phosphorus content,
highest calcium figure was 12 mg. per hundred c
centimeters, the lowest 9.3 mg. and the average •
mg. The highest inorganic phosphorus conten
4.4 mg. per hundred cubic centimeters, the m
2.8 mg. and the average 3.65 mg. As the ug
figures obtained are within the normal range an
averages are quite normal for both calcium an P ^
phorus, it would seem that the use of alkalis m
treatment does not predispose to stone , nl ‘, s .
through elevation of blood serum calcium an P
phorus. . . ]( | v

For the purpose of this investigation a detaile s -
of the records of 950 cases of peptic ulcer u as ‘
These were taken from the files of the Pres J
Hospital without selection but included a group 0
from each y'ear from 1914 to 1937 inclusive. .0

A questionnaire was directed to this group °
patients, of whom 680 replied, and the data to
sented is based on the replies received from !l f or
of 6S0 peptic ulcer patients who had had trea i

Volume 113
Number 16

KIDNEY STONES— KRETSCHMER AND BROWN

1473

periods of from three to six months, the average period
of accurate treatment being four months in duration.
Many of these patients reported that they took minor
amounts of alkaline powders over a much longer period.

INCIDENCE OF RENAL AND URETERAL CALCULI IN
CSO CASES OF REI’TIC ULCER TREATED WITH
MILK AND ALKALIS

' An interesting fact that was brought out in this
study is that twenty-one patients gave a history of
urinary calculus before they presented themselves for
diagnosis and treatment of peptic ulcer. By contrast,
there were only thirty-three cases in which there was
a history of urinary calculus that occurred sometime
after the treatment of peptic ulcer was instituted.

In many of these cases symptoms of kidney stone
.developed from ten to twenty years after the treatment
for ulcer had been discontinued. Furthermore, it must
• be borne in mind that a large proportion of this group
'of 680 ulcer cases had been treated from ten to twenty-
five years prior to the period of this inquiry; hence
in an evaluation of the data consideration must be given
to the fact that in any such cross section of the popula-
tion as represented by this group of 6S0 individuals — a
majority of them now in middle or later life — a certain
normal incidence of renal calculus is certain to exist.

Also in certain of these thirty-three cases of calculi
occurring after ulcer treatment there may well have been
an unrecognized, symptomless kidney stone at the time
of institution of ulcer treatment, since the passing of
'stones within two months thereafter was reported in
;some cases. The spontaneous passage of a single small
.stone was reported in six of the thirty-three cases.

Summarizing the facts brought out by this study
of 680 ulcer cases under treatment, there were twenty-
one (3.1 per cent) in which stones occurred before ulcer
treatment and thirty-three (4.9 per cent) in which
stones occurred after ulcer treatment. Hence, even if
the modifying factors previously mentioned (i. e., nor-
mal incidence of stone) are disregarded, it would seem
that the case against alkalis as used in ulcer treatment
as a cause of renal calculus narrows down to the differ-
ence between the 4.9 per cent of cases in which stone
.was reported after treatment and the 3.1 per cent of
cases in which stones were reported before ulcer treat-
ment, a difference of 1.8 per cent : not a grave indict-
ment of the use of alkalis.

As an approach to this problem from the urologic
point of view, the records of 1,260 cases were studied,
supplemented by many personal interviews.

In this series of 1,260 cases of renal and ureteral
calculi there were seven in which the diagnosis of stone
and ulcer was made simultaneously and in which there
had been no ulcer treatment. This group of cases is
presented in table 1.

It is interesting to note that six of the seven cases
occurred in men and that all seven cases occurred in
the fourth decade.

Among the 1,260 cases were twenty-six in which
there was a history of peptic ulcer, or 2.06 per cent,
t lie age, sex, location of the stone and treatment carried
out are given in table 2.

An analysis of this group shows that only fifteen
patients, or 57.692 per cent, received alkalis for the
treatment of ulcer. Seven of the remaining eleven
patients, or 26.923 per cent, received surgical treatment,
the operations performed were gastro-enterostomies
and gastric resections. One of the patients had three

operations for ulcer, namely a gastro-enterostomy, a
gastrojejunostomy and finally a resection. The remain-
ing four patients, or 15.384 per cent, received no alkalis
in the treatment for peptic ulcer.

Since some of the patients were treated elsewhere for
ulcer, the thoroughness with which the treatment was
carried out as far as the amount of alkalis used is con-
cerned may be open to question.

We wish to call attention to the fact that, of the
fifteen cases in which alkalis were given, in three the
stones occurred many years after the ulcer treatment
was discontinued. In one instance the stone developed
fourteen years later, in another ten years and in the
third case five years later.

Because of the long period that elapsed between the
cessation of ulcer treatment and the onset of the urinary
calculi, one may question the relationship, if any,
between the two and state that the occurrence of the
stones so many years later was purely incidental.

Table 2. — Location of Stone and Treatment in Twenty-Six
Cases of Peptic Ulcer

Case

Age

Sex

Location

Treatment

1

54

"9

Ureter

Alkalis

2

50

o'

Kidney

Gastro-enterostomy only

3

:*S

d

Kidney (bilateral) Alkalis

4

57

Kidney

No treatment

5

50

d

Kidney

Alkalis

0

41

9

Kidney

Resection, stomach

7

02

d

Kidney

No alkalis, ;nflk and cream only

8

07

d

Kidney

Gastro-enterostomy

0

53

d

Kidney

Laparotomy for ulcer

10

37

d

Kidney

No alkalis, milk only

21

53

d

Kidney

Gastro-enterostomy 4- treatment

12

44

9

Kidney

Alkalis

25

<3

d

Kidney

Alkalis

14

47

d

Kidney

Alkalis

15

01

d

Kidney

Alkalis

Ifi

54

d

Kidney

Gastro-enterostomy

17

3S

d

Kidney

Alkalis

lb

70

d

Ureter

Alkalis

10

52

d

Ureter

Alkalis

2)

43

9

Ureter

Alkalis

21

41

d

Ureter

Alkalis

22

OS

d

Ureter

Alkalis

23

55

d

Ureter

Alkalis

24

27

d

Ureter

Three operations for ulcer of
stomach

23

30

d

Ureter

Alkalis

20

OS

d

Kidney and ureter No alkalization: soda once in a
■while

These stones were small and were passed by the
patient or removed by cystoscopic manipulation.

It is interesting to note that some of the stones were
pure uric acid, others were pure calcium oxalate and
others were mixed.

Of this series of 1,260 cases of renal and ureteral
calculi, a history of having taken alkalis in the treatment
of peptic ulcer was obtained in only fifteen cases, or
1.2 per cent.

SUMMARY

1. In our present state of knowledge it is generally
agreed that the specific cause of renal and ureteral
stones is unknown, as is evidenced by the many theories
that have been advanced.

2. The difference of 1.8 per cent in the incidence of
stone formation between individuals who were given
alkalis in the treatment of peptic ulcer and in those who
were not is so insignificant as to make it improbable
that alkalis used in the treatment of ulcer play a role
in stone formation.

o. The incidence of 1.2 per cent of previous ulcer
treatment in a series of 1,260 cases of kidney and

1474

DISCUSSION ON URINARY CALCULI

ureteral stone is small. Theoretically one might expect
the alkalis used in the treatment of peptic ulcer to cause
renal stones. The incidence of only 1.2 per cent of
treated ulcer cases in a series of 1,260 renal and ureteral
calculi, however, does not support this theory.

122 South Michigan Avenue.

ABSTRACT OF DISCUSSION

ON PAPERS OF DR. HIGGINS, DR. FLOCKS AND
DRS. KRETSCHMER AND DROWN

Dr. John Morrissey, New York : Urinary stasis and infec-
tion have a most important part in the formation of renal
calculi. Vitamin A deficiency must be reckoned with as a factor
in the general deficiency aspect of the disease. Calcium pre-
cipitation in and about the tubules is found both experimentally
and clinically in vitamin D poisoning and hypothyroidism It
has also been established that the South African Negro of the
Bantu type does not form renal calculi. Nephrostomy, prolonged
pelvic drainage and uretostomy, all relatively new procedures,
have introduced important new factors into the problem of the
patient that outparallel the advance made along purely experi-
mental lines. Continued insistence on the question of urinary
stone solution, on methods of prevention and on recurrence and
other associated items are very fertile culture mediums for the
disturbed mind of the patient with stone. There is nothing
more fallacious than the belief that any drug, either directly
or indirectly through acidification of the urine, will dissolve a
stone in the body. I do not mean to minimize the importance
of the fundamental principles set forth by Dr. Higgins or the
important observations of these thirty-five cases by Dr. Flocks
with calcium stones. I do think, however, that continued insis-
tence on the importance of dietary factors, chemotherapy and
food deficiencies from vitamins A to Z all combine to place and
retain the patient, whose ailment is 100 per cent a surgical
urologic problem, in the hands of those practitioners who would
temporize, whose clinical perspective is not surgical, and whose
relative ability to handle properly the varied features of a
problem of this type are inadequate. Thorough recognition and
study of the fundamental principles set before us this morning
will enable us of ourselves to evaluate for the patient more
thoroughly, intelligently and completely his stone problem in
the light of modern scientific urologic research.

Dr. Roy J. Holmes, Miami, Fla. : I feel that the overwhelm-
ing majority of recurrent renal calculi are, in reality, false recur-
rences. When one considers that the incidence of recurrence has
been reduced from SO to 10 per cent during the past twenty
years, it seems improbable that such a marked reduction could
be accounted for in any other manner than by improved x-ray
and surgical management. By this I do not intend to minimize
the importance of recent work on true recurrence which has
been so well brought out by Dr. Higgins. Urologists have not
progressed to the point in management of the kidney that has
been operated on to account for such reduction on the basis of
control over the etiologic factors. In my series I found that,
if the renal pelvis was excluded, 80 per cent of all recurrent
calculi were confined to the lower calix. Joly found the pro-
portion six to one. This is of great importance, since it means
that either the lower calix is by far the greater stone-bearing
area or else it constitutes a stagnant pool well situated to catch
and retain small calculi from other portions of the kidney. The
predominant picture is that of a moderate sized stone blocking
the neck of the lower calix with several sandlike particles in
the minor calices. I am willing to admit that, even with the
x-ray and various types of suction, I approach the problem of
removing every vestige of sand from the lower calix with con-
siderable fear and trembling. Dr. Higgins, in recognition of
this point, has spoken favorably of heminephrectomy in selected
cases in which there is dilatation of the calix. I not only agree
with this point but might add that recently I have resorted to
what might be termed a conservative resection of the lower
calix. This work has not progressed far enough to justify more
than casual mention. I feel, however, that if by partial encircle-
ment of the lower calix with mattress sutures we can remove
that comparatively small portion which has proved itself a

Joce. A M A
Oci. It, I9j)

habitual menace to the welfare of the entire kidney, m u
have gone far in correcting the problem of false recurrences
The study by Dr. Flocks of ureteral urine taken from earl
kidney at the same time is very interesting. It is apparent that
a small stone in the kidney may, by partly obstructing the out-
how of urine, establish a vicious circle in which the higher
calcium concentration may serve to overwhelm further the pro-
tective colloids and lead to further agglutination of the crystal-
loids. The value of an intake of large quantities of water in
cases of hypercalcemia has been emphasized. This is also the
best treatment for combating urea-splitting organisms found in
about SO per cent of such urines.

Dr. Charles C. Higgins, Cleveland: One presumption that
has frequently been made in the literature and that has been
referred to is the statement that when the patient has been cn
a diet containing adequate amounts of vitamin A there is no
reason to believe that vitamin A deficiency is present, f " L
deductions are fraught with error and I believe that roi
biophotometer tests should be made in every patient with r
litbiasis. Dr. Sargent has asked the question: What ra
logic routine do you use to prove complete removal of all stoi
I believe that as a matter of routine a roentgenogram of
exposed kidney should be secured at the time of the operal
This can be done very easily' and I believe it is preferabh
the use of the fluoroscopc. The question has been asked a:
whether or not a stone wave is occurring in the United St:

In a review of the literature, I have found no evidence I
calculous disease is increasing in frequency' in this country,
has been noted by r von Lichtenberg, Geza Ulyes and others I
following the World War there was a definite increase
calculous disease in certain parts of Europe. These men h
stated that this was probably due to the fact that invad
armies, not having adequate commissaries, were required
derive their food from the locality' in which they were station*
therefore the people in these communities were on a defimt
deficient diet for extended periods of time. Obviously, otl
factors are associated with the formation of renal calculus,
have not seen the lesion of the papilla which Dr. Randall
described, although I have studied numerous kidneys "hi
were removed because of calculous disease. Dr. Randall, ho
ever, has clearly shown the frequency of its occurrence,
question is asked as to whether this lesion is similar to *

“ ' 1912. In 1912 Dr. Can

in

calcareo

described by Dr. John Caulk

described a lesion of the papilla on which there was a
deposit which chemically was found to be composed of ca ou
phosphate, and later in 1926 Macgowan described a shim ■
lesion.

Dr. Ralph C. Brown, Chicago : It is a satisfaction to a
internist to discover that the urologists are about as nine i -
the dark as to the etiology of kidney' stone as internists
regarding the fundamental causes of peptic ulcer. There ‘‘
been a fairly well defined idea that a marked increase in cr ) 5 ._ (
Ioids in the urine predisposes to stone formation and intern^
who have occasion to treat many' peptic ulcers have been s
jected to a good deal of criticism from time to time e®
of the considerable amounts of alkaline substances used m “
treatment. As a matter of fact, we have never had P 1 *
information as to what happens with respect to calculus 0
tion in individuals so treated. It was for the purpose o s ^
ing such information that Dr. Kretschmer and I undertoo '
study. On careful questioning of a large number of m ul ^
who had been on ulcer management for from three o
months, some of them longer, it was interesting to find 1 ’^j;.
incidence of kidney stone after ulcer treatment wit i 3 t
was only 1.8 per cent greater than it was before trea
Even this small figure would probably vanish if one £ a l e ocCU r-
to such a modifying factor as the normal probability o 0
rence of stone in a large group of people who were
to a questionnaire all the way from five to twenty y . ;cr _
they' had been treated for gastric or duodenal ulcer. u

:, when Dr. Kretschmer finds that only 1.2 per ccn
, . , 1 it- i vp a ni»> u 7

more

Ulltll JL-' 1 » V.IM.I11UC1 Allium IHOi *

very large series of patients with kidney stone ga'e „

of having been on peptic ulcer treatment at any * j lr,c > u | cc -
forced to draw the conclusion that the use of alka 1S ' ydnO'
management has little or no influence in the causation o

Volume 113
Number 16

PLACENTAL BLOOD-BARTON AND HEARNE

1475

stones. It is interesting to bear in mind that there is being
carried on a great public propaganda by magazine and radio
advertising under the slogan “Keep Yourself On the Alkaline
Side.” If the use of alkalis really has much to do with this
matter of stone formation, it would seem that during the next
few years urologists should be called on to deal with a tremen-
dous increase in the number of cases of renal calculus.

THE USE OF PLACENTAL BLOOD
FOR TRANSFUSION

FRANK E. BARTON, M.D.

AND

THOMAS M. HEARNE, M.D.

BOSTON

For the past two years the medical profession has
been extremely interested in blood banks. The casual
reader would be led to believe that this work had been
only recently developed. A carefully prepared bibli-
ography', however, shows that the subject of blood
banks was first described in 191S by Oswald H. Rob-
ertson, 1 then of the United States Army. The experi-
mental basis for his work was originated by Rous and
Turner, 2 affiliated with the Rockefeller Institute for
Medical Research. Dr. Robertson’s 1 original article
advocated the use of a preserving fluid consisting of 5.4
per cent dextrose combined with 3.8 per cent sodium
citrate. In a personal communication dated October
1938, Dr. Robertson still favors this use of sugar and
citrate as a preservative.

Rous and Turner 2 determined the viability of pre-
served blood cells by means of transfusion of these
cells in bulk. Rabbits were used for this purpose. A
normal rabbit was bled of a large quantity of blood,
up to half its blood volume, causing a marked drop in
the hemoglobin percentage and red cell count. Immedi-
ately afterward the rabbit was given a transfusion of
an amount of preserved rabbit’s blood equal to the
amount lost in bleeding. The hemoglobin returned
promptly to its previous level. The animal showed no
ill effects from the procedure, and the hemoglobin and
red blood cell count remained normal. This demon-
strated that the transfused preserved blood cells were
behaving as normal red corpuscles. By this means it
was found that rabbit’s blood could be kept living for
two weeks. Many similar experiments were carried
out with the same result.

Further study of the subject is illuminating, as in
1934 Lindenbaum and Stroikova 3 reported on the
various preserving fluids as studied at the Institute for
Blood Transfusions in Moscow. The solutions studied
were citrate, a mixture of citrate and physiologic solu-
tion of sodium chloride, a solution known as “IPK”
and, finally, a dextrose-citrate solution. The Moscow
workers concluded that “IPK” solution, sometimes
referred to as the Moscow solution, was only slightly
more efficacious than citrate and that the dextrose
citrate solution was superior. They' reported that
hemolysis took place in approximately ten days with
the citrate solution, in twelve day's with “IPK” and
m thirty-five days with the dextrose and citrate solution.
They considered the dextrose as a nourishing medium

HQ Frorr. the Transfusion Service of the Massachusetts Memorial

r, . 1 ’ Robertson, 0. H. : Transfusion with Preserved Red Blood Cells,
authors’ 1:091 H une 22) 1918; personal communication to the

1916’ ® ous ’ Peyton > and Turner, J. R.: J. Exper. Med. 33:219 (Feb.)

tin-c* E ,nd<:n N ura - J'. and Stroikova, X.: Laboratory Studies on Condi-
. Which Hemolysis Occurs in Preserved Blood, Deutsche
ntschr. f. Chir. 34 3 : 727. 1934.

for erythrocytes while the other solutions represented
only a culture of red blood corpuscles in their own
plasma. Three objections were raised against the use
of dextrose:

1. It represents a perfect medium for the growth of micro-
organisms.

2. Decomposition of dextrose in the preserving fluid leads
to the formation of lactic acid.

3. Difficulties are encountered in sterilization.

This subject is not in its infancy; during the same
ymar that the foregoing studies were made Balachovski
and Guinsbourg 4 experimented on the use of pre-
served blood, using an equal amount of diluent similar
to “IPK” and blood, and Ascoli and Vercesi 5 sub-
mitted from the gynecologic clinics of the University
of Palermo, Italy, a comprehensive report on the use
of placental blood in transfusions. The latter authors
were of the opinion that placental blood was more
efficacious than common blood and prophesied that
cord blood would find a wide application in general
hospitals.

In 1936 Novikova and Farberova 0 wrote a concise
and instructive treatise on the use of placental blood
from the Institute for Blood Transfusions in Leningrad.
The technic described had been in use by these authors
since 1933. They noted that placental blood averaged
from 90 to 100 per cent hemoglobin and had from 5
to 6 million erythrocytes; that there was a relatively
large amount of bilirubin and a low cholesterin and
albumin fraction of the blood, while the amount of
globulin was increased ; that the potassium and calcium
contents were relatively large and that the large amount
of copper present should form a great advantage over
adults’ blood. The authors admitted the disadvantage
of the small yield from one cord but stated that this
could be overcome by the fractional use of two or more
and warned that the blood from each cord should be
transfused separately to prevent reaction.

During the same year Stavskaya 7 reported on the
use of placental and retroplacental blood. He con-
cluded that:

Placental blood is indicated chiefly when not substitution but
stimulation therapy is required, for example: (1) in anemias,
because the placental blood contains a large amount of hemo-
globin, erythrocytes and bilirubin; the bone marrow is stimu-
lated and plastic material for regeneration of erythocytes
furnished; (2) in hemorrhagic diathesis; in these cases placental
blood is valuable because of its increased coagulability; (3) in
shock.

Keller and Limpach 8 in 1938 reported on the use
of placental blood from the Strasbourg Lying-in Hos-
pital. Their observations were similar to those of
other workers mentioned previously. However, they
did mention the beneficial results of the use of the
blood against ray sickness after ultrapenetrating roent-
gen therapy.

The pioneer work in the use of placental blood for
transfusions on this continent was done by Drs. Goodall
and Anderson of Montreal and their co-workers. 9 Dr.

4. Balachovski, S., and Guinsbourg, F.: The Transfusion of Pre-
served Blood, Sang S: 622, 1934.

5. Ascoli, M., and Vercesi, C.: The Use of Placental Blood for
Transfusions, Boll. d. Soc. ital. di biol. sper. 9: 814, 1934.

6. Novikova, L. A., and Farberova, R. S-: Organization of Collection
and Use of Umbilical Cord Blood for Transfusion in Hospitats, Sovet.
khir., 1936, No. 11, p. 794.

7. Stavskaya, E.: Transfusion of Placental and Retroplacental Blood,
Novy khir. arkhiv 37: 72, 1936.

8. Keller, R., and Limpach, J. : Transfusion of Placental Blood
Before and After Operations, as Used in the Strasbourg Lying-in Hos-
pital, Bull. Soc. d obst. et de gynec. 27: 160 (Feb.) 1938.

9. Goodall, J. R. ; Anderson, F. O.; Akimas, G. T., and MacPhail.
F. L. : An Inexhaustible Source of Blood for Transfusion and Its Preser-
vation: Preliminary Report, Surg., Gynec. & Obst. 66: 176 (Feb.) 1938.

1476

PLACENTAL BLOOD— BARTON- AND HEARNE

Jour. A. M. A
Oct, 14, 1935

Goodall not only brought to our attention the avail-
ability of placental blood for transfusions but also
contributed a workable technic for the collection of
the blood and its preservation. Dr. Goodall is an advo-
cate of the “IPK” solution as proposed by the Moscow
Institute of Hematology.

In March 1938 our hospital instituted a placental
blood bank. The technic adopted was that set forth
by Dr. Goodall. 0 Modifications of this technic have
been made and laboratory studies carried out. We have
attempted to answer the following questions: 1. Is the
blood clean? 2. What is the best preservative? 3, What
is the life of the blood? 4. Is the blood of use clinically
and if so under what conditions?

Our attempt to modify Dr. Goodall’s technic has been

( 1 ) to establish a more aseptic technic of collection,

(2) to reduce the percentage of reactions and (3) to
simplify the securing of a sample of blood for direct

typing.

average NUMBER of days before hemolysis noted

average decree of hemolysis showing decrease in erythrocytes

Fig. l. — Average degree of hemolysis of ten placental blood banks
with “IPK” and dextrose.

PROBLEMS

1. Is the Blood Clean?— With, every collection of
blood that is to be preserved for transfusion there has
been an inoculation of sterile broth. The broth is
incubated for from five to seven days. A culture is
then transplanted on plates to determine what organism,
if any, is present. The technic of securing the blood
has improved to such an extent that at present it is only
in a rare case that it needs to be discarded. v\ e con-
template omitting the incubation of the plates and
relying entirely on the examination of the broth, the
flask corresponding to the culture that is turbid being
discarded. Dr. Goodall 9 is of the opinion that any
infection becomes so attenuated that it is innocuous
after standing in the ice chest. Our technic, however, is
extremely simple and we would rather be on the safe

side

, 2.' What Is the Best Preservative ?-When ^ve began
our study of placental blood we used the IPK solu-

don advocated by Dr. Goodall. 9 Specimens were col-
lected in flasks and sent to the laboratory. These

flasks were unopened until hemolysis was observed.
The average length of time before hemolysis set in
was 14.4 days. Hemolysis was completed in these
flasks in anywhere from forty-two to ninety-one days.
Following the recommendations of Robertson 1 and o)
Lindenbaum and Stroikova, 3 we began using “IPK"
and 5 per cent dextrose. In this series the hemolysis
did not begin for 22.3 day's. This change in preserva-
tive increased the availability of the blood by eight
days. We recommend the use of this solution. Because
of the technical difficulties of the ice chest, there was
undue agitation of the flasks, which gave us our figure
of 22.3 days. W e are confident that a series of blood
specimens now being studied will show an even more
delay'ed hemolysis.

3. The Life of the Blood.— We have taken blood
counts on the day of collection of a specimen sub-
mitted. A blood count is repeated on the same speci-
men on the day when hemolysis is first noticed, when
we first began our study we counted the cells ever)
day' from the day' of collection. We found that tus
is not practical, as the agitation caused by securing

Table 1 .—Blood Count Just Previous to and Four Dap
FoUoiving T ransfnsion _

BemogloUa.

Condition Red Blood Colls V« W .

Ancmin ot the newborn nM uoo’ooo ^

Malnutrition 3.100,000- dCO.MO ^

Vomiting and diarrhea 0 ^X 9 sno 000 ’ a** 52

Postoperative perineal prostatectomy.. 60-$

Sgggg S

the blood resulted in early hemolysis. We Have pr°'jJ
to ourselves that the decrease in cell cou ■

these dates runs from 5,000 to 300,000, .but a 1 £t

increases the red cell count decreases, _ usa ble
this finding in a practicable sense, flasks a • ■ ^

until the twenty-second day when the art ^
dextrose solution are used as preservativ - jtv
time it is wise to discard them. However, •

these flasks may be used until hemolysis o
gressed ; it must be realized ot course that mo! ysis.

has decreased in comparison to the anioun d day,

Since we discarded all flasks on the tweny-
no reactions have occurred during fransfusi n-

Figure 1 shows diagrammatically the ad ,|p K »
dextrose and “IPK” as a preservative ove daJ ,
alone. Not only does hemolysis take place {our
later but blood counts taken of the soKtti j s ^blood
days following the onset of hemolysis ^ pre-
destruction carried on at a slower ra
served with the combined solution. cnccinie 115

This chart represents an average of ten s P . at ive
blood in which “IPK” was used alone as a pres To

and ten in which “IPK” and dextrose were us
interpret the curve, it is necessary to 1 ^ [jlori

as the average cell count of placental bl°°d- .^0
is diluted one half, with preservative leaving ,
as an initial factor. . u c 0 UnRj

4. Is the Blood of Use Chm rally, and jn (l „
What Conditions ? — We have used the ! W ran( i 0I n:
following conditions These are ^ j ienl or-

malnutrition, secondary anemia, post] < n> carci-
rhage, cholecystogastrostomy, pyloric obs , „ as trectomy)'
noma of the sigmoid, duodenal ulcer (g? ncr e3=
splenic anemia, carcinoma at the head ot tne 1

Volume 113
Number 1G

PLACENTAL BLOOD— BARTON AND HEARNE

14 77

(jaundice), obstructing prostate, vomiting and diarrhea,
erythroblastosis, papilloma oi the bladder and carcinoma
of the stomach.

We have made sixty-four transfusions, using seventy-
eight flasks. This has been accomplished without a
serious reaction and no fatalities.

While carrying out this study, we have compared
the blood count jiwt previous to transfusion to the
blood count four days following transfusion, with the
results given in table 1.

Table 2. — The Number oj Cases ami Percentage of Incidence
in Each Blood Type of the 120 Cases in Which Both
Maternal and Placental Bloods Were Alike

Total 0 A D A D

Xum- Per Num- Per Nuin- Per Num- Per Num- Per

ber Cent ber Cent ber Cent ber Cent ber Cent

120 100.0 04 53.3 41 34.2 11 0.2 4 3.3

The interpretation of our results would lead us
to agree with Stavskaya’s 7 report that the blood is of
more use in stimulation therapy than in substitution.
AVe are studying the effect of placental blood on the
reticulocyte count but our data at present are not suffi-
cient to warrant a conclusion.

TECHNIC

1. Establish a More Aseptic Technic of Collection . —

Fig. 2. — Table prepared for the collection of placental blood.

to the surgeon’s gown. We have modified this technic
by using large sterile cloth mittens that are slipped on
over the surgeon’s gloves and wrists, thereby preventing
contamination when handling the cord.

2. Reduce the Percentage oj Reactions . — Since 1934
all the intravenous solutions of dextrose and sodium
chloride have been manufactured in our hospital under
the supervision of the intravenous service.

Agreeing with Dr. Florence Seibert 10 that pyi'ogens
are the cause of most of the reactions when intravenous
fluids are used, and realizing that pyrogens multiply
when exposed to the air, we have preserved our blood
and its diluting fluid in air-tight flasks, using stazon

Fig, 3. — Use of the sterile mittens in collecting placental blood.

rubber stoppers instead of the familiar gauze stoppers.
Reactions are also avoided if the blood is used for
transfusion before hemolysis takes place. Our per-
centage of transfusion reactions is 4.6. This state-
ment may be modified to the extent that since the
establishment of the following technic no reactions have
occurred: (1) fractional transfusions of more than
one flask, (2) the use of blood before the twenty-second
day and (3) the use of air-tight containers.

3. Simplifying the Securing of a Sample of Blood
for Direct Typing . — Our experimental work and the
work of others show conclusively that any disturbance
of the blood while in storage hastens hemolysis.
Knowing by the label that a certain flask is of a certain

Table 3 . — Placental Blood Types in Entire Scries

O A B AB

— ^ . y - k. — ^ ^ A . ^ ^ ^

Maternal

Num-

Per

Num-

Per

Num-

Per

Num-

Per

Blood Type

ber

Cent

ber

Cent

ber

Cent

ber

Cent

O

G4

35.8

25

14.0

4

2.2

A

13

7.3

41

22.9

2

l!l

2

*i!i

B

G

3A

2

1.1

11

G.l

3

1.7

AB

2

1.1

4

2.2

type is not sufficient reason to use that flask for trans-
fusion. A direct typing must be done. If a flask is
to be uncorked and a sample obtained with a pipet
and found to be incompatible, this flask will hemolyze
much sooner than an unopened flask. To make it
unnecessary to distm-b the blood, a pilot tube is attached
to the outside of the flask. This tube contains a speci-
men of the blood and diluting fluid. AAffienever trans-
fusion is contemplated with this flask, a sample of the
blood in the tube is removed for direct typing, and if it
is found incompatible the blood has not been disturbed.

PLACENTAL AND MATERNAL BLOOD GROUPING
There were 179 cases in which the type of blood in
both niaternal and placental blood was determined. An
analysis of these blood groupings revealed some very
interesting data.

— w. — ■ — • - jj. . otfuac vi .uaiiy rewrne iteacuons roil

Intravenous Injections, Am. J. Physiol. 71:621-651 (Feb.) 1925.

1478

PLACENTAL BLOOD— BARTON AND HEARNE

Jouh. A. M. A.
Oct. 14, 19J?

In 120 cases, or 67 per cent of the total series, the
maternal and placental bloods were of the same type.
These 120 cases were further subdivided with the
results seen in table 2.

Table 3 shows the relative incidence and percentage
of incidence of the various combinations of blood group-
ings found between the maternal and placental bloods
in the entire series of 179 cases.

Table 4. — Placental Blood Type of Ninety-Three Cases in
Which Maternal Blood Type Was O

Placental Blood Type

— %

O A B AB Total

Num- Per Num- Per Num- Per Num- Per Num* Per

ber Cent ber Cent ber Cent ber Cent ber Cent

64 6S.S 2.5 26.9 4 4.3 i'3 1CO.O

Table 5. — Placental Blood Type of Fifty-Right Cases in
Which the Maternal Blood Type l Fas A

Placental Blood Type

0

A

B

AB

Total

Num-

Per

Num-

Per

Num-

Per

Num-

Per

r'~ r ~ A V

Num- Per

ber

Cent

ber

Cent

bor

Cent

her

Cent

ber Cent

13

22.5

41

70.7

2 0.4

2

3.4

5$ 1C0.0

Tables 4, 5, 6 and 7 show the breakdown of the cases
by maternal blood groupings.

DESCRIPTION OF TECHNIC

Into a 300 cc. Erlenmeyer flask is placed 12.5 cc. of
50 per cent dextrose solution. To this is added, by
weight, 100 cc. of freshly distilled water and the con-
tents of an ampule of citro-seroid 11 (25 cc.). The
formula of citro-seroid is sodium citrate 5 Gm., sodium
chloride 7 Gm., potassium chloride 0.2 Gm., magnesium
sulfate 0.04 Gm. and distilled water 1,000 cc. In
Lindenbaum and Stroikova’s 3 original article this
formula is referred to as “IPK.” A stazon rubber
stopper is loosely placed in the neck of the flask. The
flask is wrapped and autoclaved. While the contents of
the flask are cooling the stopper is inserted in the neck
of the flask without the wrapping being removed. This
allows the exterior of the flask to remain sterile.

The setup for the collection of the blood includes a
flask containing the preservative, a pair of sterile mit-
tens, a funnel, three small test tubes, a bottle of broth,
a pipet, two Kelly clamps and a pair of scissors.
Following delivery the cord is prepared with iodine,
two clamps are applied and the cord is cut between
the clamps. The gloved hands are now covered with
a pair of sterile mittens. The cord is again sharply
cut proximal to the clamp. The end of the cord is
pointed downward and the blood collected in the flask
through a funnel. The cord may be milked to add

to the yield. .

As the flow diminishes, blood is collected in two
small test tubes, one for a Wassermann test and one
for typing. The flask is slightly agitated and 10 cc
of the solution is obtained with a sterile pipet. One half
of the content is used to inoculate the broth for a
check on contamination; the other half is placed in
the third tube and stoppered with a cork stopper. The
stoppered test tube containing a mixture of the blood

and solution is attached to the flask with elastic bands.
The flask is sealed air tight with a stopper and is not
to be reopened until it is to be used for transfusion.
The stoppered tube containing the mixture of blood and
preservative is known as the pilot tube.

A tag is attached to the flask. On this tag is
recorded the name of the patient, the collection number
and the date and a space for tj’pe, 'Wassermann reaction
and culture report. The flask is then placed on the
lower shelf of the refrigerator and kept at a tempera-
ture of 38 F. When the blood has been typed and the
Wassermann reaction and culture reported negative,
these data are placed on the tag and the flask is placed
on the shelf above ready for use.

Placenta] blood may be collected on cesarean section.
In these cases there is no chance of contamination. The
only variation from the technic used in normal delivery
is that the blood collected for the Wassermann test
and typing is obtained after the placenta has been
delivered.

When transfusion is contemplated, a flask of suitable
type is chosen. A sample of the blood in the pilot
tube is removed for direct typing. Usually two or
three flasks are used for a single transfusion. These
flasks are warmed in a bath and a continuous intrave-
nous injection of physiologic solution of sodium chloride
is started with an open Kelly bottle. A funnel is placed
in the neck of the bottle with a gauze strainer and the
contents of one flask are poured into the bottle.

The average yield of a flask is 100 cc. of blood,
a larger amount of blood is desired it may be added m
a fractional manner, each flask added separately with a
small amount of saline solution intervening between
the contents of the flasks. Reactions may follow if con
tents of two or more flasks are added together.

Table 6.

-Placental Blood Type of Twenty-Two Cases m
Which the Maternal Blood Type Was B __

Placental Blood Type

O

A

B

AB

Total

Num- Per
ber Cent

6 27.3

Num- Per
ber Cent

1 9.1

Num- Per
ber CeDt

n so.o

Num- Per
ber Cent

3 13.6

Num- Per
ber Cent

22 100 0

Table 7.-

— Placental Blood Type of Six Cases
the Maternal Blood Type IV as AB

in jVhich

Placental Blood Type ,

O

A

B

AB

Total

r~ t

Num- Per
ber Cent

Num- Per
ber Cent

Num- Per
ber Cent

2 33.3

Num- Per
ber Cent

4 C6.7

Xutn- rcr
ber Cent

C, 100.0

SUMMARY AND CONCLUSION j.

From our experience with a placental bloo ® £
which was inaugurated one year ago, eye favor p-
md “IPK” as a preservative. We believe that I ^
tentage of reactions during a transfusion neec ^

ligher than a whole blood transfusion (1) 5 T i j 5
s used before hemolysis sets in, (2) 1 ^ ie ’ ta ; ne rs
ised m a fractional manner and (3) it me ..

ire kept air tight. We also believe that the
afe, economical and efficacious.

29 Bay State Road.

11. Ayerst, McKenna & narrison.

Voi.UME 113
Number 16

PSITTACOSIS— GEIGER ET AL.

1479

ADMINISTRATIVE PROBLEMS IN CON-
NECTION WITH PSITTACOSIS

AND THE IMPORTATION OF AUSTRALIAN PARROTS
J. C. GEIGER, M.D.

A. B. CROWLEY; IC F. MEYER, Pii.D.

AND

BERNICE U. EDDIE, M.A.

SAN FRANCISCO

On Jan. 24, 1939, a shipment of fifty-five Australian
parrots arrived at the port of San Francisco on the
S. S. Monterey of the Oceanic Steamship Company.
The cargo had been en route from Queensland, Aus-
tralia, and was intended for exhibition at the Australian
Building during the Golden Gate International Expo-
sition. The birds had been obtained from an aviary
in Queensland and sixty-two were apparently healthy
at the time they left the port of origin. En route seven,
mostly King parrots, died. On arrival, the shipment
passed through quarantine and was isolated on Janu-
ary 25 contrary to the usual custom at the Australian
Pavilion on Treasure Island, which was declared a
quarantine area by the United States Public Health
Service. The collection of psittacine birds was inspected
by the representatives of the United States Public
Health Sendee and the State Department of Agriculture.
According to a statement from the representative of the
Department of Agriculture, the parrots were “in good
health.” Notwithstanding three days after arrival ten
dead birds (two King parrots [Alisterus], three Crim-
son parrots [Platycercus] , two cockatoos, one Blue-
Cheeked parrot, one Yellow-Mantled parrot and one
Blood-Stained cockatoo) were delivered to the George
Williams Hooper Foundation, University of California,
in accordance with an agreement between the founda-
tion and the Surgeon General, United States Public
Health Service, which requires the examination of all
dead psittacine birds of importations held in quarantine
in the ports of San Pedro and San Francisco. Gross
examination of the cadavers revealed general emacia-
tion, moderate to severe hemorrhagic enteritis, and small
and pale spleens.

According to subsequent reports, the cages had been
held outside the exposition buildings during a rainy
night of January 25. The deaths of the nine parrots
were attributed to exposure. One bird, found dead on
arrival at the port of San Francisco, was included in
the delivery made at the laboratory of the Hooper
Foundation. Although the usual markings of psitta-
cosis were absent, the organs were injected into mice.
Within five days some of the mice died with lesions
and microscopic appearances suggestive of psittacosis.
Ultimately the virus was demonstrated in nine of the
ten birds. On February 1 one dead King parrot and
one Blood-Stained cockatoo in an advanced state of
decomposition were submitted for examination; the
King parrot was emaciated and the enlarged spleen
contained the virus of psittacosis. The cause of death
of the cockatoo was not determined. On February 13
these observations were reported to the representative
of. the United States Public Health Service and to the
Director of Public Health of San Francisco, who had
not been advised of the arrival of the shipment despite
the fact that the sanitation of Treasure Island is entirely

From the Department of Public Health, San Francisco (Geiger and
Y 0 '™T) and the Hooper Foundation for Medical Research, University

California (Meyer and Eddie).

under his jurisdiction. Investigation conducted by the
San Francisco health department on February 14 dis-
closed the fact that the' parrots were still housed in the
Australian Building and that the caretaker considered
the quarantine to have expired on February 7 and 8.
A check-up by the representative of the San Francisco
Department of Public Health revealed that ten birds
were missing. On inquiry it was found that the parrots
had died, and since it was presumed that the quaran-
tine had been lifted it was not deemed necessary to
send the cadavers to any laboratory for examination.
In fact, they were buried in the rear of the building.
Apparently, the representative of the Australian exhibit
bad not been advised that the quarantine period invari-
ably extends fifteen days from the date of the last
death. Since the last bird bad died on February 1
the quarantine would still have been in force on Febru-
ary 14 and the cause of death of the ten birds which
succumbed between February 8 and February 14, in
all probability to psittacosis, would have been definitely
established. At the time the San Francisco health
department made the inspection, thirty-one live and
one dead King parrots were found. The director of
public health of San Francisco requested the immediate
removal of the thirty-one parrots to the Angel Island
Quarantine Station.

The King parrot found dead on February 13 was
examined the next day and presented the lesions of
acute psittacosis with extensive necrosis in the liver.
On direct examination the exudate covering the peri-
cardium was teeming with elementary bodies. Epi-
demiologically, this observation amply confirmed pre-
vious observations that improper care and exposure
activate the latent virus in carriers so frequently present
among imported parrots, and acute infections may fol-
low within two to three weeks among the cage mates.
The systematic investigations of Burnet 1 on psittacosis
in wild Australian parrots in 1935 fail to mention the
King parrot (Alisterus or Aprosmictus scapularis).
However, in a more recent report by Burnet 2 (1939),
notable deaths among this species in the wild state in
various sections of Australia attest its susceptibility.
The experiences with the Australian shipment indicate
that the King parrot may have escaped nest infection
and thus proved highly susceptible as an adult. The
majority of the psittacine birds which died en route
belonged to this species. It is reasonable to suspect
that they became infected by exposure to the carriers
which were in the shipment.

On February 18 a Sulphur-Crested cockatoo was
found dead with the gross lesions of pneumonia and
enteritis; no virus was found.

A close clinical examination of the remaining thirty-
one psittacine birds at Angel Island left the impres-
sion with a group of investigators who are familiar with
bird diseases that, with the exception of a King parrot,
a Blood-Stained cockatoo, a Crimson parrot and a
quarrion, the shipment consisted of apparently healthy
specimens. However, in the light of past experiences
it was fully realized that a fair percentage of the parrots
were carriers. Under the ideal conditions of housing
in separate cages and uniform temperature there was
little likelihood that further deaths would occur. In
fact, between February 15 and March 1 the sick
birds greatly improved and without a previous history

jrMuacosis in \vna Australian carrots,

35:412 (Aug.) 1935.

2. Burnet, F. M.; Psittacosis in Wild Australian Parrots, M. T.
Australia, to be published; Psittacosis in Australia, Sixth Pacific Con-
gress, to be published.

14S0

PSITTACOSIS — GEIGER ET AL.

lots. A. M. A
Ocr. 14 , 1)3

of the shipment or laboratory observations the par-
rots would doubtless have been released. To permit
the exhibit of survivors of a consignment of parrots in
which deaths have occurred would, however, have meant
courting disaster. Recent experiences in the London
zoo amply attest such possibilities. In order to exhaust
every means to decide the fate of the shipment and to
test some newer diagnostic methods, it was decided to
bleed the thirty-one parrots and to subject their blood
serum to complement fixation tests with the psittacosis
antigen. At the time of the bleeding on March 1 the sick
King parrot and one quarrion were killed and the
autopsy of both revealed residuals of a psittacosis
infection with positive virus. The serum tests yielded
a fairly large percentage of positive or suggestive reac-
tions with the psittacosis antigen. The director of
public health of San Francisco therefore refused the
admission of the shipment to Treasure Island. On
March 9 the remaining twenty-nine “healthy parrots”
were bled to death and examined. One carrier was
found among the corellas (Kakatoe sanguinea) ; one
of the quarrions (Nymphicus hollandicus) and three of
the Sulphur-Crested cockatoos (Kakatoe galerita) har-
bored the psittacosis virus in the enlarged spleens and
livers.

COMMENT

The experiences collected in connection with the
importation of Australian parrots for exhibition pur-
poses to the American continent amply confirm similar
observations previously reported by Levinthal 3 in 1935
in England and the studies of Burnet 1 on native birds
collected in the forests of Queensland, Brisbane and
Victoria. Since spontaneous psittacosis is widely dis-
tributed in the psittacine birds of the Australian archi-
pelago, the risk of reintroducing this malady into
aviaries of other countries is great. Ornithologists and
inspectors should by this time appreciate the funda-
mental fact that a clinical examination is utterly useless
in judging the state of health of a shipment of parrots.
Laboratory examinations by property qualified and
experienced workers are paramount in deciding the
admission of a consignment. Such examinations are
particularly indicated when the past history of the
shipment reports fatalities en route. Unfortunately this
type of information is not always available since the
shipment is not accompanied by a reliable caretaker.
The shipping companies have paid little or no attention
to these dangerous consignments. How many passen-
gers have been exposed to the risk of psittacosis by
these careless methods of transportation remains
unknown. Fortunately, only two persons came in con-
tact with the shipment under discussion. One of the
men developed a severe “influenza”; unfortunately, be
refused a complement fixation test and consequently the
exact nature of his illness presents an unsolved and
intriguing problem, since psittacosis is suspected.

From an administrative point of view the handling of
the importations left a great deal to be desired. Tire
parrots were not quarantined in an area specialty
reserved for purposes of this kind but were housed on
an exhibition ground at a time when a great many
working men could have readily been exposed to the
contagion. There was no supervision by the authority
entrusted with the maintenance of the quarantine. The
collection and the transmission of the dead birds were
left to the discretion of a caretaker. It is to his credit
that he did the work well and carried out instructions

3. Levinthal, \V.: Recent Observations on Psittacosis, Lancet 1: 1207
(May 25) 1935’.

implicitly. Doubtless be could have contracted psitta-
cosis, and one wonders who would have assumed the
responsibility for this illness, since this work was done
under the instructions from the federal authorities;
but his maintenance was paid by the consignee.

On numerous occasions, attention has been called to
the inadequacy of the present quarantine regulations
governing the importation of psittacine birds. A period
of fourteen clays is rarely sufficient to complete the
mouse inoculation tests required to prove the presence
or absence of tire virus in the organs. Present and
past experience has shown that acute psittacosis inlec-
tions frequently develop during the quarantine period
or shortly thereafter. Apparently healthy birds are
released to the importer or dealer, who in turn promptly
sells them to the public. Recently a Panama parrot was
returned to a bird shop. Examination disclosed acute
psittacosis and the significant fact that the bird had
been released from quarantine two weeks before. ^ The
present regulations doubtless have protected the United
States from widespread outbreaks of the character
observed in 1929-1930. However, there is ample evi-
dence to connect the South American and Mexican
importations with human infections in California, M"
York and Oregon. Moreover, it is not unlikely tin
these shipments may have contributed to the mainte-
nance of psittacosis in bird shops and aviaries of t £
United States.

In order to be effective, the period of quaranin
should be extended to not less than three months, P re
erably six months. Finally, to derive the full
of benefit from such a measure, the freedom o
importation from disease should be determined by
ratory tests. For larger parrots the blood serum
plement fixation test done by an experienced labor! i
may be valuable, since sufficient blood may be re
collected from one of the wing veins. O ne s '
however, weigh judiciously the risk to which the p -
holding the parrots during the act of bleeding nu
exposed. The three psittacosis infections m ^
personnel reported from Germany by ^

Kruckeberg 4 in connection with the organiza
control measures amply attest the probable ^
Since the large and expensive parrots are usua - nei j
separately, the cages may be covered with r
cloths while putting the birds under anest rest ,
the dispersion of the virus particles adherent o
into the air may be redued to a. minimum. '
event, it is advisable to employ, if in any v J
ticable, those who have had psittacosis or w io
tests would indicate resistance to the infection. ^

Shipments of parrotlets or smaller psa ac ^ 0 [
should be treated in a manner similar o . , ( j, e
parrakeets. A sample of from 10 to 20 pc c *y Jtwr .
importations should be killed and examine p u jj.
tem, and the organs tested for virus by mouse
tions. Occasionally the virus is weak an
passages extending over several weeks may
to demonstrate it conclusively. ... f ((r ;)jdi

Tiie various procedures just outlined w
reasonaby dependable information relative vV jiose
tence of psittacosis in a consignment. sr ( j on j
blood serum gives positive complement fixa i
may or may not be carriers or sliedders o | ia) e
However, there is no reasonable doubt t ia e y r d-
had contact with the psittacosis virus. ■ 51 •„[[,, s (crik
with enlarged spleens which are bacteriolog — — ^

4. Haagen, E., and Krucbeberg, V.: Verofrcntl. a.
gesundhdienst. 4S:3S1, 1937.

Volume 113
Number 16

PELLAGRA— SPIES ET AL.

1481

on lifeless mediums but yield no virus on mouse passage
tests must be considered very suggestive of psittacosis.
The shipment may harbor a few carriers which may,
under adverse environmental conditions, suffer from
relapses and may become dangerous shedders. On the
other hand, the absence of anatomic signs coupled with
the absence of deaths among the parrots during the
prolonged period of observations gives reasonable assur-
ance that active psittacosis is in all probability not
present in the importation. While in quarantine, cages
with ricebirds (Padda oryzivora) should be suitably
distributed throughout the rooms or building to test
for the contamination of the air with virus which
originates from the desiccated excreta of carriers or
cases.

The procedures outlined will ultimately confront the
health officer with important decisions. It may be
necessary to rule that any consignment of parrots or
parrakeets must be destroyed if active psittacosis infec-
tion is proved or even suspected. Any other procedure,
in particular the release of survivors of a group in
which deaths have occurred, is incompatible with sound
public health practice. Doubtless, the health officer
will be confronted with the accusation of ruthless
slaughter. In case the shipments consist of parrakeets
and parrotlets, he should remain adamant in his deci-
sion. On the other hand, as an alternative there may
be permitted the periodic blood testing of the large and
expensive parrots. Should the tests reveal no new
infections over a period of six months, there may be
safely transmitted the healthy birds selected from an
infected shipment to the importer. The disadvantages
of the latter procedure are largely economic, and until
means have been found to defray the costs of the tests
and those of an extended quarantine it is doubtful
whether the bird dealers are prepared to risk importa-
tion of tropical birds. Thus the trade in psittacine birds
and with it the danger of psittacosis would be enor-
mously reduced. There remains, however, another
source of trouble — importations to zoological gardens.
It would doubtless be disastrous to prohibit or to curtail
the exhibit of psittacine birds in these institutions, which
are of great educational value. Fully cognizant of its
paramount importance to society, the British Ministry of
Health has exempted the consignments of birds of the
parrot family for zoological gardens from the regulations
which govern the importations to Great Britain. Recent
experiences in London 5 have prompted the Zoological
Society to impose a three months quarantine on all
newly acquired parrots arriving at the zoological gar-
dens. Precautionary measures have been adopted to
protect the personnel supervising the birds while in
quarantine and to dispose of the excreta in a sanitary
manner. The wearing of rubber gloves, masks and
goggles by the attendants looking after the birds is
mandator)'. Similar steps should be taken in the
United States. In fact, if and when the directors of
the zoological gardens agree to a three to six months
quarantine in approved buildings and under expert
supervision, the federal authorities and the local health
officer may grant permission to admit psittacine birds
to zoological gardens without previous isolation at the
port of entry.

Only too often the health official has to meet argu-
ments propounded by representatives of the bird trade
that human infections due to exposure of imported

5. Troup, A. G.: Adam, Robert, and Bedson, S. T.: Outbreak of
]Qrq C0Sls nl ^ le London Zoological Gardens, Brit. M. J. 1: 51 (Jan. 14)

psittacine birds are rare. In this connection it is
important to emphasize that the course of the disease
is by no means characteristic and is more readily camou-
flaged by tbe diagnosis of influenza. Moreover, indi-
viduals showing no clinical signs of illness may, none
the less, be infected. With the aid of the complement
fixation test, these silent infections may be detected.
It is doubtless good public health practice to insist on
a blood examination of persons who have been exposed
to a consignment of diseased parrots.

Evidence produced in this report leaves no doubt
that the trade in wild parrots and cockatoos introduces
new problems in the control of psittacosis and makes it
doubtless expedient to take protective measures.

PELLAGRA IN INFANCY AND
CHILDHOOD

TOM D. SPIES, M.D.

CINCINNATI

ALFRED A. WALKER, M.D.

AND

ARTHUR W. WOODS, M.D.

BIRMINGHAM, ALA.

During the past four years we have been studying the
natural course of the development of pellagra in an area
in which the disease is endemic. The habitual environ-
ment and dietary of more than 800 pellagrins in the
Nutrition Clinic of the Hillman Hospital, Birmingham,
Ala., have been studied. Since it seemed likely that
each member of the household would be subjected to
the same type of diet as the patient, we extended our
studies to include the families of these pellagrins.
Accordingly, the nutritional status of each member of
the household was ascertained and we found that from
one to six persons, including infants and children,
showed evidence of pellagra. (It is interesting to note
that blacktongue, a canine analogue of pellagra, was
found in the dogs fed scraps of the food eaten by these
families.) A diagnosis of pellagra was made in 194
children and in six infants, and in each case the diag-
nosis was confirmed by therapeutic tests. These studies
are still in progress, but certain points concerning the
manifestations of pellagra in infancy and early child-
hood have been clarified and form the basis of the
present communication.

The children of pellagrous parents have been examined
repeatedly, with particular attention directed toward
the diet of the mother during pregnancy and lactation
and of the child since birth, toward the physical and
mental development of the child, and toward the pres-
ence or absence of lesions diagnostic of pellagra.

A careful history of the mother often revealed that
her diet during pregnancy and lactation was inadequate
and that, as a result, the quality of her breast milk was
probably poor and the supply often insufficient for the
child’s needs. The nursing infants, therefore, had to be
weaned soon after birth and were given some sort of
food, which in many cases was inadequate for their
nutritional needs. As they grew older, the majority of
these children had poor appetites and usually ate very
irregularly. Most of them preferred carbohydrate
foods and often refused most of the other foods offered.

From the Department of Medicine of the Cincinnati General Hospital,
Cincinnati, and the Hillman Hospital, Birmingham, Ala. This investiem
I.. 00 a "?£d w grants to the University of Cincinnati College of Medi.

cine from the Rockefeller Foundation, the John and Marv R Marti,.
Foundation and Mead Johnson & Co. ° Markle

1482

PELLAGRA— SPIES ET AL.

Jour. A. SI. A.
Oct. », 193?

The parents seldom attempted to change the food habits
of the children, even if a good diet was made available.
Analysis of the dietaries of such children shows that in
most cases their diets were unbalanced and failed to
supply in adequate amounts the foods essential for
proper nutrition.

These children usually are underweight and under-
developed for their age and appear to be undernourished
and in ill health. Their parents state that they are
irritable, easily frightened and “fretful” and that they
cry a great deal. They are listless, tired and appre-
hensive and they do not manifest the normal interests of
childhood. Those of school age find it difficult to con-
centrate and as a rule have made poor progress in school.
Although the children seem too tired to play, they can-
not rest. They do not sleep well at night but instead
toss about and frequently awake ciying. Many of them
complain of soreness of the tongue and lips and of burn-
ing and pain in the stomach. Usually they suffer from
constipation but they may have occasional attacks of
diarrhea during the spring and summer months.

The response of infants and children to antipellagric
therapy is as dramatic as it is in adults. The admin-
istration of nicotinic acid or yeast is followed by rapid
improvement, and recent studies have shown that similar
improvement follows the administration of monocar-
boxylic and dicarboxylic acids of pyrazine. 1 The prep-
aration and use of these two chemical compounds have
recently been described by one of us. 2 The total daily
dosage of nicotinic acid and of the monocarboxylic and
dicarboxylic acids of pyrazine is from 50 to 300 mg. We
suggest 10 mg. tablets of nicotinic acid for children up
to 6 years of age and 20 mg. tablets from 6 years of
age up to puberty. They should be given not less than
one hour apart. The monocarboxylic or dicarboxylic
acid of pyrazine is dissolved in water and given in
divided doses. One and a half ounces (45 Gm.) of
brewers’ yeast is recommended for children up to 6
years of age and 2 ounces (60 Gm.) for children from
6 years of age up to puberty. The daily dosage of yeast
is mixed with milk and given in divided doses. The
advantages of using crystalline chemical compounds are
the ease of administration and rapidity of action. Yeast,
although it is less easily administered, supplies several
essential nutrients which these children lack.

Even in the absence of diagnostic lesions of pellagra
the disease should be suspected in infants and children
of families who have subsisted for long periods of time
on an inadequate diet. Frequent examinations often
reveal early signs of the disease. The administration of
one of the therapeutic agents specific for pellagra in such
cases offers a valuable therapeutic test, for these children
will show prompt improvement following such therapy
if early pellagra is present.

The representative history presented here illustrates
the development of pellagra with typical diagnostic
lesions early in childhood, and the response to diet and
yeast therapy :

Case 1. — R. J. A., an American white boy aged 3 years, was
admitted to the pediatric ward of the Hillman Hospital with
characteristic pellagra. The following history was obtained
from his mother and father: He was allowed to eat whatever
he chose and no attempt was made to have him eat anything he
didn’t like. His diet usually consisted of rice, honey, syrup, jelly,
peanut butter, corn bread, biscuit crust, and occasionally oranges

] The yeast, nicotinic acid and monocarboxylic and dicarboxylic acids
nvnrine" were furnished by Mead Johnson & Co.

' mils Charles E.; McDonald, Francis G., and Spies, Tom D.:

&p and ^ M ~

and prunes. Occasionally he drank a small amount of butter-
milk but always refused sweet milk. During the spring of the
previous year he had an attack of pellagra which was charac-
terized by a symmetrical erythema over the hands, elbows, knees
and around the neck. For the past six months he had occasional
diarrhea and vomiting, resulting in a steady loss of weight.

Physical examination showed that the child was under-
nourished and poorly' developed and was unable to walk. There
was an area of erythema over the nose and malar surfaces cf
the cheeks, and large areas of pigmented, desquamating skin
over the elbows, dorsum of the wrists, hands, and lower third
of the forearms. A smaller area was present on the right side of
his neck (collar of Casal).

The child was placed on a high caloric, high vitamin diet,
supplemented with IS Gm. of yeast in iced milk three times a
day. Feedings had to be given frequently and in small amounts
throughout the day and night. Although on admission he
refused to take anything but fluids, he began taking semisolid
foods such as scrambled eggs and applesauce on the fourth day
in the hospital. His appetite improved remarkably and within
ten days he was eating everything in a high caloric diet. The
acute lesions over the face and dorsum of the hands healed first
and the more chronic ones later. On discharge from the hos-
pital , the pigmented skin on his face, hands and arms was clear
and he appeared more alert mentally.

The following case history illustrates pellagra without
characteristic lesions in an 11 months old infant. The
relationship of the nutritional state of the mother to
the child, the necessity for repeated examinations o
children of pellagrous parents, the value of the thera-
peutic test in establishing a diagnosis of the disease
and the response to nicotinic acid therapy are demon

strated clearly.

Case 2.— J. McC., a white boy aged 11 months, was admitted
to the pediatric service of the Hillman Hospital because
diarrhea. Various treatments were instituted, including e *
sive trials on scraped apple, pectin preparations, neo ?J on ,
paregoric, crystalline vitamin Bi, skimmed milk, acl ®P
milk, evaporated milk and mashed banana. There w a
improvement in the diarrhea during this period. The o m i
history was given by the parents : The child’s mother as a .
eaten an. unbalanced diet, high in carbohydrate and on ,n ^
tein, minerals and vitamins, despite the fact that a > c ”
varied food supply was available until eight years ago. °
the past eight years, however, the family income ias ^
irregular and always inadequate for their food nec s -
mother and the six other children showed diagnostic eu
of pellagra during 1939 and all were under treatment. ^

The diet of the mother preceding the birth of this c 1 ^

inadequate both quantitatively and qualitatively. ! c . anS|
had more than one meal a day, which consisted o ue
potatoes and occasionally oatmeal with a small amoun 0 . c( j

rated milk. Following the birth of the child her die r ^
unchanged, and although she had little milk she nurs ^
until he was 2 months old. For the first two mon ,s
child’s life he received an insufficient amount o ’U , , . 0 f
which, because of the mother’s deficient diet, was k r on ; 3 .

poor quality. At the age of 2 months he h ad P ^
Because he was undernourished, the doctor advised " = cc )

and prescribed for him a mixture containing 4 ounces l ^ j, e
of evaporated milk and the juice of one orange dai J- . ea5C( J
was 6 months old the quantity of evaporated niuk " a on e
to 14 ounces (420 cc.). In addition he was g*' en °" “ ra | u ni
serving of green beans or turnip greens an J n( ] his
crackers daily. He usually took all the food presen > j ( .

diet, since he was 6 months old, had been adequa e - ^ an( j

vitamin D content. He had intermittent diarr iea, ; nrr hca

failed to gain weight. One week before admission, ^ |,jc

Jdiicv-I IU ytun wugm. ** r A

became severe and since this time he had re use

food.

priori

Because of the failure of the child to respon ^ 0 f (lie
accepted methods of therapy for diarrhea an > though

family history', a diagnosis of pellagra was ma

Volume’ 1 13
Number 16

ACUTE PERICARDITIS— VANDER VEER AND NORRIS

1483

there were no characteristic lesions of the disease. One hun-
dred and twenty-five mg. of nicotinic acid daily was added to
his milk for two days. Within twenty-four hours the diarrhea
disappeared and there was marked improvement in his general
physical condition and appetite. Convalescence was rapid. The
diagnosis of infantile pellagra, therefore, was confirmed by thera-
peutic test.

The following case history illustrates pellagra in early
childhood and the response to treatment with mono-
carboxylic acid of pyrazine:

Case d. — B. H., a white boy aged 16 months, was admitted
to the nutrition clinic of the Hillman Hospital with severe
superficial stomatitis. The following history was given by the
parents: The mother had always eaten an unbalanced diet,
high in carbohydrates and fat, low in protein, minerals and
vitamins. Until the child was 12 months old he received only
breast milk. At this time, in addition to breast milk, which he
continued to take until he was 14 months old, he began eating
potatoes, dried beans, bread and occasionally an orange. He was
allowed to eat as much of these foods as he wished and the
amount he ate varied from time to time. He gained weight and
seemed well until he was 14 months old, at which time he had
"colitis” and for two weeks ate but little food, lost weight and
became very weak. He was taken to a physician who advised
weaning him. Since this time he had 1 pint of buttermilk daily,
small amounts of oatmeal, potatoes and crackers, and occasion-
ally an egg. His appetite was poor, he was not well, and he
did not gain the 6 pounds (2.7 Kg.) he lost during his illness.
Two weeks prior to admission he began refusing to eat and
since this time he had only a small amount of oatmeal and
buttermilk daily-. The day he was admitted he became stuporous
and was taken to a physician, who advised admitting him as an
acute emergency case.

On admission the child was emaciated and apathetic. His
tongue and buccal membranes were covered with superficial
grayish ulcerations surrounded by fiery red erythema. No other
physical abnormalities were noted. On two successive days the
child was given 200 mg. of monocarboxvl ic acid of pyrazine,
which was dissolved in sugar water. Twelve hours after
administration the child willingly took food and his apathy dis-
appeared. Many of the ulcerations had begun to heal and the
erythema had vanished. One week later his mouth was entirely
healed. He was alert mentally and was rapidly regaining his
lost weight.

These studies suggest that infants and children who
have subsisted on inadequate diets or whose parents have
pellagra should be examined frequently for signs of the
disease. The prognosis for a child is usually better than
it is for an adult, but unless proper therapy is instituted
the disease is likely to become increasingly severe as
the person grows older until finally the skin, alimentary
tract and nervous system become involved. Recovery
is rapid and complete if a well balanced diet is given,
supplemented, when necessary, with nicotinic acid, yeast
or monocarboxylic or dicarboxylic acids of pyrazine.

SUMMARY AND CONCLUSIONS

1. The present study shows that, in an area in which
pellagra is endemic, the disease is common among
infants and children.

2. Nutritional histories often reveal that the mothers
of these children subsisted on inadequate diets during
pregnancy and lactation, thus establishing a definite rela-
tionship between the diet of the mother and the nutri-
tional state of the infant.

3. Lesions characteristic of the disease are seldom
seen in infancy but frequently appear early in childhood.
In the absence of typical lesions, the administration of
one of the therapeutic agents specific for pellagra offers
a valuable therapeutic test in 'confirming a diagnosis of
latent pellagra.

THE ELECTROCARDIOGRAPHIC CHANGES
IN ACUTE PERICARDITIS

JOSEPH B. VANDER VEER, M.D.

AND

ROBERT F. NORRIS, M.D.

PHILADELPHIA

Since it is usually a complication of a more easily
recognized disease, acute pericarditis in the absence of
an obvious pericardial friction rub or of a striking
pulsus paradoxus is frequently overlooked. Despite
the fact that a definite electrocardiographic pattern
almost pathognomonic of acute pericarditis has been
described, the value of this method of dignosis has not
been generally recognized. In our limited experience,
moreover, several electrocardiograms typical of acute
pericarditis have been erroneously attributed to coro-
nary occlusion.

In 1929 Scott, Feil and Katz 1 described transitory
elevation of the RT segments in all three leads of the
electrocardiogram in a case of hemopericardium and
in one of purulent pericarditis. These changes were
attributed to cardiac tamponade resulting from increased
amounts of pericardial fluid and it was emphasized that
this type of electrocardiogram could be differentiated
from that of acute myocardial infarction. Since then
electrocardiographic changes have been described by
others 2 in cases of pericarditis, hemopericardium and
stab wounds of the heart. In most of these reports the
electrocardiographic changes were likewise thought to
be caused by ischemia of the myocardium resulting from
cardiac tamponade. Experimental work on animals,
meanwhile, showed that definite and reversible changes
in the RS-T segments and T waves could be produced
by increasing the intrapericardial pressure. 3 No con-
stant electrocardiographic pattern was observed in these
various studies, but frequently the changes closely
resembled those seen clinically.

In 1937 we 4 reported a study of fourteen cases of
acute pericarditis in which serial electrocardiograms

From the Morris W. Stroud Jr. Fellowship in Cardiology, the Medical
Services and the Ayer Clinical Laboratory of the Pennsylvania Hospital.

1. Scott, R. W. ; Feil, H. S., and Katz, L. W. : The Electrocardio-
gram in Pericardial Effusion: I. Clinical, Am. Heart J. 5:68 (Oct.)
1929.

2. These include:

Purks, \V. K. : The Occurrence of a Coronary T Wave in Purulent
Pericarditis, South. M. J. 24: 1032 (Dec.) 1931.

Elkin, D. C., and Phillips, H. S.: Stab Wounds of the Heart, Electro-
cardiographic Studies of Two Cases, J. Thoracic Surg. X: 113 (Dec.)
1931.

Porter, W. B., and Bigger, I. A.: Nonfatal Stab Wounds of the
Ventricles, Am. J. M. Sc. 184 : 799 (Dec.) 1932.

Harvey, John, and Scott, J. W. : Changes in the Electrocardiogram in
the Course of Pericardial Effusion with Paracentesis and Peri-
cardiotomy, Am. Heart J. 7: 532 (April) 1932.

Clowe, G. M. ; Kellert, Ellis, and Gorham, L. W. : Rupture of the
Right Auricle of the Heart, ibid. 9: 324 (Feb.) 1934.

Koucky, J. D., and Milles, George: Stab Wounds of the Heart, Arch.
Int. Med. 56:281 (Aug.) 1935.

Schwab, E. H., and Herrman, George: Alterations of the Electro-
cardiogram in Diseases of the Pericardium, ibid. 55:917 (June)
1935.

Wood, Paul: Electrocardiographic Changes of a Te Pattern in Peri-
cardial Lesions and Stab Wounds of the Heart, Lancet 2:796
(Oct. 2) 1937.

3. These works include:

Katz, L. N. ; Feil, H. S., and Scott, R. W. : The Electrocardiogram in
Pericardial Effusion: II. Experimental, Am. Heart J. 5:77 (Oct.)

Foulger, Margaret, and Foulger, T. H.: The Blood Pressure and
Electrocardiogram in Experimental Pericardial Effusion, ibid. 7: 744
(Aug.) 1932.

Bay, E. B.; Gordon, Wayne, and Adams, Wright: Electrocardiographic
and Blood Pressure Changes in Experimental Pericardial Effusion
and Occlusion of the Venae Cavae, ibid. 8 : 525 (April) 1933.

Randles, F. S.; Gorham, L. W., and Dresbach, Melvin: Changes in
the RS-T Component of the Electrocardiogram Produced by Experi-
mental Rupture of the Auricles of the Dog’s Heart and bv Peri-
cardial Injection, ibid. 9: 333 (Feb.) 1934.

Herrmann, George, and Schwab, E. H. : Some Experimental and Clini-
cal Electrocardiographic Observations on RS-T and T Changes in
Pericarditis, Tr. A. Am. Physicians 49:229, 1934.

4. Vander Veer, J. B., and Norris, R. F. : The Electrocardiographic
Changes in Acute Pericarditis, Am. Heart J. 14: 31 (July) 1937. b 1

1484

ACUTE PERICARDITIS— VANDER VEER AND NORRIS

were taken. In addition to the usual three leads a chest
lead, with the apex of the heart and the left leg (lead 5
of Wolferth and Wood r '), was employed as a routine.
A characteristic electrocardiographic pattern was pres-
ent in five of seven cases of purulent pericarditis and in
one case of hemopericardium but in none of six cases
of nonpurulent pericarditis. This pattern consisted of

Jobs. A. it. A.
Oct. 14, 1939

tion to the conventional limb leads. A similar electro-
cardiographic pattern was found in nearly 50 per cent
of the cases of nontuberculous pericarditis and in two
of twenty cases of tuberculous pericarditis. Deflec-
tions of the RT segments in the chest leads were at
times more marked than in the limb leads. They also

ul noupuruiem pericarditis, this pattern consisted of concluded that the changes of the RT segments were
t e F, S ‘ em T s m . thc usually caused by subepilrdial myocardi if

niost marked in lead 2, without the occurrence of sig-
nificant Q waves. No definite changes were observed
in the chest lead. These acute changes persisted for
only a few days and in some cases returned to norma!
despite progression of the disease, with increasing
amounts of pericardial fluid and signs of cardiac tam-
ponade. Postmortem examinations were done in ten of
the eleven fatal cases. Correlation of the observations

Fig. 1 (case 1). — A, record taken two days after a pleuropericardial

friction rub was heard, shows an elevation of the RT segments in the

three limb leads, greatest in lead 2, and a striking elevation of the RT
segments in the precordial lead (apex and right arm). This is the
typical pattern of acute pericarditis. B, record taken four days later,
shows the changes still present though less marked. C, record taken a
few hours before death, shows that RT segments have returned to the

normal level and the T waves are diphasic in all leads. Some of this

T wave change is probably “digitalis effect,” as the patient was receiving
full doses of this drug. Postmortem examination revealed 6S0 cc. of
thick pus in the pericardial sac, empyema (both pneumococcus type II)
and evidence of congestive heart failure.

made on clinical, electrocardiographic and postmortem
examinations indicated that there was little or no rela-
tion between the amount of pericardial fluid and the
electrocardiographic changes. The conclusion was
reached that this typical electrocardiographic pattern
was associated with superficial myocarditis secondary
to inflammation of the epicardium.

Belief and McMillan c subsequently reported a larger
series of cases of acute pericarditis in which the three
chest leads of Wolferth an d Wood 8 were used in addi-

5. Wolferth, C. C„ and Wood, F. C: The Electroardiographic Diag-
nosis of Coronary Occlusion liv the Use of Chest Leads, Am. J. -W. Sc.

1S 6. : lleUet^Satnueh and McMillan T . M- =

terns in Acute Pericarditis, Arch. Int. Med. C1.3S1 (March;

by subepicardial myocarditis.

Since our previous report we have been using a dif-
ferent precordial lead in the study of cases of peri-
carditis. This lead is one of those which has recently
been recommended • for routine use by the American
Heart Association and the Cardiac Society of Great
Britain and Ireland. 7 By' these organizations, lead 4 F
(apex and left leg) was given slight preference to
lead 4 R (apex and right arm) as a lead for ordinary
use. Lead 4 F is the inverted mirror image of old
lead 5 of Wolferth and Wood and, in both of these
leads, deviations of the RT segments in acute peri-
carditis are usually minimal or absent. 8 In contrast to
this, we have found that elevation of these segments in
lead 4 R may be even greater than in the limb leads. 5
To illustrate this point and to reemphasize the impor-
tance of the electrocardiogram in the diagnosis of acute
pericarditis, the following cases are reported:

REPORT OF CASES

Case 5. — D. R., a Negro aged 55, admitted to the medical
service of Dr. Garfield G. Duncan Nov. 16, 1937, for four
days had symptoms typical of lobar pneumonia. On examina-
tion, signs of consolidation were elicited over the lower lobe o'
the left lung. The temperature remained elevated between 101
and 104 F. Pneumococcus type II was cultured from both the
sputum and the blood. A pleuropericardial friction rub, heard
near the apex of the heart November 20, disappeared a few
days later. November 28, 45 cc. of cloudy fluid, thought to he
removed from the pericardial sac, showed no growth on culture.
The pericardial sac was not again tapped. November M
120 cc. of cloudy hut sterile fluid was withdrawn from the left
pleural cavity, but on subsequent occasions small amounts ol
purulent fluid aspirated from the left pleural cavity gave pure
cultures of pneumococcus type II. Roentgenograms of the chest
at first confirmed the clinical impression of lobar pneumonia
in the lower lobe of the left lung and later of a small empyema
of the left pleural cavity. The heart shadow was at all times
enlarged, but no progressive increase in size was demonstrate! •
The patient continued to have a high fever and became increas
ingly dyspneic and cyanotic. The superficial veins of the
were engorged and the liver became enlarged and tender. S <g
peripheral edema was noted. Digitalization had little bene cia
effect on the cardiac failure and he died December 11, t" en >
five days after admission and twenty-nine days after the onse
of the illness. ■ <

Of the laboratory data, the electrocardiograms were of cspcct
interest. Repeated electrocardiograms, the first of which i' a
taken November 22, two days after the friction rub was brs
heard, showed elevation of the RT segments in all leads. ‘
gradual return of these changes to normal began Novcm cr -■
ami by December 10, the day before death, the only abnormal-
ities were diphasic T waves in all leads, which may hace c >
secondary to digitalization (fig. 1). . . r

The anatomic diagnosis was : lobar pneumonia of the
lobe of the left lung (pneumococcus type II) ; marked h r
purulent pericarditis and superficial myocarditis (pneumoco
type II) ; empyema of the left pleural cavity (pneumococ -
type II) ; atelectasis of the lower lobe of the left lung, c ir
passive congestion of the lungs, liver, spleen and panerc.
hypoplasia of the bone marrow.

7. Joint Recommendations of the American Heart ^““nation “ ! 1>rc .
Cardiac Society of Great Britain and Ireland : Standar.liiat < ]9J j;

cordial Leads, J. A. M. A. 110:. 196 (Jan. 29). 6S> deb. -to
Am. Heart J. 15:107 (Jan ). 235 (Feb.) 1938 f ,|ir Chc‘!

S. Edwards. J. C., and % andcr \ccr, J. B-. A “f ,L 0 n~jli««»

Leads of the Electrocardiogram i .with . an i-'jlmUm of the ■ 1

the Frecordial Electrode, Am. Heart T. 1G; 431 (Oet.) • • , 4 ha*

9. The exact technic that we employed w taking this ie.iu i
been recently described in a report by one of us.

r OLlWE 113
fUMBER 16

ACUTE PERICARDITIS— VANDER VEER AND NORRIS

1485

At necropsy 650 cc. of thick green pus was found in the
ericardial sac and about 400 cc. in the left pleural cavity,
hire cultures of pneumococcus type II were obtained from
oth these exudates. The thick purulent cpicardial exudate was
lrcady organizing and there was no cellular infiltration of the
nderlying muscle. The outer portion of the myocardium of
oth ventricles, however, was pale staining. Many of the fibers
ontained droplets of fat and the fibrils were broken. Most of
he nuclei were vacuolated. Since the lower lobe of the left
jug was evidently compressed by the pleural exudate, the
lveolar walls were partially collapsed. Nowhere in sections of
he lungs was there any evidence of bronchitis or pneumonia,
.arge patches of edema and “heart failure” cells, however, were
resent in the parenchyma. The splenic pulp and the central
ortions of the lobules of the liver were engorged with blood,
nd the acini of the pancreas were shrunken. The activity of
he bone marrow of a rib and vertebral body was subnormal,
['he immediate cause of death was thought to be congestive
leart failure.

The clinical diagnosis of acute pericarditis secondary
o lobar pneumonia was confirmed by the electrocardio-
gram. The elevation of the RT segments persisted for
inly a week even though pus continued to be present
n the pericardial sac. It is noteworthy that at necropsy
nost of the 650 cc. of pus in the pericardial cavity was
losterior to the heart because of anterior intraperi-
:ardial adhesions. The return of the electrocardiogram

0 normal, the failure to demonstrate a progressive
inlargement of the pericardium and the failure to
ispirate purulent fluid from what was thought to be
he pericardial sac influenced the clinicians against
iurgical drainage of the pericardium. The fever con-
inued, however, and digitalization had no influence on
he signs of heart failure. Since there was no residual
meumonia at necropsy, and the apparent cause of
leath was cardiac failure, surgical drainage of the
deural and pericardial cavities might have been life
saving.

Case 2. — M. L,, a white woman aged 67 , admitted to the
nedical service of Dr. David L. Farley July 17, 1938, had
noticed weakness and shortness of breath for a number of
nonths and had been acutely ill with fever and cough, produc-
tive of thick yellow sputum, for four or five days. The day
before admission, persistent pain in the lower left part of the
diest was first experienced. On examination the patient was
senile and acutely ill. Herpetic lesions were seen about the
lips. She was dyspneic and cyanotic but there was no peripheral
edema. The contour of the chest suggested emphysema. Evi-
dence of consolidation was found at the bases of both lungs.
The area of cardiac dulness was slightly increased. Although
the heart sounds were very faint and a marked pulsus paradoxus
was present, a pericardial friction rub was not heard. On
fluoroscopy no definite pulsation of the heart was seen and a
roentgenogram showed patches of pneumonia in the lower lobes
of both lungs. After several unsuccessful attempts to aspirate
fluid from the pericardial sac, on July 23, 330 cc, of cloudy
fluid was obtained at the apex of the heart in the fifth left
intercostal space. Before the fluid was completely removed
the pulsus paradoxus disappeared and the cyanosis and dyspnea
were lessened. In a smear of this fluid, numerous gram-positive
cocci were seen but no growth occurred on culture. Because of
the return of cyanosis, dyspnea and pulsus paradoxus on August

1 and 2, 10 cc. and 250 cc. of cloudy fibrinous fluid respectively
were removed from the pericardial sac. Air injected at the time
of the last paracentesis was shown in a roentgenogram to be
in the pericardial cavity. Cultures of both these specimens,
however, showed the presence of Staphylococcus aureus.

During August further attempts at removing fluid from the
pericardial sac were unsuccessful. August 3 and 26, 250 cc. of
slightly cloudy but sterile fluid was aspirated from the left
pleural cavity. At first the patient’s temperature varied between
98 and 101 F., but during August the temperature slowly
returned to normal. At the same time the signs of consolidation
"i the lungs gradually became less marked and the heart sounds

became louder. A pericardial friction rub was never heard.
In September, however, although pulsus paradoxus was only
infrequently present, the patient became dyspneic and cyanotic.
The liver was enlarged and tender, and edema of both legs
appeared. Late in September the right leg became increasingly
swollen, red and tender. Incision and drainage of the leg
because of a suppurative cellulitis were necessary. Staphylo-
coccus aureus was cultured from the pus. The patient recovered
satisfactorily from this infection and the signs of congestive
failure diminished with digitalization. Temporary auricular
fibrillation was noted and partial heart block with occasional
dropped ventricular beats was observed after the administration
of digitalis. Because of senile dementia the patient was trans-
ferred to another hospital on October 26.

For much of her stay in the hospital there were a moderate
leukocytosis and slight anemia. Small amounts of albumin
were present in the urine. At first the blood urea nitrogen

Fig. 2 (case 2). — Bronchopneumonia. A, a routine record taken two
nays alter hospital admission, shows the characteristic pattern of acute
pericarditis, which was not suspected clinically. Note the elevation of
the RT segments in all. leads. These changes persisted for nearly ten
days and_ gradually subsided. Purulent fluid with Staphylococcus aureus
was obtained on pericardial tap. B shows auricular fibrillation, which
was transient, and return of the T waves to the normal level, C, record
taken three months later, shows that there is a lowering of the amplitude
of the QKb complexes in the limb leads and diphasic T waves. No
evidence of pericarditis was present at this time, but digitalis was being
given because of mild cardiac failure.

varied between 30 and 53 mg. per hundred cubic centimeters
but in September a normal level was present. Other laboratory
data were irrelevant. After admission repeated electrocardio-
grams showed marked elevation of the RT segments in leads
1, 2 and 4. These changes returned to normal July 30. During
August the T waves of leads 1, 2 and 4 first became diphasic
and then inverted, and a slight lengthening of the PR interval
was noted. No'further change of the RT segments had occurred
when the patient left the hospital (fig. 2).

A routine electrocardiogram was responsible for the
discovery of acute pericarditis in this patient, who was
acutely ill with bronchopneumonia. Because of the
patient’s age and the apparent subsidence of a mild
pericarditis following aspiration, operation was deemed
inadvisable. It was felt that the typical electrocardio-

1486

ACUTE PERICARDITIS— VAN DER VEER AND, NORRIS

Joint. A. 1J. A
Ocr. H, 19J)

graphic pattern of pericarditis as well as the clinical
condition excluded the possibility of coronary occlusion.

Case 3— D. G., a white boy aged 13 years, admitted to the
medical service of Dr. David L. Farley June 22, 1938, com-
plained of anorexia and diarrhea. He was known to have had
rheumatic heart disease since the age of 6 years and had
attended the cardiac clinic of the Pennsylvania Hospital. For
two weeks before admission he had fever, loss of appetite and
slight diarrhea. On admission, the previous diagnosis of mitral
stenosis and insufficiency and aortic insufficiency was confirmed.
The systolic blood pressure was 120 and the diastolic 30 mm.
of mercury. He appeared feverish and acutely ill. At first
the patient’s temperature was elevated daily as high as to 103 F.
but the fever gradually subsided and he appeared improved. In
the hospital he had no diarrhea. During August, however, he
became worse and his temperature varied between 99 and 102 F.
A pericardial friction rub was first suspected August 11 and
by August 13 was marked to the left of the sternum, from the
second to the fourth interspace. A pulsus paradoxus was not
noted at any time and the venous pressure was not determined.
He complained of precordial pain, became dyspncic and had a
dry, nonproductive cough. The liver became larger but there
was no peripheral edema. The- patient was thought to have
an acute exacerbation of rheumatic carditis and early congestive
heart failure. In spite of the severity of the illness, his family
signed his release from the hospital August 19.

Repeated blood counts showed moderate anemia and leuko-
cytosis. The sedimentation rate at all times was much increased.
Roentgenograms of the chest showed a progressive increase in
the size of the heart, particularly to the left, but fluoroscopically

Fie. 3 (case 3). — Active rheumatic heart disease. A, record taken just
after admission to the hospital, shows partial heart block (PR interval

0.24 second) but nc • - . B, record taken sixteen

days later and after shows a conduction time

just within normal e month later when there

was clinical evidence of active rheumatism with fever, dyspnea and pre-
cordial pain, shows the typical pattern of acute pericarditis. A loud
pericardial friction rub was subsequently present for several days. Ao
digitalis was being given. Note the elevation of the RT segments in all
leads, greatest in leads 2 and 4.

cardiac pulsations were definitely visible. An electrocardiogram
taken the dav 'after admission showed a partial heart block
(PR interval of- 0.24 second) but by July 9 this abnormality
bad disappeared arid the PR interval was 0.18 second. On

August 12. elevation of the RT segments in all leads of the
electrocardiogram was first noted and was thought to be tvpica!
of acute pericarditis (fig. 3). ,

Thee acute pericarditis in this case undoubtedly
resulted from rheumatic fever. At the time of admis-
sion there was no evidence of pericarditis, although

Fig. 4. — A, electrocardiogram of a patient with’ a iftcent ro
myocardial infarction. Note the elevation of the RT segments \m » -
2 and 3, greatest in the latter, and the slight depression of *\.r,
segments in lead 1. The precordial lead (4 R) shows . a -confer
depression of the RS*T segments. Note also the definite U e

lead 3, which became more prominent as the T Waves ra P J T 5 ..1 «J
inverted in leads 2 and 3. The T waves in leads 1 and 4 ret t
quickly to normal. B, record of a patient with a recent anterto . ^
cardial infarction. Definite elevation of the RT segments are prefer ^
leads 1 and 2 with beginning inversion of the T waves. c i:„|,tlr

definite Q waves in these leads and that the RT elevation is
higher in the first lead. Slight depression of the RT segment. » . 3 .
in lead 3. Lead 4 shows a relatively deep Q wave and some k ‘ ^
tion. The presence of definite O waves in leads 1 and 4, wnn.

t,«t>

^ sl and 4, ^

reciprocal action of the RT segments in leads 1 and 3, ma l£ s 0 f "a
n os is of myocardial infarction quite definite. C, electjoca rt pj" va{ ,' 0 h 0 f

patient with a combined anterior and posterior infarction. _ Ele\ahon
the RT segments is seen in all * - ,; “ I - 11

the limb leads, greatest in * §
waves are present in all leads, however, and there are marked c £.j t j ve

;r, aim uicig " v-t n o5i

the QRS complex of the chest lead with the loss of the *: n the

deflection (R wave). There was subsequently a rapid cnang an( j aa
record with deep inversion of the T waves in leads 1 add ;v3 yrs
increase in the size of the Q waves in these leads. The deep V frtf A
persisted in the precordial lead and the T waves became snarpi> ; j t
(The precordial lead taken originally in this case was the out ‘c ^ ; t
has been reprinted by inverting and reversing the negative ter j, r eta-
conforms to the new terminology. This in no way alters tne c hange»
tion and makes it comparable to the other records.) Although i 0 f zeu't
in the RT segments per se in this record conform to the chan?* 5

pericarditis, the development of typical Q waves and the
m the precordial lead easily differentiate it from this condition.

the electrocardiogram showed a temporary partial 1
block (delayed PR interval). The electrocardiog ;
then returned to normal and, following an exaccr a
of the infection, the typical clinical and electroca r
graphic signs of acute pericarditis were observed.

comment . j c

A definite and characteristic electrocardiograp^
pattern is found in many cases of acute P erica ^ j,>p
This typical pattern consists of elevation of 1 1 "j
segments in the three limb leads and in the dies
4R (apex of heart and right arm) which
employed. In the case of the limb leads, clevatio y
be especially' marked in lead 2 or in leads -J..
together. The RT segments may also be more -

Volume 113
Number 16

BIRTH CONTROL— RODGER

148 7

ingly elevated in the chest lead than in any of the limb
leads. These changes may be caused by any type
of pericarditis but most frequently by acute purulent
pericarditis or hemopcricardium. The abnormalities
of the electrocardiogram arc usually found early in the
disease, are transient and may persist for only a few
days. It is especially important to remember that the
electrocardiogram may return almost to normal even
though the infection and inflammation of the pericardial
sac may. be continuing and the pericardial effusion
increasing. In contrast to acute pericarditis, most cases
of chronic pericarditis show no definite electrocardio-
graphic pattern, and abnormalities arc usually limited
to nonspecific changes in the T waves.

. The most common lesion with which the electro-
cardiogram of acute pericarditis is confused is that of
coronary occlusion. Since the clinical manifestations
of precordial pain, fever, pericardial friction rub, leuko-
cytosis and the like may be present in both diseases,
the differentiation between them may at times depend
largely on the interpretation of the electrocardiogram.
In the case of myocardial infarction caused by coronary
occlusion, the early transient abnormalities of the
electrocardiogram are 11311311}' characterized by recipro-
cal deflections in leads 1 and 3. Thus in anterior infarc-
tion the elevated RT segments in lead 1 are usually
associated with slight depression of these segments in
lead 3,. and in posterior infarction the elevation of the
RT segments in lead 3 are also associated with depres-
sion of. these segments in lead 1 (fig. 4 A). In the
case of coronary occlusion, furthermore, definite Q
.waves are. often present in leads 1 or 3 (fig. 4 B), but
in acute pericarditis significant Q waves are generally
absent in all leads except when they have been present
before the onset of the pericarditis. Acute myocardial
infarction involving both the anterior and the posterior
wall of the left ventricle may give an elevation of the
RT segment in all leads similar to that seen in acute
pericarditis. 10 In these rare instances, however, the
presence of Q waves in the limb leads and changes in
the precordiaT lead establish the identity of the lesion
(fig. 4 C). The recently described electrocardiographic
pattern of acute lateral infarction, moveover, does not
in any way resemble that of acute pericarditis. 11 Finally,
if there is a return toward normal in the electrocardio-
graphic pattern and particularly if the patient survives,
it has been our experience that the subsequent tendency
for the T waves to become inverted is much less marked
in acute pericarditis than in coronary occlusion.

Until recently the abnormal deflections of the RT
segments in cases of acute pericarditis and hemoperi-
cardium were explained largely on the basis of myo-
cardial ischemia secondary to cardiac tamponade.
Increased amounts of pericardial fluid were thought to
increase the intrapericardial pressure to such an extent
that coronary insufficiency resulted. To corroborate
this view there were several experimental studies on
animals in which an increase in intrapericardial pres-
sure produced electrocardiographic changes, some of
which closely resembled the pattern which had been
described clinically. 2 These changes were reversible in
most instances. Recent clinical studies, however,
demonstrate that the typical pattern of acute pericarditis
is frequently seen with no increase in the amount of
pericardial fluid and that a marked pericardial effusion

10. Wolferth, C. C., and Wood, F. C.: Acute Cardiac Infarction
Involving Anterior and Posterior Surfaces of the Left \ entricle, Arch.
Int. Med. 56: 77 (July) 1935

11. Wood, F. C.; Wolferth, C. C., and Bellet, Samuel: Infarction of
the Lateral Wall of the Left Ventricle: Electrocardiographic Character-
istics, Am. Heart J. 16: 387 (Oct.) 1938.

may accumulate slowly or rapidly without significant
deflections of the RT segments. Postmortem examina-
tion in a number of cases has also indicated that the
typical changes in the electrocardiogram are associated
with and are probably caused by a subepicardial myo-
carditis. If the inflammation does not involve the myo-
cardium, however, the pericarditis even though purulent
may cause little or no change in the electrocardiogram.

Like any laboratory aid, the electrocardiogram is of
greatest value when it gives positive evidence. Nega-
tive evidence must always be considered with caution.
The electrocardiogram in acute pericarditis may return
almost to normal within a few days, even though the
changes have previously been striking and even though
the patient has not improved. We wish to emphasize,
however, that a definite electrocardiographic pattern
typical of pericarditis has been described and that the
importance of the electrocardiogram in the diagnosis
of this disease has been established.

SUMMARY

1. The definite and characteristic electrocardiographic
pattern seen in many cases of acute pericarditis was
found in the three cases here presented.

2. The electrocardiographic pattern of acute peri-
carditis can be differentiated from that of acute myo-
cardial infarction.

3. In cases of acute pericarditis, the changes in the

electrocardiogram are generally caused by subepicardial
myocarditis. '

4. Lead 4R (apex and right- arm) is; more, valuable
than lead 4 F (apex and left leg) in demonstrating the
electrocardiographic changes in acute pericarditis.

5. The electrocardiogram is' important in. the -diag-
nosis of acute pericarditis. ■■ ■

302 South Nineteenth Street.

Clinical Nates, Suggestions and
New Instruments - -

AN UNSUCCESSFUL '.METHOD OF BIRTH CONTROL
JonN R. Rodger’, M.D.,. Bellaire, ^IrcK.,' .

The physician called on to advise' his patients with/ regard
to birth control is constantly on the. lookout for some method
just as effective as' but simpler in technic than the. commonly
accepted methods ' of vaginal diaphragm or cbndom used with
an intravaginal jelly.

One such product, marketed now for several years, -consists
of a jelly which is forcibly blown into the vaginal vault by a
special applicator. The jell}'- itself -does 'not have an unusual
formula, consisting of a gum tragacantb base,' boric acid, sodium
chloride, oxyquinoline sulfate, lactic acid and glycerin. It does
not melt at body temperature. This very effective ' type of
applicator “splashes” the jelly into the vicinity, of- the. cervix,
and in the advertising material a contrast medium' picture shows
the external os well plugged by jelly.

The theoretical consideration of such a method nearly con-
vinces one of its simplicity and effectiveness. The product
appears even more attractive after one reads photostatic copies
of letters from physicians who report using it successfully in
their practice, one such report even coming from the head of
the obstetric department in a university hospital. However,
following is the record of twenty-three patients who used this
method — patients in a small town practice where one’s birth
control failures do not become lost from sight but "come home
to roost” on one’s own confinement calendar. This series, while
neither large nor observed over a long period of time, never-

1488

HYPERSENSITIVITY— McMANN

Jodi. A. It. A.
Ocr. 14, 19B

theless permits certain definite conclusions. These patients were
all of average or above average intelligence, all had had the
method fully explained to them and, from careful questioning,
all apparently followed directions closely.

Of twelve nulliparous patients, ten have thus far successfully
used this method over an average time of 10.1 months, the
shortest period of observation being six months and the longest
eighteen months. In the nulliparous group there were two fail-
ures, one after two months and the other after three months.
In the parous group were eleven patients. Successful were
three, with an average time of observation of ten months.
Pregnancies resulted in eight of the eleven. Two became preg-
nant one month after beginning this method, two more became
pregnant in three months ; the longest period of protection was
eight months and the average for the group was only 4.1
months.

CONCLUSION

Twenty-three patients were studied who used as a birth con-
trol method a jelly forcibly sprayed into the vaginal vault with
a special applicator. In the group of twelve nulliparous patients
two became pregnant; of the eleven parous patients eight
became pregnant.

This method of birth control is only fairly reliable for nullip-
arous women and is markedly unreliable after there has been
a pregnancy.

HYPERSENSITIVITY' TO SOLUTION OF POSTERIOR
PITUITARY

Walter McMann, 5I.D., Danville, Va.

In 1936 1 1 reported a case of profound shock following the
administration of solution of posterior pituitary. To this patient,
following a spontaneous abortion, solution of posterior pituitary
was given in 0.5 cc. doses at half hour intervals for four doses.
Approximately a half hour after the last injection the patient
was in shock. Later 1 cc. of solution of posterior pituitary
was given, which almost immediately put her into a profound
and frightening shock condition.

I am here reporting another case of hypersensitivity to solu-
tion of posterior pituitary. This is being done to add another
case to the all too meager literature and to try to make the
physician more cognizant of the bizarre and sometimes danger-
ous reactions that may follow the administration of a commonly
used drug.

REPORT OF CASE

Mrs. F. F., a tertigravida aged 27, was admitted to the
hospital May 14, 1939, with a history of having had vague
abdominal and sacro-iliac pains at regular intervals for about
twelve hours. Two weeks before she had entered the hospital
and had remained there twenty-four hours for the same com-
plaint. At that time she was discharged after the uncomfortable
condition had been controlled with sedatives. After thirty-six
hours of vague abdominal discomfort it was thought that the
wiser procedure would be to induce labor. The patient was
at term and also, as an added deciding factor, she lived 24 miles

from the hospital.

At 6 a. m. 2 ounces (30 cc.) of castor oil was given. At
6 : 30 she had a bowel action and a hot, high soapsuds enema
was given. As this was being expelled (6 : 40) 2 minims
(0.13 cc.) of solution of posterior pituitary was given hypo-
dermically. Ten minutes later the patient had urticarial wheals
over the whole body. She was gasping for breath and was
nauseated, the tongue, face and legs were swollen, there was
marked pallor and she had the sensation of impending death.
The blood pressure, which had been 140 systolic, 80 diastolic,
was 76 systolic, 50 diastolic. Epinephrine was given imme-
diately and most of the symptoms disappeared in a short time
or were markedly lessened. Vaginal examination at 8 o’clock
revealed a cervix effaced and one and one-half fingers dilated.

From the Obstetric Service, Danville Community Hospital.

I. HcMann. Walter: Pituitary Shook, Am. j. Obst. & Gynec. «1.
1047 (June) 1936.

The presenting part,' the vertex, was dipping into the pelvis.
At this time the membranes were ruptured artificially. She
was delivered at 2 : 28 p. m. by elective low forceps of a normal
boy baby weighing 8?i„ pounds (3,686 Gm.). The placenta was
expelled three minutes afterward. During labor morphine one-
eighth grain (0.008 Gm.), scopolamine Vi oo grain (0.0006 Gm.)
and pentobarbital sodium 7 / grains (0.5 Gm.) were given in
divided doses. The labor was not abnormal — just what would
be expected from one that had been induced.

The patient had had two previous deliveries, in 1936 and
1938. She had been nauseated for the entire duration of both
of these pregnancies. The second one had been complicated
by polyhydramnios. The first labor had been short, the second
long. After both she had received 1 cc. of solution of posterior
pituitary with no untoward results.

During this pregnancy, the third, she had had only the symp-
toms that a nervous multipara would have. There were no signs
of toxemia. The Wassermann reaction was negative. She
did have polyhydramnios, however. At no time were there any
allergic signs or symptoms, and the past history was negative
for any allergic manifestations.

On her third postpartum day, with her permission, 1 minim
(0.06 cc.) of solution of posterior pituitary was injected hypo-
dermically. Almost immediately she had the same reaction
that she had had before. The urticaria was worse, particularly
on the thighs and back, itching was more intolerable, ai^d
dyspnea was not quite as marked and the blood pressure did
not drop as far. This may have been because we gave epineph-
rine as soon as we were sure that an anaphylactic reaction
was starting. The hands, feet and face were more swollen than
at the time of the previous reaction.- Epinephrine was repeated
three times, morphine one-sixth grain (0.01 Gm.) was given
once. In spite of this, twelve hours later she was very uncom-
fortable. She complained bitterly of abdominal cramps; the
uterus seemed to be in tetanic contraction most of the time-
The next day her condition was normal, and three weeks later
it was still normal.

COMMENT

Because of the constant and universal use of the drug, '•
seems strange that more cases of hypersensitivity to solution
of posterior pituitary have not been reported. Hasson casua 5
mentions that there have been cases previous to his reporie
one in 1930. De Lee in a personal communication says he a*
observed the phenomenon and Dieckman, quoted by De ,
warns against the possibility. Twelve references were ° un ^
in the literature, most of the cases being similar to the on
reported here. Simon, and Pendleton and his associates su
jected their patients to scratch tests with different bran 5 a 1c
solution of posterior pituitary with positive results, bu
exact mechanism of the phenomenon is not definitely no '
Simon denies that there is excessive oxytocic action arc ^
panying the reaction, while Pendleton insists that there is-
is interesting to note that in my case the first injection 1
cause, tumultuous uterine contractions. Three days a ^ erw
however, when 1 minim was given, uterine cramps vere v -
painful. My patient would not permit scratch tests to e 111
either on her or on her baby. , j.

There have been several series of cases of postpartum s
reported in the recent literature, in some of which the e 1
factors have been unexplained. It would be interesting 0
to how many of these patients solution of posterior pi w
had been given. Perhaps many more cases of shock occu
this cause than one suspects. For this reason I show >
before giving large doses and particularly repcate 0
solution of posterior pituitary. In cases of postpartum 1 ^

rhage from atonic, uteri, ergonovinc preparations are pro
safer and should be more efficacious. It is suggested ia > ^

solution of posterior pituitary is given, epinephrine 1 • > ^

ready for instant use. If there is a reaction which can ^
controlled by epinephrine, magnesium sulfate might c
intravenously.

Masonic Temple.

Volume 113
Number 16

TREATMENT OF PERITONITIS— ORR

1489

Special Clinical Article

TREATMENT OF PERITONITIS

CLINICAL LECTURE AT ST. LOUIS SESSION
THOMAS G. ORR, M.D.

KANSAS CITY, MO.

From the surgeon’s point of view, peritonitis arising
from perforations and leakage from intra-abdominal
viscera is of chief interest. Since there is no specific
therapy for peritonitis, treatment may he divided into
procedures for the removal of the source of the infec-
tion and supportive measures to aid natural defenses.
When the treatment is being planned, an estimate should
be made of the pathologic condition, the altered physio-
logic function and changes in body chemistry, and the
methods to be employed should lie based on this estimate
in each individual case.

Factors in the treatment of acute peritonitis worthy
of special consideration may be outlined and discussed
under the following headings:

1. Operation and abdominal drainage.

2. Decompression of the distended intestine.

3. Maintenance of the intestinal tone.

4 . Use of peristaltic stimulants.

5. Maintenance of water and chemical balance.

6. Food supply.

7. Local application of beat.

8. Antitoxic serum therapy.

9. Chemotherapy.

10. Bed posture.

11. Oxygen therapy.

12. Blood transfusions.

OPERATION AND ABDOMINAL DRAINAGE
In the early stages of a perforated abdominal viscus
it is logical to remove the source of the infection or
close the leak by operation to prevent general peritoneal
contamination. The results of early operation before
abdominal distention and intestinal stasis have developed
have been satisfactory. After the infection has become
generalized and abdominal distention and inhibition of
intestinal activity have occurred, operation is probably
of little value unless there is a local accumulation of
pus. Conservative treatment of general peritonitis,
first advocated by Ochsner and now considerably elabo-
rated, is fundamentally sound. Since peritonitis secon-
dary to appendicitis has received the greatest attention,
the value of the conservative method of treatment may
be based on this type of infection. Unfortunately a
unanimity of opinion does not exist among surgeons
concerning the operative and nonoperative treatment of
peritonitis due to appendicitis. However, if the issue
is not clouded by the inclusion of local or early perito-
nitis and localized abscess, the weight of evidence is
in favor of the nonoperative or conservative method of
treatment. Mont Reid 1 warns that the total mortality
of acute appendicitis may actually be increased unless
the entire medical profession learns the clear indications
for conservative therapy. It seems obvious that in a
discussion of the treatment of general peritonitis only
those cases presenting the clinical signs and symptoms
of such infection should be segregated for nonoperative

^rom the University of Kansas Hospitals, Kansas City, Kan.

Surgical Division of the General Scientific Meetings at
e ^Ninetieth Annual Session of the American Medical Association,
, Lo J» s . May 16, 1939.

jgjg ^ e, d, M. R. : The Appendicitis Problem, Surgery 3:601 (April)

treatment. In cases in which there is abscess formation,
resolution may result if judicious restraint is practiced
by the surgeon.

The futility of attempting to drain the peritoneal sur-
face is now generally recognized. As early as 1905
Yates 2 concluded that drainage of the general peritoneal
cavity is physically and physiologically impossible. Any
operative procedure designed to expose infected areas
and place multiple drains in contact with the peritoneum
can only do harm. There is a growing belief that
complete closure of the abdomen in the presence of
diffuse peritonitis is preferable to any type of drainage.
Buchbinder and his associates 3 observed that abdominal
drainage increased the mortality in experimental peri-
tonitis. Clinical reports have also indicated a reduction
of mortality in acute peritonitis when the abdomen is
closed without drainage. 4 Since there is no universal
agreement concerning drainage of peritoneal infections,
definite recommendations applicable to all cases are diffi-
cult to make. When localized collections of pus or
necrotic material are encountered at operation, drainage
is indicated. Massive drainage is never indicated. Drains
should not be placed on the assumption that purulent
exudate will collect at a certain site and the presence of
drains will prevent it. Any drain within the abdominal
cavity is soon surrounded by adhesions and acts as a
foreign body. The principle of placing drains so that
contact with the peritoneal surface is minimal is good
physiologic surgery. If drains are used for diffuse
peritoneal infections they should be placed near, but
not on, the original source of infection and should be
removed early. When purulent exudates are found
within the abdomen, adequate drainage of the abdominal
wall is essential. Much suturing in the presence of
infection adds foreign material and closes contaminated
areas which predispose to the development of serious
wound infection. In severe infections the peritoneum
should be sutured • and the remainder of the wound
packed open or loosely closed with sutures passed
through the full thickness of the abdominal wall down to
the peritoneum.

Various procedures have been suggested for cleans-
ing the abdominal cavity at operation. This type of
treatment should be abandoned. Complete removal
of all infection by washing or chemical sterilization of
the peritoneum is quite impossible and contrary to
known physiologic principles. Careful removal of
excessive exudate by suction as part of the operation is
in order, but extended efforts to cleanse the peritoneal
surfaces disturb the natural protection against infection.
As an infection progresses over the peritoneal surface
a defensive exudate is elaborated which, when disturbed
or removed, increases rather than decreases absorption.
The experimental work of David and Sparks D has
shown that a well developed plastic peritonitis almost
completely prevents the passage of Bacillus coli from
the peritoneal cavity into the lymphatic or blood streams.
This was found true also of the diphtheria toxin. From
the normal peritoneum or in the presence of a transu-
date, both Bacillus coli and diphtheria toxin passed
freely into the blood and lymph streams.

, ir - ■ An experimental study ot the Local Effects of Peri-

toneal Drainage, Surf,'., Gynec. & Obst. 1:173 (Dec.) 1905.

3. Buchbinder, J. R.; Droegemuellcr, W. A., and Heilman. F. R.: The
Effect of Drainage upon Experimental Diffuse Peritonitis, Surg., Gynec.
& Obst. 53: 726 (Dec.) 1931.

4. Cott_is_, G. W., and Ingham, H. W. : The Nondrainage Treatment
of Peritonitis, New York State J. Med. 35:49 (Jan. 15) 1935. Rhodes.

-k -J C , T L , ; John: Peritonitis and Drainage, California & West.
Med. 42: /9 (Feb.) 1935.

5 ; David, V. C., and Sparks, J. L.: Peritoneum as Related to Peri-
tonitis, Ann. Surg. S8: 672 (Oct.) 1928.

1490

TREATMENT OF PERITONITIS— ORR

A caieful selection of cases for operation is necessary.
1 he presence or absence of intestinal distention aids
much in the decision. When there is no distention
operation is usually successful. When diffuse infection’
abdominal distention, rapid pulse and dehydration are
present, conservative nonoperative treatment is the
choice.

DECOMPRESSION OF THE DISTENDED INTESTINE
Any rational treatment of intestinal distention must
be considered from the standpoint of the effect of such
distention on the organism. Is distention a part of
nature’s protective mechanism or is it evidence of an
advanced pathologic condition? Certainly the degree of
distention with reduction of peristaltic activity must be
considered in estimating the condition of the patient.
When auscultation of the abdomen reveals intestinal
sounds, peristalsis is present in some degree. Audible
peristalsis is a more hopeful sign than a completely
silent abdomen. As distention develops, the blood sup-
ply of the bowel is reduced by intraluminal pressure.
Excessive distention causes tissue destruction or gan-
grene. Absorption from the intestine is diminished as
the intestine distends. Toxic products may be absorbed
through the peritoneum when the blood supply to the
intestinal wall is destroyed. Decompression of the
intestine prevents necrosis of tissue from lack of Wood
supply, prevents peritoneal absorption and aids in main-
taining the tone of the intestinal muscle. This treatment
is then effective by preventing dangerous complications
due to overdistention during the height of the infective
process.

Continuous gastric and duodenal nasal suction as
described by Wangensteen 0 is indicated in the treatment
of intestinal distention resulting from peritonitis. The
problem is not unlike that of intestinal obstruction.
Constant suction through an indwelling nasal tube
removes not only the liquid content of the bowel but the
equally important gas and swallowed' air that are always
present. As signs of improvement in the patient’s
condition develop, the indwelling tube may be used for
testing the return of function of the stomach and
intestine. By clamping the tube for a period of two
or three hours and measuring the intake and output
of liquid, one can make an estimation of function. If
the aspirated liquid is less than the intake, it may be
assumed that peristalsis is again active and the tube may
be removed. While the tube is in place the patient may
be permitted to drink water and other liquids, which
will pass freely through the tube. Drinking and chew-
ing gum add much to the patient’s comfort by satisfying
thirst and keeping the mouth moist.

The Miller-Abbott 6 7 double lumen tube is useful in
empyting the entire small intestine above an obstruction
and is applicable to the treatment of intestinal distention
due to peritonitis. After the technic of its use has been
mastered, excellent results may be expected with this
type of tube drainage.

The principal danger of continuous suction treatment
of the stomach and upper part of the intestinal tract
is the reduction of essential secretions, especially the
chlorides. Ulceration in the stomach and esophagus and
infection of the middle ear in babies have been men-
tioned as complications of the indwelling tube. The
advantages of the tube far outweigh its disadvantages,
and the latter are mentioned only as a safeguard.

Jour. A. Jf.
Oct. 14, 1919

Tlie use of enterostomy as a means of decompress^
the distended intestine complicating diffuse pehtonhfs
is somewhat questionable. . When decompression is
most needed the intestine has usually lost its propulsive
power and when such a condition exists only a short
segment will be drained by enterostomy.. After peri-
stalsis has been restored, drainage of the intestinal con-
tent is not needed. When true organic obstruction or
adhesive obstruction has developed with active peri-
stalsfs, enterostomy may be indicated. Organic occlusion
requires surgical release, whereas acute inflammatory
adhesions causing obstruction will usually subside after
temporary' drainage and permit restoration of intestinal
function. High jejunostomy is no more efficient than
suction drainage and is not indicated in the treatment
of peritonitis.

Under the heading of intestinal decompression and
drainage may also be considered the use of enemas.
Liquids given in quantity by rectum, when the intestine
is inactive, are frequently difficult to expel and may
increase distention and discomfort. Animal experi-
ments have shown that the solutions usually employed
for enemas do not stimulate peristalsis in the small
intestine and therefore would not aid in reducing its
distention. 8 When the critical stage of the disease has
passed and intestinal function has begun to be restored,
small enemas may' be given with benefit. The colon
tube may be useful in any stage of the disease to aid
in removing gas from the colon.

MAINTENANCE OF THE INTESTINAL TONE
To maintain the intestinal tone is to maintain the
intestinal circulation. The decompression methods dis-
cussed obviously aid in maintaining and restoring intes-
tinal tone. Morphine is known to stimulate rhythmic
contractions of the intestinal muscle and raise the
muscle tone as evidenced by increased intraluminal
pressure. 0 Morphine may then be given with assurance
in the treatment of peritonitis not only to increase me
muscle tone but in sufficient quantity to make the patient
comfortable, promote rest, relieve anxiety and minion*
thirst. Overdosage signals are cyanosis and respirations
below 1 5 per minute. When the patient begins to improve,
morphine should be promptly diminished and when
peristalsis has been restored it should he discontinued

it i r> - « • < « m.

IUUIULC, VVllW Lite paUCUL U CgJlid *•'

morphine should be promptly diminished and
peristalsis has been restored it should be disconU
entirely. Since hypertonic sodium chloride solutions
stimulate intestinal tone and peristalsis, it is reasonable
to believe that by maintaining the blood chlorides at a
normal level the tone of the intestinal musculature will
be favorably influenced. To prevent overdis tenbon
of the bowel with its resulting disturbed circulation
and at the same time to avoid disturbance of the enor s
of the body' to protect itself against infection is n ic
principle of such treatment.

USE OF PERISTALTIC STIMULANTS

In view of the generally accepted opinion concerning
the protective mechanism of diminished intestm
activity in peritoneal infections, the use of any stin'
lant which will produce active peristalsis during J
acute stage of the disease may be considered harm ^
Some clinical evidence has been presented which sec

to negative this point, of view. Potter

doses of 1 cc. of pitressin intramuscularly, beginnuv
at the time of operation and given t hereafter eu to.

S. Carlson, H. E., and On-, T. G. : Tlie Effect of Enema* on
tinal Motility, Arch. Surg, 30:881 (May) 1935.

9, Orr, T. G.: The Action of Morphine on the Stnau In
Its Clinical Application in the Treatment of Peritonitis ano
Obstruction, Ann. Surg. OS; 835 (Nov.) 1933. , .

10. Potter, P. C.: Acute Diffuse .Peritonitis Following ■£* 1 * 4 1

citls with Report of Twenty-Five Cases, S. Cbn. North A
379 (April) 1934.

6. Wangensteen, O. H.: The Early Diagnosis of Acute Intestinal
Obstruction with -Comments on Pathology and Treatment, Tr. Western
S. A., 1931, p. 4S3.

7. MUler, T. G.. ami Abbott, W. O.: Intestinal Intubation: A Prac-

tical Technic, Am- J. M. Sc. IS 7: 595 (May) 1934.

Volume 113
Number 16

TREATMENT OF PERITONITIS— ORR

1491

two to four hours until intestinal tone lias been regained.
Brown 11 has expressed doubt about the protective
mechanism of intestinal distention against infection and
has recommended peristaltic stimulants at the first
sign of toxic intestinal paralysis. Since the value of
such stimulants is somewhat controversial, they should
be used with discrimination. A fall in blood pressure
with ’ evidence of shock after the use of pitressin and
prostigminc has been observed. When used, the dosage
should be small at first and increased if reaction is
not noted. The blood pressure is a valuable guide in
controlling the patient’s tolerance. Indiscriminate use
of peristaltic stimulants in all cases of intestinal dis-
tention is bad therapy. Further and more scientific
research in the clinical application of these preparations
is very desirable.

MAINTENANCE OF WATER AND CHEMICAL
BALANCE

Since vomiting and inability to assimilate liquids
when given by mouth occur with peritonitis, dehydra-
tion and loss of essential secretions of the upper part
of the gastrointestinal tract assume great importance.
When vomiting is excessive, hypochloremia, disturbed
acid-base balance and nitrogen retention may result.
These changes can be determined by chemical analysis of
the blood, which should be done in all cases of serious
illness from peritonitis. After a few days of inability
to take food, nutritional disturbances may ensue with
lowering of the total blood protein, predisposing to
general edema and edema of the lungs. 12

The disturbance in water and chemical balance is best
treated by parenteral administration of sodium chloride
and dextrose solutions. Ringer’s or Hartman’s solu-
tion may be used, if preferred, instead of physiologic
solution of sodium chloride. Sufficient sodium chloride
should be given to maintain the chloride content of the
blood at a normal level. The quantity of water and
chloride necessary will vary with individual patients.
Since the daily liquid intake of the average normal
adult patient is from 2 to 3 liters, it is reasonable to
assume that the sick patient will require at least similar
quantities. Coller and Maddock 13 have quite accurately
estimated that a sick patient showing definite signs of
dehydration has lost liquid approximately equal to 6 per
cent of his body weight. A patient weighing 60 Kg.
would therefore require 3,600 cc. of water to combat
existing dehydration. To this should be added in the
first twenty-four hours of treatment 2,000 cc. to replace
the insensible loss through the skin and lungs during
that period, plus 1,500 cc. to make up the normal urine
output. The total liquid requirement for the seriously
dehydrated patient in the first twenty-four hours would
equal the sum of 3,600 cc. plus 2,000 cc. plus 1,500 cc.,
or 7,100 cc. After the initial dehydration has been
corrected, the daily’’ necessary intake of liquid will
usually not exceed 3,500 cc. When the water deficiency
of any patient is estimated, the quantity lost by vomiting
or suction, bleeding, drainage from fistulas, diarrhea and
massive exudate must be determined and a like quantity
restored to the body. As the patient improves and
begins to retain liquid and food taken by mouth, the
parenteral intake should be proportionately decreased.

As a practical plan for administering the estimated
3,500 cc. of water required in twenty-four hours, it

H. Brown, H. P. : Peristalsis and Peritonitis, Ann. Surg. 100:167
(July) 1934.

12. Jones, C. M., and Eaton, F. B. : Postoperative Nutritional Edenm,

A ™»- 27 : l $ 9 (July) 1933. _ . „ .

13. Coller, F. A., and Maddock, \V. G.: The Water Requirements of
Surgical Patients, Ann. Surg. 9S: 952 (Nov.) 1933.

is suggested that 2,000 cc. of solution be given by vein
in the forenoon and 1,500 cc. by hypodermoclysis in the
afternoon and evening. Patients who absorb solutions
slowly when given by hypodermoclysis should receive
the entire daily quantity by vein. The injection of
solution should be discontinued before 11 p. m. so that
rest during the night will not be disturbed.

Proctoclysis is a time-honored method of supplying
liquid to ill patients and undoubtedly has definite merit
in selected cases. However, when given to the patient
sick with peritonitis it may increase existing distention
and discomfort. It is also frequently difficult to estimate
accurately the quantity absorbed by the body, since
unknown quantities may be expelled about the intake
tube or with bowel movements. Proctoclysis is therefore
considered inferior to parenteral methods of administra-
tion of liquid, especially during the acute stage of
peritonitis with abdominal distention.

It is possible to give a patient too much water and
sodium chloride. Clark 14 has called attention to the
danger of overburdening a weakened circulatory sys-
tem by rapidly increasing the blood volume. General
edema and edema of the lungs may result with exces-
sive hydration when the solution given contains too
much sodium chloride. At the first sign of edema
the sodium chloride intake should be reduced or dis-
continued and the injected solution continued as a 5 per
cent dextrose solution. Coller and his associates 15 have
determined that for each hundred milligrams per hun-
dred cubic centimeters which the plasma chlorides need
to be raised to reach the normal the patient should be
given 0.5 Gm. of sodium chloride per kilogram of body
weight. If this rule is followed and frequent esti-
mations of the blood chlorides are made, the danger of
excessive chloride intake will be reduced to a minimum.

FOOD SUPPLY

To maintain metabolic balance during the destructive
activity of disease would approach the ideal in therapy.
Since this is not possible, especially in diseases of the
gastrointestinal tract which prohibit the normal intake
of food, parenteral feeding must be used as a poor
substitute. At present dextrose is the food of choice
which may be given safely intravenously or hypo-
dermically. It is usually given by vein in a 5 or 10
per cent solution. A 5 per cent solution of dextrose is
isotonic and may also be given by injection under the
skin. Dextrose is particularly valuable in supplying
liver glycogen and stimulating diuresis. Recognition of
the importance of liver and kidney damage in many
disease conditions has emphasized the therapeutic value
of dextrose.

Very recently Mueller 10 has recommended the
intravenous administration of a 5 or 10 per cent solution
of alcohol in the treatment of peritonitis. The alcohol
is added to the dextrose and saline solutions to furnish
additional, much needed calories. He estimates that
2 liters of 5 per cent dextrose will supply about 400
calories, and if 100 cc. of alcohol is added nearly twice
as many calories are available.

Solutions injected intravenously should be given
slowly, usually, at a rate not exceeding from 60 to
80 drops a minute. The rate of administration of
hypodermoclysis must be governed by the rate of

i. icsem L/augcr

_ * e.aiuidc A^uaiauon: i^ver rresen

Intravenous Injections, J. A. M. A. 89:21 (July 2) 1927
, v lS ^ CoUe , r ' A - Bartlett, R M.; Bingham, D. L. C.; Maddock,
G., and Pedersen, Svend: The Replacement of Sodium Chloride in
Surgical Patients, Ann. Surg. 108:709 (Oct.) 1938.

16. Mueller, Sterling: The Use of Alcohol Intravenously with Special
?01(ApriI) O 19l9 VaIU ' S ' Vere Peritonitis . S. Clin. North America 19:

1492

COUNCIL ON PHYSICAL THERAPY

Jour. A. M. A.
Oct. H, 1939

absorption. Excessive tumefaction of the tissues should
be avoided. Discomfort may be minimized by adding
50 cc. of 0.5 per cent procaine hydrochloride solution
to each liter of liquid to he injected.

LOCAL APPLICATION- OF HEAT

Judging by clinical observations, the application of
moist or dry heat to the abdomen is of value in the
treatment of peritonitis. Experiments have shown that
heat at a temperature usually applied clinically will
penetrate the abdominal walls of children and thin
adults. 17 Ochsner 18 believes that heat stimulates peri-
stalsis. Patients are often made more comfortable by
heat applied to the abdomen. Heat may also favorably
influence the blood supply to the peritoneum. The
dangers of heat therapy are almost nil if the skin is
adequately protected against blistering.

ANTITOXIC SERUM THERAPY
Serums have been used with apparent benefit by
some authors. 18 Because of the great variety of organ-
isms which may infect the peritoneum from the gastro-
intestinal tract, the use of polyvalent serums, antitoxic
to all pathogenic bacteria causing peritonitis, would be
necessary to estimate the true value of such treatment.
To date, the benefit derived from serum therapy has
not been sufficiently convincing to warrant its routine
use.

CHEMOTHERAPY

The value of specific drug therapy is yet to be deter-
mined. Sulfanilamide and the newer allied chemicals
have not yet proved their worth in the treatment of
peritonitis. bed posture

The semisitting and Fowler positions increase vital
capacity and add to the patient’s comfort. What effect
such positions have on localizing infection in the lower
part of the abdomen is difficult to determine. It is
possible that gravity may be a factor in preventing the
extension of the infection from the lower to the upper
part of the abdomen, especially before distention and
plastic exudates limit the spread of liquid infectious
material. oxygen therapy

A certain degree of anoxemia develops in patients
with peritonitis as a result of reduced vital capacity,
intestinal distention and toxemia. Oxygen should be
given to such patients early in the treatment and not
as a last resort after cyanosis has developed and dissolu-
tion is imminent. Fine and his associates 20 have made
the important observation that the administration of
high concentrations of oxygen promote the absorption
of gas from the distended intestine. The importance
of oxygen therapy has been emphasized by Thalhimer, 21
who has stressed the conclusions of Haldane that mild
degrees of anoxemia have serious effects on the nervous
system and that moderate or severe degrees may be
fatal. Oxygen may be given by nasal tube. If the end
of the tube is properly placed in the oropharynx, a flow
of 6 liters of oxygen a minute will furnish a 50 to
60 per cent concentration to the patient.

17. Carlson, H. E., and Orr, T. G.: The Penetration of Moist Heat

Applied to the Abdomen and Its Effect on Intestinal Movements, Arch.
Surg. 30: 1036 (June) 1935. _ . .

18. Ochsner, Alton: Postoperative Treatment Based on Phj’Siologic

Principles, South. Surgeon 4: 197 (June) 1935. ,

19. Priestley, J. T.: Further Observations on Serum Therapy in Treat-
ment of Peritonitis Secondary to Appendicitis, Proc. Staff Meet., ftlayo
Clin. 11:213 (April 1) 1936. Gundel, M., and Sussbrich, F.: Ergeb-
nisse weiterer klinischer und mikrobiologischer Untersuchunpen uner die
Peritonitis und ihre Serumprophylaxe und -therapie, Kim. \\ chnschr. 13:

32 2§. Fin? Jacob; 3 Srars. J. B.. and Banks. B. M.: Effect of Oxygen
Inhalation on Gaseous Distention of the Stomach and Small Intestine,
Am. J. DiRest. Dis. & Nutrition 3:361 (Aus.) 1935.

21. Thalhimer, William: When Is OjyKen Therapy Indicated and
Hoir Is It Best Given? Mod. Hosp. 3S:10a (Feb.) 193_.

BLOOD TRANSFUSIONS

If the disease is prolonged or if anemia develops,
transfusions are indicated. Inability to take protein
foods by mouth soon causes nutritional disturbances
resulting in a decrease in the total blood proteins which
predisposes to edema. Transfusions cannot be given in
sufficient quantity to restore the blood protein to normal
but may be of definite value as a supporting measure.

COMMENT

Since treatment of acute peritonitis is still some-
what controversial in some of its aspects, positive or
unqualified statements concerning methods of therapy
would hardly be justifiable. Published mortality rates,
which vary' from 1.5 to 50 per cent, indicate that there
has not been a uniform understanding of the pathology
of peritonitis and its complicating disturbances of
physiology and chemistry. The impression is gained
by reading statistical reports that too much emphasis
has been placed on total mortality rates and not enough
on the segregation of similar pathologic processes with
an accurate estimate of the death rate in each group.

Much of the treatment outlined here is unnecessary
in mild types of peritonitis. In the fulminating types
of infection any treatment may fail. Uniformity of
opinion concerning the treatment of peritonitis cannot
develop unless a uniformity of pathologic states is con-
sidered by every one studying the subject.

315 Alameda Road.

Council on Physical Therapy

Tiie Council on Physical Therapy has authorized publication
of TnE followinc REroRTS. Howard A. Carter, Secretary.

AIRCO OXYGEN HUMIDIFIER
ACCEPTABLE

Manufacturer: Air Reduction Sales Company, 181 Pacifi

Volume 113
Number 16

COUNCIL ON PHYSICAL THERAPY

1493

of the oxygen delivered is somewhat low, but no injurious
clinical effects were observed. No pharyngitis was seen or
other irritation attributable to insufficient humidity. ' The amount
of humidity required for nasal or oropharyngeal administration
of oxygen is ati individual problem with each patient anyway.
The unit was used interchangeably with another humidifier of
known efficiency and no clinical difference was observed. The
volume of water is rather small and must be replenished fre-
quently.

In view of the foregoing report, the Council on Physical
Therapy voted to accept the Airco Oxygen Humidifier for
inclusion in its list of accepted devices.

LIEBEL-FLARSHEIM IMPROVED SW2-C
STANDARD MODEL SHORT WAVE
GENERATOR ACCEPTABLE
Manufacturer: The Liebel-Flarsheim Company, 303 West
Third Street, Cincinnati.

This unit is similar to the Liebel-Flarsheim SW2-C Model
Short Wave Generator previously accepted by the Council
(The Journal, Nov. 23, 1935, p. 1682) except that it has been
improved to allow for an increase in power output. It is recom-
mended for medical and minor surgical purposes. Applications
may be made by inductance cable, treatment drum, cuffs, pads
and orificial electrodes, and the unit may
be employed to induce fever for hyper-
pyrexia treatments.

The unit is supplied in a portable wooden
cabinet with separate subcabinet and in this
form the net weight is about 76 pounds
and the shipping weight is about 110
pounds. It is also supplied optionally in a
onc-piece all metal cabinet and in this form
the net weight is 163 pounds and the ship-
ping weight is 265 pounds.

Two oscillator tubes are utilized in a
tuned plate, tuned grid, circuit generating a
wavelength of about 22.6 meters. The
patient, cable and drum circuits are induc-
tively coupled to the oscillator. A filter is
employed in the supply line for the purpose
of minimizing line feed-back for possible
radio interference. The circuit also incorporates a device which
protects the oscillator tubes from overload and gives an audible
signal when the unit needs readjustment. An electric fan pro-
vides forced-draft ventilation.

The firm submitted engineering data to support its claim for
the power output of the machine. This is as follows:

Calorimetric Method . — The temperature rise induced in a given amount
of water in a given time indicates an average output of 465 watts on the
pad circuit and 470 watts on the cable circuit, with an input of 1,160
f watts and 1,175 watts respectively.

| Photoelectric Celt Method . — Two 300 watt bulbs were arranged in parallel.

j Measurement of light indicated an average on the coble circuit of 540

watts output with 1,185 watts input, and on the pad circuit 495 watts
1 output with 1,180 watts input.

\ Tests were carried out for the Council to substantiate these

| claims. Three separate calorimetric tests were carried out with

1 the apparatus, and the results showed that the claimed output

^ of 470 watts at an input of 1,160 watts could be obtained readily.

■j The unit was operated at full load for two hours. The

\ transformer temperature rise was found to be low enough to
meet the requirements of the Council.

To provide evidence as to the functioning of the machine in
, heating the human body, the firm submitted a series of tests
performed in a reliable clinic.

Treatments were given for twenty minutes each in accordance
with the patient’s tolerance. For the coil technic, four turns
: °f the cable were wrapped around the thigh with approxi-

■' mately 1 inch spacing of turkish toweling. Two turns were

- taken high up on the thigh, then about 4 inches of spacing was

/ allowed for inserting the thermocouples, and two more turns

were taken below the incision. When the treatment drum was
[< U5ec! it was applied over the thigh, as close to the skin and as

. nearly over the point where the temperatures were read as the

thermocouples would permit. For the cuff technic, two cuff
electrodes with approximately one half inch of felt spacer 'under
each were wrapped around the thigh with about 4 inches
spacing between the proximal edges.

A Chapman orificial electrode also was used. This electrode
was drilled out so that a thermometer could be passed through

Average Temperatures of Six Observations

Deep Muse!

e, Degrees F.

A

Oral, Degrees F.

Coil technic

Initial

98.6

Final

30 6.3

Initial

98.6

Final

98.9

Treatment drum technic

98.4

105.8

98.5

98.8

Cuff technic

98.0

105.3

98.4

98.8

and be in actual contact with the cervical tissue, giving tem-
perature readings from the cervix and not the interior portion
of the electrode. A large short wave pad was used as the

dispersive electrode and was spaced 2 to 3 inches from the
lower part of the abdomen by means of a folded turkish towel.
The thermometer was left in position throughout the treatment.
The duration of each treatment was thirty minutes.

Average of Six Observations, Orificial Technic

Initial, Degrees F. Final, Degrees F.

101.5 normal 110.2

Nine other tests were made at another hospital, giving the
results shown in the table.

Average of Nine Observations, Orificial Technic

Initial, Degrees F. Final, Degrees F.

98-6 109.6

In addition, eight fever treatment charts were submitted as
evidence of the efficacy of the unit in supplying heat for hyper-
pyrexia. The Liebel-Flarsheim Fever Cabinet was used.

Average of Eight Observations

Initial, Degrees F. Time Required to Reach 106 F.

5^.9 1 hour 41 minutes

The unit was tried in a clinic acceptable to the Council. It
was found to give satisfactory service and to perform in accord-
ance to the claims submitted by the manufacturer.

In view of the foregoing report, the Council on Physical
Therapy voted to accept the Liebel-Flarsheim SW2-C Improved
Standard Model Short Wave Generator for inclusion in its
list of accepted devices.

1494

EDITORIALS

Jouk. A. M. .V
Ocr. 14, 1939

the journal of the

AMERICAN MEDICAL ASSOCIATION

535 North Dearborn Street - - - Chicago, III.

Cable Address .... "Medic, Chicago’*

Subscription price Eight dollars per annum in advance

Phase send w promptly notice of change of address, giving
both old and new; always state whether the change is temporary
or Permanent. Such notice should mention all journals received
from this office. Important information regarding contributions
will be found on second advertising page following reading matter.

SATURDAY, OCTOBER 14, 1939

SIGMUND FREUD: 1856-1939

On September 22, in his eighty-third year, Sigmund
Freud, founder of psychoanalysis, died in London.
Men in the future may evaluate fully his contribution
to medicine. No doubt much of his teaching will he
modified and some of it will be discarded. Certain,
however, is the revolutionary influence he has had on
psychiatry. Freud was born in 1856 in Freiberg, a
small provincial town of Moravia, then belonging to the
Austro-Hungarian Empire, a son of simple Jewish
parents. His nationality and his race influenced his
career. He became a physician though later confessing
that- his secret desire had been to become a novelist.
He was destined to be a profound student of human
nature.

In his medical studies Freud was stimulated far
more by Charcot and Bernheim in France than by his
Viennese teachers. The Vienna Medical School was
dominated by the mechanistic attitude of Virchow’s
cellular pathology. In the light of that concept the.
unity of the human being as manifested in the function-
ing of the highest integrating centers (personality) was
lost. Freud began his medical career as a neurologist,
with contributions on aphasia and on infantile cerebral
palsy. Like many of his contemporaries, he soon
became aware of the sterility, ineffectiveness and funda-
mental inadequacy of current neurologic practice in the
care of the neuroses. In a search for more light he
went to Charcot, whose fame was then at its peak.
Charcot had demonstrated experimentally that ideas
can produce bodily symptoms. By hypnotic suggestions
he had succeeded in reproducing artificial!}- in his
patients hysterical symptoms similar to those of which
they complained spontaneously.

From Bemhcim’s and Liebeault’s post-hypnotic
experiments in Nancy Freud learned that unconscious
psychologic processes may influence overt behavior.
Next came the observations of Joseph Breuer in Vienna,
with whom Freud collaborated after his return from
France. The real discoverer of psychoanalysis was
Breuer’s famous patient Anna, who began to talk

freely under hypnosis of forgotten experiences. This
reminiscing while under hypnosis was not simple
remembering. It involved a dramatic display and
expression of repressed emotions. This verbal outburst
of emotions in hypnosis, which had such a beneficial
effect on Anna’s hysterical symptoms, Freud and Breuer
called “cathartic hypnosis” ; Anna herself gave it the
name “talking cure.”

These two factors, remembering of forgotten trau-
matic emotional experiences and the expression of pent
up emotions, have remained two important therapeutic
factors in psychoanalysis. Cathartic hypnosis, how-
ever, lacked one important element of modern psycho-
analytic technic: insight, the intellectual digestion of
the repressed forgotten emotional experiences. Under
hypnosis the conscious personality of the patient was
entirely eliminated. Freud recognized this defect of
hypnotic therapy. He tried to reproduce the procedure
without hypnosis and during these attempts discovered
the most fundamental dynamic fact of psychology— the
fact of repression and resistance. In the waking state
patients could not face these repressed emotions which
came to the surface in hypnosis. Our resistance toward
the recognition of emotions, wishes and tendencies
which are painful and in conflict with accepted stand'
ards Freud called repression. During patient experi-
mentation between 1895 and 1900 Freud discovered
the method of free association by which he was able
to circumvent the emotional resistance of patients
against facing and recognizing their unconscious niotne
forces. In free association, conscious control is elim
inated. The patient gives free course to his ideas,
which drift — now converging toward, now recedi't,
from, the pathogenic repressed material. During 11
procedure, more and more of the unconscious represse
material becomes conscious. The physicians role is
not active. His influence on this process of self IC ' C a
tion consists mainly in increasing the patients courage
and confidence to face his real self. Now sexual > na
ters, which had been shunned by physicians and p atiel |J
but which are nevertheless a significant part o 01
lives, began to become apparent as determining factor
in some psychologic disorders. Challenging the
critical attitude of his time, Freud described se ^
phenomena objectively. The first rejection with
his views were met was mainly due to the pub ica

of these discoveries. . ■ I it

The aim of psychoanalysis, as Freud convene ’
was not to tell people unpleasant truths about
selves but to cure patients by giving the Integra ^
powers of their rational and conscious persona i >
opportunity to deal with those psychologic forces n ^
were excluded from their conscious mind. Most in ’P^
tant was the discovery that repressions may g°
to early' childhood, when the infantile ego is ^ 00 ^

to deal with the onslaught of violent emotions.
certain conditions, when these repressions arc too cx
sive. the repressed impulses find a morbid ou

Volume 113
Number 16

EDITORIALS

1495

neurotic and psychotic symptoms : irrational fears and
ideas, depressions, delusions and the whole gamut of
psychopathologic phenomena. Psychoanalytic therapy
is based on the principle that the mature conscious ego
can deal with repressed emotions which the childish
ego cannot tolerate.

Most shocking to contemporary attitudes was the
discovery of what Freud called the “family tragedy.”
Naturally, the first emotional difficulties in which the
child becomes involved concern its parents. The typical
combination of love and hate which the small child
feels toward his parents Freud called the “Oedipus
complex.” More recently, the application of psycho-
analysis to children has become a source of important
information about early emotional and intellectual
development.

The emotional reactions to the freudian observations
and formulations made objective evaluation extremely
difficult. They permeated scientific discussions and
developed strange accusations. Freud was accused of
pansexualism, mysticism, dogmatism and unsound
speculation. Moreover, Freud was held responsible
for every vagary of his actual disciples and many a
pseudoscientist who claimed to speak in his name. He
was a pioneer working in an unknown territory — the
dynamics. of the mind; naturally his first generaliza-
tions were somewhat vague groping attempts. Never-
theless many of his observations have already passed
the test of scientific scrutiny. The facts of repression,
resistance, transference, infantile sexuality and its
typical manifestations in family life, the unsconscious
emotional origin of psychoneurotic and many psychotic
symptoms, the principal laws of psychodynamics as
observed in such mechanisms as rationalization, pro-
jection and overcompensation form the basis of both
normal and morbid psychology.

Sigmund Freud was 35 years old when he returned
from Paris to Vienna and laid the foundations of
psychoanalysis. Failing to be accepted and supported
by his colleagues in Vienna, including at last even
Breuer, he worked for ten years entirely alone. Gradu-
ally a few students began to gather around him. Among
these early followers were Karl Abraham, Sandor
Ferenczi, Max Eitingon, Karl Jung, Alfred Adler,
Wilhelm Steckel, Otto Rank, Hans Sachs, Ernest
Jones, and others whose names did not become so well
known. Some of these pupils were unwilling to follow
completely along the untrodden paths into which Freud
was leading them. Chief among these dissenters were
Jung, Adler and Rank. Yet already psychoanalysis
has become firmly established in psychology, in edu-
cation and in medicine. The technic of psychoanalytic
therapy has become standardized and is taught to psy-
chiatrists in psychoanalytic institutes. A number of
well trained psychoanalysts are united in scientific
societies. The effects of emotional factors on physio-
logic and pathologic processes are being studied by
adequate methods. Such generalities as worry, fear and

overwork as causes of physical disturbances are being
replaced by precise descriptions of the emotional fac-
tors. By this pathway Freud’s influence on general
medicine will be most felt in the future. But his influ-
ence on our times cannot be evaluated by restricting
attention to the medical implications of his teachings
alone. All the scientific fields which deal with man’s
relation to man and all the social sciences have received
a new impetus from his dynamic psychology.

DISTRICT COURT IN TEXAS RULES
STATE MAY REQUIRE CITIZEN-
SHIP IN LICENSURE OF
PHYSICIANS

Citizenship may lawfully be required by the state of
Texas of an applicant for a license to practice medicine,
as a condition precedent to the issue of a license, in
the opinion of the district court of Travis Count}',
Texas, in a case brought by a citizen of Mexico. 1 Such
a requirement was held not to deprive an alien of any
right guaranteed him by the federal constitution. As
far as available records show, this is the first time that
a court has been called on to pass directly on this ques-
tion. Under the provisions of the constitution a state
cannot deny to an alien the right to follow a “common ■
occupation” under the same conditions that it imposes
on citizens. The practice of medicine, the Texas court
observed, is not “a common occupation” but is a profes-
sion impressed in many instances with semiofficial
duties.

Physicians have duties in connection with many
important matters relating to the public welfare : duties
in connection with governmental birth, sickness and
death records; with the execution of certificates of
inability of witnesses, or even of the defendant, to
attend trial ; with matters relating to communicable dis-
eases and quarantine; with the execution of certificates
of freedom from disease, required by law in connection
with the issuance of marriage licenses, and with the
enforcement of state and federal narcotic laws, and
many other duties of similar nature. All these duties
are imposed on physicians by the government in the
furtherance of policies adopted by the state for the
welfare of the people as a whole. A physician who
is a citizen will be better able to cooperate with the
state in carrying out its policies than a physician of
foreign allegiance and training who is unfamiliar with
the ideals and institutions of our country.

In epidemics, the court pointed out, the closest
cooperation is required between the medical profession
and various governmental agencies. The virtual end of
epidemics of many diseases, such as cholera and small-
pox, has resulted from the close partnership that has
been maintained between the practicing physicians and

1. Manuel Garcia-Godoy v. State Board of Medical Examiners
(Texas) , in the District Court of Travis County, Texas, 53d Judicial
District, No. 61938.

1496

EDITORIALS

Jovk. A. M. A.
On. H, 1939"

administrative agencies of the state and federal govern-
ments. For the preservation of gains that have been
made and in the furtherance of similar objectives, the
court thought that the legislature had a perfect right
to declare it to be of utmost importance that the
practice of medicine be limited to citizens. Again, in
time of war the services of physicians constitute a neces-
sary and most important link in our fighting forces;
the court thought that physicians who have not signified
a belief in the fundamental ideals of this country would
be in a position to exert a subversive influence tending
to undermine and destroy those ideals and to thwart
the attainment of the objectives for which we might

be fighting. For these and other reasons the court felt
that it was within the police power of the state to deny
to aliens the right to practice medicine to the end that
public health, safety and morals might be furthered and
preserved.

The court, incidentally, expressed great difficulty in
understanding why Texas had ever permitted examina-
tions for medical licensure to be conducted in any
language other than English, believing a thorough
knowledge of our language to be of prime importance
to a physician if he is fully to understand the informa-
tion imparted by a patient and if he is adequately to give
instructions to that patient.

CITIZENSHIP AS A CONDITION PRE-
CEDENT TO MEDICAL LICENSURE
IN THE UNITED STATES 1

Numerous alien physicians, and particularly physi-
cians from Germany and the nations it has taken over,
have been coming into the United States during recent
years for permanent residence. In some states difficult

Germany and Austria. 2 During the following fiscal
year, which ended June 30 last, immigrant physicians
numbered 1,38 4, of whom 819 came from Germany,
which during that year included the area formerly
known as Austria. During the fiscal year 1931, immi-
grant physicians numbered 329, while during the fiscal
year 1939, just ended, they numbered 1,384.

Statutes and Regulations Governing License to Practice

Citizenship Required

First Papers Required

Neither Citizenship nor
First Papers Require^

By Statute

By Regulation
of Medical
Examining Board

By Statute

By Regulation
of Medical
Examining Board

Arkansas'

Delaware 1

Florida

Georgia 2

Idaho

Louisiana 3

Nebraska

New Hampshire 4

New Jersey

South Dakota

Texas

Wyoming

1

Alabama 1

Iowa 5

Kansas

Kentucky

Michigan

Minnesota 0

Missouri

Montana

Nevada

North Carolina
Oklahoma

South Carolina
Tennessee

Washington

West Virginia

Connecticut

Illinois 7

Massachusetts s

New Mexico

New York 0
Pennsylvania

Rhode Island ln
Wisconsin 51

Colorado 12

Maine

Maryland 12
Mississippi

North Dakota

Ohio

Oregon

Utah

Virginia

Arizona^

California .

District of Columbia
Indiana

Vermont

1. In Alabama and Delaware, citizenship is required of graduates of
foreign medical schools.

2 In Georgia, persons who had resided in the state for at least three
months prior to March 23, 3939, who were graduates of a medical school
approved by the Association of American Medical Colleges or the State
Board of Medical Examiners of Georgia, who had practiced in a foreign
state or country for at least twenty years and who had filed first
citizenship papers may be issued temporary permits valid for six years.
If at the end of that period full citizenship is not obtained, no further
license may be issued. . , . , 4 ,

3. In Louisiana, temporary permits may be issued to applicants who
have taken out first naturalization papers. By board ruling, licentiate
must obtain full citizenship within the time limit prescribed by the
federal law on penalty of withdrawal of temporary permit.

4. In New Hampshire, citizenship is required of all applicants except

citizens of “a Canadian province in which like privilege is granted to
citizens of the United States/' e ...

5. In Iowa, citizenship is required of graduates of foreign medical
schools, except Canadian schools.

6. In Minnesota, citizenship is required of all appli canls

citizens of Canada. obtains

7. In Illinois, the law provides that an applicant sitau ; n (entio n »
first citizenship papers “or having made such declaration woniiflS
has filed a petition for naturalization within thirty a ays

eligible to do so." . within

8. In Massachusetts, licentiate must complete natural

five years or else the license is revoked, . . tc0 y C ais

9. In New York, licentiate must obtain full citizeusn p

or else his license is revoked. . . .. ... obtain fi»*

10. In Rhode Island, by board regulation, licentiate musi

citizenship within five years. . , , .. r j, 0 by

11. In Wisconsin, the law provides that an appl'C 3 " 1 v '‘2duate off

of his nationality is ineligible to citizenship, who June

reputable professional college in the Umt?d ^ ates f a license,
1933, and who possesses all other qualifications to secu . Ilceiucn-
at least one of whose parents is a native of tsconsin, ‘ required

12. In Colorado and Maryland, first citizenship P a P er5 *
of graduates of foreign medical schools.

situations have been created. During the eight federal
fiscal years immediately preceding June 30, 1938, 3,165
immigrant physicians arrived, of whom 1,221 came from

3. The data in the table and accompanying it, so far as they relate
to statutory requirements, have been compiled by the Bureau of Legal
Medicine and Legislation from the statutes of the several states. The
data relating to regulations promulgated b>; state boards of medical
examiners have been compiled from information supplied the Council on
Medical Education and Hospitals of the American Medical Association
by the boards of medical examiners of the several states.

How and where these 4,549 alien physicians are
located, what they are doing and what their prospc ^
are of establishing themselves in the practice o * ^
profession, if they have not already done so, is
known. Those who have not yet become Unit edj^

2. Immigration of Alien Immigrant Physicians, J. A. M. A. 1
(Feb. 25) 1939.

Volume 113
Number 16

MEDICAL NEWS

14 97

citizens or even taken out first papers are confronted
by statutes and regulations which, except in four states
and the District of Columbia, will bar them from
licenses to practice. The various statutes and regula-
tions in force governing the matter are herein briefly
summarized.

Current Comment

PITUITARY EXTRACT AND LABOR
Although the use of pituitary extract after delivery
and in some instances during the final stage of labor
has become almost a routine procedure, the questions
relating to its indications or possible harmfulness have
not yet been settled. Recent reports serve to reopen
this important problem. Williams 1 studied fifty normal
primiparas given solution of posterior pituitary imme-
diately after the birth of the child and fifty controls
treated in exactly the same manner except for the
pituitary. Curiously the incidence of postpartum hemor-
rhage was more than doubled in the pituitary extract
series, although the number of patients was too small
to warrant definite conclusions on the etiologic role of
the drug. There was an average reduction of about
five minutes in duration of the third stage of labor for
the pituitary group. One contraction ring was encoun-
tered, but whether this was due to uterine manipulations
or pituitary extract could not be stated. Percival 2
observed the effects of the intramuscular injection of
5 units of solution of posterior pituitary immediately
after the birth of the child in sixty-nine cases of labor.
During the same period seventy-four control cases were
observed and recorded under similar conditions. He
also emphasized that the number of cases studied was
too small for the results to carry conviction. As far
as the investigation has gone, the intramuscular injec-
tion of 5 units of solution of posterior pituitary directly
after the birth of the child showed that the duration of
the third stage was not appreciably affected, the average
loss of blood was less, the incidence of postpartum
hemorrhage was less and also there was no tendency
for the chorion to be retained ; there was no tendency for
a contraction ring to form and there was no case of
pituitary shock. Clayton 3 found, however, that the
average duration of the third stage was slightly shorter
m cases in which pituitary was given, that the incidence
of postpartum hemorrhage of more than 20 ounces
(600 cc.) was not reduced and that there is danger of
hour glass spasm of the uterus with the ensuing risk
of manual removal of the placenta. The definitely
uncertain results of the administration of solution of
posterior pituitary as obtained by these observers indi-
cate the need for reviewing the entire question of its
routine administration. If pituitary extract can be
demonstrated to be without the desired effect and even
harmful, it should certainly be omitted as a routine
procedure in spite of its present wide acceptance and use.

1. Williams, B. L. : The Effects of Injection of Pituitary Extract
Immediately After Delivery, Proc. Roy. Soc. Med. 32 : 920 (June) 1939.

2 - Percival, R, C. : On The Effects of Pituitary Extract (Posterior
1939^ Stage of Labor, Proc. Roy. Soc. Med. 33: 923 (June)

3. Clayton, S. G.: The Effects of Injections of Pituitary Extract
Immediately After Delivery, Proc. Roy. Soc. Med. 32 : 926 (June) 1939.

Medical News

(Physicians will confer a favor by sending for

THIS DEPARTMENT ITEMS OF NEWS OF MORE OR LESS
GENERAL INTEREST: SUCH AS RELATE TO SOCIETY ACTIV-
ITIES, NEW HOSPITALS, EDUCATION AND PUBLIC HEALTH.)

ARKANSAS

Seventh Course on Postgraduate Study. — The commit-
tee on postgraduate study of the state medical society offered
its seventh course at the University of Arkansas School of
Medicine, Little Rock, October 10-11. The speakers included:

Dr. Barnett P. Briggs, Chronic Nontuberculous Infections of the
Respiratory Tract.

Dr. Robert Lee Hoffmann, Kansas City, Mo., After Urinary Anti-
septics: What About Kidney Infections?

Dr. Paul F. Stookey, Kansas City, Mo., Diagnosis and Treatment of
Meningitis.

Dr. Oliver C. Melson, The Role of the Internist in the Care of Patients
with Thyroid Disease.

Drs. George V. Lewis and Carl A. Rosenbaum, Surgical Treatment of
Hyperthyroidism.

Dr. William R. Brooksher, Fort Smith, Ark., Roentgen Irradiation in
the Treatment of Toxic Goiter.

Dr. Edgar V. Allen, Rochester, Minn., Occlusal Disease of the
Peripheral Arteries.

Dr. Robert L. Schaefer, Detroit, Clinical Indications of Anterior
Pituitary -like Sex Hormone.

Dr. Stuart P. Cromer, dean, The Medical School in a Program of
Graduate Medical Instruction.

Dr. Paul C. Williams, Dallas, Texas, A Classification of the Arthritides:
A Clinical Demonstration.

Dr. Joy K. Donaldson, Appendicitis: Errors in Management and
Educational Needs.

W. E. Hutchison, D.D.S., A Dentist Talks to Physician Friends.

Drs. Paul L. Mahoney and John S. Agar, Effects of Drugs in the
Nose.

CALIFORNIA

Lectures on Family Relations. — A series of lectures on
family relations is being offered at the University of California
in Wheeler Auditorium, Berkeley, Tuesday afternoons at 4
o’clock. The lectures are designed among other things, to
clarify personal and emotional factors associated with sex and
human relations, to survey objectively a demonstrable situation
regarding sex and society and to consider means of applying
this knowledge to individual and social welfare. Chauncey D.
Leake, Pli.D., professor of pharmacology at the university’s
medical school, will direct the series.

Lectures on Mental Hygiene. — The Mental Hygiene
Society of Northern California will present a series of lectures
on “Mental Health in Action” at the Mount Zion Auditorium,
San Francisco. The speakers will be :

Dr. Walter L. Treadway, U. S. Public Health Service, San Francisco,
October 18, The Poor, the Sick, the Bad.

Ernest R. Hilgard, Ph.D., Stanford University, October 25, Motives
in Industry.

Dr. Herbert E. Chamberlain, Sacramento, November 3, Mental Hygiene
in Daily Life.

Dr. Jacob Kasanin, San Francisco, November 8, Psychoanalysis and
Mental Health.

Norman Fenton, Ph.D., Stanford University, Calif., November 15,
Mental Hygiene and the Teacher.

DISTRICT OF COLUMBIA

University News. — Dr. George W. Thorn, Baltimore, lec-
tured before the naval medical and dental officers on duty in
the District and vicinity October 9 on “Supportive Treatment
of Infections.”

New Department of Psychology and Psychiatry. — The
Catholic University of America, Washington, recently created
a department of psychology and psychiatry under a grant from
the Rockefeller Foundation. The work of the department of
psychology, which had been in existence since the founding of
the university, has been extended to form the department
of psychology and psychiatry. Dr. Thomas V. Moore is head
of the department.

Society News.— The Urological Society of the District of
Columbia will be addressed by Drs. James T. Priestley, Roch-
ester, Minn., November 8, on “Surgical Procedures in Urol-
ogy-” A t a meeting of the Washington Heart Association

November 15 Dr. Tinsley R. Harrison, Nashville, Tenn., will
discuss recent advancements in the study of hypertension and
renal disease. Dr. Nolan D. C. Lewis, New York, addressed
the section on gastro-enterology of the Medical Society of the
District of Columbia October 2 on “The Nervous and Mental
Signs of Gastrointestinal Disorders.”

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Volume' 113
Number 16

MEDICAL NEWS

1499

pletcd, the T shaped building will have a capacity of seventy
beds with laboratories, equipment for visual training, recrea-
tion and assembly room. It will cost $136,000.

Society News. — At a meeting of the St. Louis Medical
Society September 26 the speakers were Drs. Louis L. Tureen
and John Albert Key on “Fractures of the Vertebrae During
Metrazol Therapy”; Paul O. Hageman, “Treatment of Strep-
tococcic Infections," and William B. ICountz, “Treatment of

Peripheral Vascular Diseases.” Drs. Alexis F. Hartmann

and Henry L. Barnett, St. Louis, discussed sulfanilamide before

the Jackson County Medical Society September 26. Dr.

Thomas G. Miller, Philadelphia, will address the Kansas City
Academy of Medicine October 20 on “Recent Advances in
Gastroenterology.”. At a meeting of the Kansas City South-

west Pediatrics Society September 19 the speakers were Drs.
Francis A. Carmichael Jr. and Edwin H. Schorer on “Diag-
nosis of Cerebral Conditions in Childhood” and “The Business

Side of Pediatrics” respectively. Dr. Thomas M. Paul, St.

Joseph, discussed “The Physiologic Basis for the Therapeutic
Effects of ‘Splenic Extract’ " before the Buchanan County
Medical Society, St. Joseph, October 4.

NEW JERSEY

-Society News. — Dr. William Goldring, New York, will
address the Academy of Medicine of Northern New Jersey,
Newark, October 19 on “Clinical Aspects of Hypertension and
Arterial Heart Disease.” Dr. John H. Garlock, New York,
will address the section on surgery October 24 on “Surgical
Treatment of Carcinoma of the Thoracic Esophagus.”

Changes in State Board of Health. — Drs. Frederick P.
Lee, Paterson, and Walter G. Alexander, Orange, have been
appointed members of the state board of health. Robert P.
Fischelis, Pliar.D., secretary of the state board of pharmacy,
has also been appointed a member of the board under a new
law increasing the membership to include a registered
pharmacist.

NEW YORK

Society News. — Capt. Rollin L. Bauchspies, M. C., U. S.
Army, assistant professor of military science and tactics, Syra-
cuse University School of Medicine, addressed the Onondaga
County Medical Society, Syracuse, October 3 on “Medical Ser-
vice of the U. S. Army in the Field." Drs. Joseph R.

Wiseman and David F. Gillette, among others, will address
the Syracuse Academy of Medicine October 17 on “Drug
Allergy with Specific Reference to Tryparsamide.” — — - Drs.
Gordon D. Hoople, Syracuse, and Marguerite P. McCarthy,
Solvay, addressed the Allergy Society of Syracuse October 11
on “Bronchoscopy in the Diagnosis and Treatment of Asthma”
and “Analysis of Results in Treated Hay Fever Patients at

the Allergy Clinic” respectively. Dr. Norman H. Jolliffe,

New York, addressed the Medical Society of the County of
Nassau, Garden City, September 26 on “Recent Advances in

Vitamin Therapy (Vitamin B Complex).” Dr. Philip L.

Forster, Albany, addressed the Medical Society of the County

of Albany September 27 on “Fat Embolism.” Dr. John H.

Ferguson, Syracuse, addressed the annual joint meeting of the
Syracuse Academy of Medicine with the Utica Academy of
Medicine at the Teugega Golf Club in Rome September 21
on “Crime Detection and the Doctor.”

New York City

First Harvey Lecture. — Dr. Arne W. K. Tiselius, Uppsala
University, Uppsala, Sweden, will deliver the first Harvey
Society Lecture of the current series at the New York Acad-
emy of Medicine October 19 on "Electrophoretic Analysis and
• the Constitution of Native Fluids.”

Medicine in Newspaper Forum Program. — One session
of the ninth annual Forum on Current Problems sponsored
by the New York Hcrald-Tribunc, which will be held at the
Waldorf-Astoria October 24-26, will be devoted to “Science
on the Side of Civilization.” Arthur H. Compton, Ph.D.,
professor of physics, University of Chicago, will give the key-
note address, and the other speakers will be Drs. Perrin H.
Long, Baltimore, on the development of sulfanilamide in treat-
ment of disease; Francis Carter Wood, New York, progress
in the treatment and control of cancer, and Allan Roy Dafoe,
Callander, Ont., physician to the Dionne quintuplets, “Better
Citizens Through Stronger Children.”

The Twelfth Graduate Fortnight. — The twelfth Graduate
Fortnight of the New York Academy of Medicine will be held
October 23 to November 3. The subject will be “The Endo-
crine Glands and Their Disorders.” There will be round table

conferences at the academy building each morning and clinics
at hospitals in the afternoons. Evening sessions will be held
at the academy with the following speakers:

Dr. Herbert M. Evans, Berkeley, Calif., Historical Sketch of the
Development of Endocrinology.

Dr. James B. Collip, Montreal, Can., Physiology of the Anterior Lobe
of the Pituitary Gland.

Dr. Leopold Lichtwitz, New York, Pituitary Hypothalamic Syndromes.

Dr. Leo M. Davidoff, Brooklyn, Hypopituitarism and Hyperpituitarism.

Dr. Elmer L. Sevringhaus, Madison, Wis., Therapeutic Application of
Female Sex Hormones.

Dr. David Marine, New York, Physiology and Principal Interrelations
of the Thyroid.

Dr. James H. Means, Boston, Hypothyroidism.

Dr. Harold Thomas Hyman, New York, Medical Aspects of Hyper-
thyroidism.

Dr. Frank H. Lahey, Boston, Surgical Treatment of Hyperthyroidism
and Other Diseases of the Thyroid Gland.

Dr. Walter B. Cannon, Boston, The Adrenal Medulla.

Dr. Robert F. Loeb, New York, Adrenal Insufficiency.

Dr. Cyril N. H. Long, New Haven, Conn., The Adrenal Cortex.

Dr. Bernard S. Oppenheimer, New York, The Cushing Syndrome:
Neoplasms of the Adrenal Gland.

Dr. Hugh H. Young, Baltimore, Overfunction of the Adrenal Cortex.

Dr. Rollin T. Woodyatt, Chicago, Relation of Diabetes to the Endo-
crine System.

Dr. John F. Fulton, New Haven, Conn., The Influence of the Central
Nervous System upon Endocrine Activity.

Dr. William G. MacCallum, Baltimore, Physiology and Pathology of
Parathyroids.

Dr. Henry L. Jaffe, New York, Hyperparathyroidism.

Philip E. Smith, Ph.D., New York, Physiology of the Ovaries.

Carl R. Moore, Ph.D., Physiology of Testes and Therapeutic Applica-
tion of Male Sex Hormones.

Dr. Robert T. Frank, New York, Puberty, Menstruation and Pregnancy.

Dr. Ephraim Shorr, New York, Menopause.

Several of the programs for the evening sessions were
arranged in cooperation with other medical societies and sec-
tions of the academy.

NORTH CAROLINA

Symposium on Diseases of the Lungs. — A three day
symposium on diseases of the lungs and thorax will be held
at Duke University School of Medicine and Duke Hospital,
Durham, October 19-21. The speakers will include:

Dr. Edward C. Churchill, Boston, Anatomical and Physiological Con-
siderations Involved in the Surgical Treatment of Intrathoractc
Lesions.

Dr. Frederick T. Lord, Boston, Clinical Aspects and Diagnosis of
Pulmonary Lesions.

Dr. Daniel M. Brumfiel, Saranac Lake, N. Y., Pneumoconiosis.

Dr. Chester A. Stewart, Minneapolis, Evolution of Tuberculosis in
Children.

Dr. Harry A. Bray, Ray Brook, N. Y., Clinical Diagnosis of Early
Pulmonary Tuberculosis.

Dr. Cameron Haight, Ami Arbor, Mich., Surgical Treatment of Pul-
monary Tuberculosis.

Dr. William DeW. Andrus, New York, Mediastinal and Other Thoracic
Tumors.

Dr. Isaac A. Bigger, Richmond, Va., Trauma to the Thorax.

Dr. Charles R. Austrian, Baltimore, Medical Treatment of Suppurative
Diseases of the Lungs.

Dr. Dickinson W. Richards Jr., New York, Pulmonary Fibrosis and
Emphysema: Recent Methods of Diagnosis and Treatment.

Dr. William F. Rienhoff Jr., Baltimore, Surgical Treatment of Lung
Abscess and Bronchiectasis.

Dr. Stuart W. Harrington, Rochester, Minn., Clinical Manifestations
and Surgical Treatment of Diaphragmatic Hernia.

Dr. Maxwell Finland, Boston, Treatment of Pneumonia.

Dr. Daniel C. Elkin, Atlanta, Ga., Postoperative Pulmonary Com-
plications.

Dr. Gabriel Tucker, Philadelphia, Bronchoscopy in the Diagnosis and
Treatment of Intrathoracic Disease.

OREGON

Society News. — Dr. Conrad A. Loehner, Salem, addressed
the Lane County Medical Society, Cottage Grove, September

17 on “Barbiturates and Hypnotics.” Dr. Peter H. Rozen-

dal, Klamath Falls, was elected president of the state associa-
tion of city and county health officers at the annual meeting
in Portland September 1-2. Drs. David R. Rich, La Grande,
and Walter H. MacDougall, Oswego, were elected vice presi-
dents and A. Edward Bostrom, Portland, reelected secretary.

Lectures by Dr. Goodpasture.— A series of lectures will
be given by Dr. Ernest W. Goodpasture, professor of pathol-
ogy, Vanderbilt University School of Medicine, Nashville,
Tenn., before the Portland Academy of Medicine October 23-25.
His subjects will be: “Investigations of Virus Infections and
Immunity by Means of Chick Embryo Technic”; “Experi-
mental Bacterial Infections of the Chick Embryo,” and “A
Consideration of Pathogenesis of Virus and Bacterial Infec-
tion, with' a Review of Some Virus Diseases.”

1500

GOVERNMENT SERVICES

Jobs. A. M. A.
Oct. 14, 1939

PENNSYLVANIA

Personal. — Dr. Tom Outland, Sayre, Pa., has been appointed
chief surgeon at the Elizabethtown State Hospital for Crippled
Children to succeed Dr. James R. Martin, who was appointed
James Edwards professor of orthopedic surgery at Jefferson
Medical College, Philadelphia (The Journal, August 26, p.

866).. -Dr. Theodore Wollak, superintendent of the Torrance

State Hospital, Torrance, since 1936, has resigned, it is reported.

Society News. — Dr. Carl J. Wiggers, Cleveland, addressed
the Washington County Medical Society, Washington, Septem-
ber 13 on “Physiology in the Practice of Medicine.” At

the first fall meeting of the Dauphin County Medical Society,
Harrisburg, September 5 the speakers are Drs. Ross H. Cliil-
derhose, on “Diagnostic Features and Modern Medical Treat-
ment of Tuberculosis”; William Devitt, Allenwood, “Surgical
Treatment of Tuberculosis,” and Clarence R. Phillips, “Proper
Relationship Between the Lay Organization and the Medical
Society.”

UTAH

Dr. Freudenberger Named Acting Dean. — Clay B. Freu-
denberger, Ph.D., professor of anatomy, University of Utah
School of Medicine, Salt Lake City, has been appointed acting
dean during the absence of Dr. Lyman L. Daines, dean, who
has been seriously ill since early in September. News at the
university includes the promotion of Dr. Edward I. Hashimoto
as assistant professor of anatomy, and the construction of an
addition to the medical school building which will increase the
facilities by 50 per cent, it is reported.

Hobby Show. — The Salt Lake County Medical Society
devoted its meeting September 11 to a hobby show. Under
the leadership of Dr. Fuller B. Bailey, the following, among
others, displayed their work : Drs. George A. Allen “Live
Birds” ; Quince B. Coray, “Painting and Charcoal Drawings” ;
Orlindo L. Ross, James Albert Peterson and Edward S.
Pomeroy, “Water Colors and Paintings,” and Thomas F.
Welsh and Ralph C. Pendleton, “Photography.”

State Medical Election. — Dr. Alfred C. Callister, Salt
Lake City, was chosen president-elect of the Utah State Medi-
cal Association at a meeting of the house of delegates at the
University of Utah, Salt Lake City, September 4. Other offi-
cers include: Drs. Warren O. Christenson, Wellsville, Edwin
M. Neher, Salt Lake City, Wilford J. Reichmann, St. George,
David E. Ostler, Richfield, vice presidents ; David G. Edmunds,
Salt Lake City, secretary; Richard P. Middleton, Salt Lake
City, treasurer. The next meeting of the state association will
be held in Ogden in 1940.

Control of Venereal Disease. — The state department of
health has established a bureau of venereal disease control to
cooperate with the U. S. Public Health Service in launching
a statewide program. Dr. Welby W. Bigelow, Salt Lake City,
has been named director of the bureau. Subsidized by federal
funds, the state board has adopted a revised system of report-
ing venereal diseases, and the distribution of free antisyphilitic
drugs for indigents and those in low income groups is being
made available to regularly licensed physicians. To facilitate
reporting as well as free antisyphilitic drug distribution to the
private physicians, a system has been set up whereby the physi-
cians will report cases to and receive drugs from their respec-
tive district health officers except in Davis and Salt Lake
counties. Physicians in these counties will apply respectively
to the Davis County health department at Farmington and to
the state board of health in Salt Lake City. District health
offices are located at Ogden, Cedar City, Price, Provo and
Richfield.

GENERAL

Reprints on Infantile Paralysis— A limited number of
bulletins entitled “Care During the Recovery Period in Para-
lytic Poliomyelitis” are available for distribution by the National
Foundation for Infantile Paralysis. No charge will be made.
The association is sending copies to members of the American
Academy of Orthopedics and the American Orthopedic Asso-
ciation, but interested physicians may have them on request.
The brochure is technically designated “Public Health Bulletin
No. 242, Revised 1939,” U. S. Public Health Service. Requests
should be directed to the foundation at 120 Broadway, New
York.

Leaflet for Patients Explains Gonorrhea. — The U. S.
Public Health Service has issued a leaflet entitled “Gonorrhea
the Crippler,” designed for physicians to distribute to their
patients. The division of venereal diseases prepared it in
response to a recommendation by an advisory . committee in
January 193S, urging the development of a campaign for educa-
tion of the public and issuance of printed materials. The text

explains the symptoms, points out the fallacies of several com-
mon beliefs and gives practical advice, with emphasis on care
by a physician. This folder is one of a “dollar-a-hundred" series
on venereal disease published by the service. It is available
from the Superintendent of Documents, Washington, D. C.,
at §1 a hundred copies.

Aero Medical Meeting. — The eleventh annual meeting of
the Aero Medical Association of the United States will be
held at Hollywood-by-the-Sea, Florida, November 3-5, with
headquarters at the Hollywood Beach Hotel. The speakers on
the scientific program include:

Pr- Charles L. Leedham, Randolph Field, Tex., The Syndrome of
Vasomotor Instability as Seen in Examination of Cadet Applicants
for Flying.

Ross A. . McFarland, Ph.D., Boston; Dr. Ashton Graybiel, Boston;
Dr. Eric Liljencrantz, San Francisco; Col. Arnold D. Tuttle, Chicago,
An Analysis of the Physiologic and Psychologic Characteristics of
Two Hundred Civil Air Line Pilots.

Lieut. Comdr. William W. Davies Jr., Pensacola, Fla., Some Observa-
tions on Cadet Selection.

One feature of the program will be a forum on airline medi-
cal problems.

Meeting of Health Officers. — The annual institute of
instruction on the practical administrative affairs of the health
officer will constitute the yearly session of the International
Society of Medical Health Officers in Pittsburgh October 16.
The session will be in cooperation with the health officers
section of the American Public Health Association. Among
the speakers will be:

Edward Henry Lewinski Corwin, Ph.D., The Problem of Cost Account-
inp in Public Health. t .,

Dr. Huntington Williams, Baltimore, Practical Staff Policies of a Healtli
Department.

Dr. John L. Rice, New York, Increasing Administrative Efficiency.

Henry F. Vaughan, Dr.P.H., Detroit, Organizing the Health Pepar •
ment for an Epidemic.

Dr. Thomas Parran, surgeon general, U. S. Public Health
Service, Washington, D. C., will speak.

New Society of Physical Therapy Physicians. — Dr.
Frank H. Ewerhardt, St. Louis, and Dr. William Bierman,
New York, were chosen president and president-elect respec-
tively of the Society of Physical Therapy Physicians at its
organization and first annual meeting during the annual ses-
sion of the American Congress of Physical Therapy m
York September 5-8. Other officers include Drs. Frank n.
Krusen, Rochester, Minn., and John S. Coulter, Chicago, v
president and secretary-treasurer respectively. Altnougn t
group met informally in 1938, the society was not omcia )
organized until the recent meeting. Its membership wm
restricted to physicians who devote themselves exd lusively
the practice of physical therapy in contradistinction to tli
of the American Congress of Physical Therapy, which inc
all ethical physicians and surgeons who are invested
physical therapy while engaged in general practice. I he n)
bership will be limited to 100 bona fide specialists who
devoted at least five years to this specialty and have or
holding teaching and directoral positions in physical therapy
America. Membership will be offered to qualified men
individual invitation, according to the Archives oj ‘ ») .
Therapy. The 1940 session will be held separately but
the annual session of the congress at Cleveland.

Government Services

Physicians Wanted for the CCC
Vacancies now exist in the CCC in the eighth cor P j v |[ an
ivherein the services of physicians can be utilized as
employees (physicians) or as contract _ physicians. Jsw .j
should be graduates of approved medical sepoojs ana ‘ arc3i
iddress their applications to the surgeon, eighth < c0 F (0
Fort Sam Houston, Texas. Consideration win be 8 , re
applicants as follows: (1) Medical reserve officers ,

eligible for active duty and promotion. They may 1 ^

an duty under classification P-2 at the initial ra * e , 0 r j].e
?2,600 per year. (2) Physicians who are not members
nedical reserve corps can be placed on duty as contr ? ,; r , n ts
rians at the initial rate of pay of §2,600 per year. APP
nust consider themselves physically qualified ; it sei 0(Vn
nust report to their first place of assignment at . . j a t

txpense and if found physically qualified will be aPP at
he respective rates. If on being relieved from duty, ,fj C

he request of the individual or for the convenient: ^

;overnment, the return transportation must also ne
xpense of the individual.

Volume 113
Number 16

FOREIGN LETTERS

1501

Foreign Letters

LONDON

(From Our Regular Correspondent)

Sept. 23, 1939.

The London Hospitals in Wartime
The London hospitals have been cleared as far as possible of
ordinary patients, mainly with the object of transferring them to
places safer from air raids and also to provide accommodations
for the large number of casualties expected from this cause.
But they still maintain 20 per cent of their accommodations for
cases of urgent illness or casualties apart from air raids. One
restriction is imposed: only cases from the district in which
the hospital is situated are admitted. In normal times the
reputation of the hospitals drew patients from far and wide,
even from overseas. Operations are now performed in rooms
specially equipped on the lower floors. A limited outpatient
service is maintained. The enormous medical machine which
was created almost overnight for the treatment of casualties
from air raids is kept “ticking over.” In certain directions
medical services are necessarily curtailed. The use of radium
is an example. Most of the national stock of radium has been
buried at the foot of a 50 foot hole specially drilled for use in
war time at one of the hospitals. The radium and its con-
tainers are in a steel cylinder, which before being lowered was
loaded at the well head by an operator who stood for protection
behind a thick block of lead. This valuable stock of radium is
thus protected against risk of accident not only with the object
of preserving it but as a safeguard against the damage which
might be caused if it should be scattered by an explosion. For
the present, high voltage roentgen therapy will be used instead
of radium treatment wherever possible. The resumption of
radium treatment in some parts of the country will soon be
considered.

The Use of Poison Gas and Bacteria in War
In the House of Lords, Viscount Halifax, Secretary of State
for Foreign Affairs, stated that the British ambassador in
Berlin, when asking for his passports from the German govern-
ment, presented a note inquiring whether the Geneva Gas
Protocol of 1925, which prohibits the use of poisonous gas and
bacteriologic methods, would be observed by the German govern-
ment. That government had now replied in the affirmative
through the Swiss minister in London as follows : “The German
government will observe for the duration of the war the pro-
hibitions which form the subject of the Geneva Protocol. It
reserves full liberty of action in the event of the provisions of
the protocol being infringed by the enemy.” But we are taking
no risks in this matter. Not only the fighting forces but every
civilian has a gas mask, and in London no one goes any dis-
tance without taking his mask. There are special ones for
young children and for babies, who could not wear an ordinary
mask, a protective helmet in which air is kept circulating by
a bellows. Instruction in the use of this helmet is given daily
to mothers at the centers for air raid precautions.

The Need for Pharmaceutic Reform
At the British pharmaceutic conference Mr. J. Rutherford
Hall referred in his presidential address to the misleading and
fraudulent advertisements of nostrums which the government
did not control in any way. There was need for some central
authority to recognize proper and reliable medicaments. A
combination of the British Pharmacopeia and the United States
Pharmacopeia might be the first stage in securing a Universal
Pharmacopeia. But this did not solve the whole difficulty in
settling what were proper and reliable medicaments. New drugs
and methods of treatment were being constantly introduced.

Some standing authority was therefore necessary, with power
to act and make recognitions and regulations as occasions arose.
He had in mind some such body as the Council on Pharmacy
and Chemistry of the American Medical Association, which
published an approved list of new and nonofficial remedies, the
purpose of which was to protect the medical profession and the
public against fraud, undesirable secrecy and objectionable adver-
tising in connection with proprietary medicines. Such a body,
to be effective, would need legal sanction.

The welter of names and the confused nomenclature of
medicaments called loudly for some simplification. The same
substance should not be put on the market under different
proprietary names. There should also be some limit to the
putting up of known substances under a proprietary name and
so overloading the pharmacy shelves. The public was protected
against poisoning by the Pharmacy and Poisons Act, which
confined the sale of poisons to duly qualified pharmacists. There
was a strong case for much wider control. It would be in the
interest of the community that the dispensing and distribution
of all medicaments should be similarly confined to pharmacists.
Though they might know little or nothing about pathology and
should not presume to diagnose or prescribe, they knew enough
to be able to warn a purchaser that the article he wanted was
contraindicated.

Red Cross Relief Fund

The British Red Cross Society has issued an appeal for
funds, stating that in this war it is certain there will be vast
suffering and distress and that the relief of the sick and wounded
of the fighting forces and of the civilian population will call
for much voluntary effort and financial support. Considerable
voluntary help has already been secured, but it remains to find
the money necessary to pursue the work. In the great war
and indeed at all times appeals made by the British Red Cross
Society have obtained a good response. Though the fund was
opened only a few days ago, §375,000 has already been sub-
scribed. Individual donations are as high as §5,000.

Royal College of Surgeons Takes Precautions
Against Air Raids

The more valuable contents of London’s museums, libraries
and art galleries which would be irreplacable if destroyed by
air raids have been removed to places of safety in basements
or to the country. The world-famous Hunterian collection of
surgical specimens at the Royal College of Surgeons has been
removed to a bomb-proof vault in the college basement. All
the more important manuscripts, books and pictures in the college
library have been sent to the country.

BERLIN

(From Our Regular Correspondent)

Aug. 24, 1939.

Meeting of Neurologists and Psychiatrists

The Society of German Neurologists and Psychiatrists met
this year in Wiesbaden. The president, Professor Riidin,
Munich, pointed out that psychiatry in its efforts for improving
racial hygiene performed a timely and progressive service. He
credited psychiatry with having been the first division of medi-
cine to point out to the state and the national socialist party
the dangers latent in psychopathic persons and to give impetus
to the well known legal measures taken. It is fallacious to
assume, he said, that psychiatry would become increasingly
superfluous, because psychopaths according to the laws governing
racial hygiene would soon die out. This assumption involves
the danger of deterioration for the psychiatric profession,
whereas psychiatry requires the most competent physicians,
because it deals with many dangerously ill with hereditary
psychoses. “The individual therapeutist may bungle and mar

1502

FOREIGN LETTERS

Jomt. A. M. A
Oct. 14, 1933

one or two human lives, but a poor psychiatrist, whole genera-
tions.” Riidin warned against undermining the reputation of
psychiatrists.

Scientific attention was given, especially, to the psychic dis-
orders attending advancing years. Max Burger, the Leipzig
clinician, treated the subject from the pathophysiologic point of
view. He pointed out, as the basis of his own investigations,
that processes characteristic of old age begin in youth and
represent a basic phenomenon of life. Ferdinand ICehrer, psy-
chiatrist in Munster, treated the subject from the clinical point
of view and presented a systematic account of mental diseases
in later life. A. von Braunmuhl, Eglfing, Bavaria, showed how
precipitations and swellings, modifications in the dispersion rate
of the colloidal brain substance and other changes of a colloid
chemical nature manifest themselves. G. Gischof-Kutzenberg
spoke on the hereditary relations of the psychoses of advancing
years. A special position must be accorded to involutional
depressions. Our knowledge, he said, of climacteric and pre-
senile psychoses is still fragmentary. Besides, it appears that
manic-depressive psychoses that make their first appearance in
advancing years require special classifications and do not fit in
the frame of hereditary manic-depressive insanity.

Seventieth Birthday of Prof. F. K. Kleine

One of the most deserving of German tropical scientists and
for many years collaborator of Robert Koch, Prof. Friedrich
Karl Kleine, has celebrated his seventieth birthday, far from
his native land, in San Carlos on Fernando Poo (Spanish
West Africa), where he is engaged in research work. When
an officer in the public health service he was ordered in 1900
to report to the Robert Koch Institute in Berlin, where he
soon became a co-worker of Robert Koch in his investigations
of the significance of tuberculosis of cattle for human beings.
In 1903-1904 he accompanied Koch to Rhodesia and Egypt on
the expedition to study coastal fever in cattle and in 1906-1907
to East Africa to study trypanosomiasis. In 1908-1913 Kleine
was in charge of the German campaign in East Africa for
combating trypanosomiasis and was extraordinarily successful
in his scientific activity. The best known result of this activity
was the discovery that the agent must pass in the tsetse fly
through an evolution similar to that of the malarial parasite in the
anopheles mosquito. During the World War Kleine was
ranking physician of the German forces in Cameroon. After
the war he became divisional director and subsequently presi-
dent of the Robert Koch Institute for Infectious Diseases in
Berlin until his retirement from public service in 1934 on
reaching the retirement age. Kleine enjoys an international
reputation.

Small Families of Physicians

According to a report that appeared in Volk und Rasse,
families of physicians are among the smallest of the German
population. In 1938 about 21 per cent of the 27,800 physicians
of Germany, exclusive of Austria and the Sudetenland, had
no children. Fifty per cent had only one or two children ; only
23 per cent had three or four children. Large families of five
or six children were found in only 4.5 per cent. Conditions in
Berlin, Munich and Leipzig were especially bad. Berlin with
32.2 per cent and Munich with 32 per cent showed the largest
percentages in marriages without children.

Diabetic Retinitis

Dr. Reinhold Braun has treated diabetic retinitis in a critical
examination of the 770 diabetic patients in Professor Umber’s
ward in the Hospital Westend in Berlin. One hundred and
fifteen of these patients had modifications of the retina. Insulin
produced no change. Older patients and those with serious
diabetes were more frequently affected than younger ones. Of
the factors contributing to metabolic disturbances in diabetes,
acidosis and the secretion of ketone bodies seem to be most

causative of diabetic retinitis. Perhaps changes in the vascular
system of the. retina play a part; hypertonia is not involved
Moreover, a certain effect on the evolution of diabetic retinitis
seems also to be attributable to the excretory functioning oi
the kidneys and to disturbances in the sympathetic nervous sys-
tem and in the balance between the hormones of Langerluns’
islands and the chromaffin system. Treatment of diabetic retinitis
is almost completely unavailing; however, insulin is in nowise
injurious to the retina.

Tuberculosis Among Sailors
The fight against tuberculosis occupies a prominent position
in the hygienic welfare work connected with social insurance.
The sailors’ vocation is not favorable to tuberculous men, but
quite the contrary, because of the strenuous work and the con-
stant exposure to cold. Recognizing this the sailors’ union
about a year ago undertook to examine crews in active sendee
for tuberculosis. About 18,000 examinations have been com-
pleted. Hereafter sailors will no longer be employed on German
ships without certificates of examination. No charges are made
to sailors for these tests.

Professor Riecke’s Seventieth Birthday
Prof. Erhard Riecke, dermatologist, completed his seventieth
year May 11. He had been full professor since 1920 in the
department of dermatology and venereology in Gottingen and
recently retired on reaching the retiring age. Riecke made a
reputation by the publication of a textbook on cutaneous and
venereal diseases, a book that enjoyed numerous editions and
is the most widely used German textbook in this field.

AUSTRALIA

(From Our Regular Correspondent)

Sept. 1, 1939.

Social Service in New Zealand
The social security scheme in New Zealand this year w®
cost £12,000,000, distributed over a population of only one
million people. Payments include £6,910,000 in old age bene G
£1,050,000 for invalids, £1,010,000 for widows, £508,000
sickness benefits, £306,000 for maternity benefits, £73S,00 0
hospitals, £100,000 for medical expenses and £459,000 for admin
istrative expenses. Of the total cost £5,550,000 will be obtain^
from wages, £3,050,000 from other income and £ 2 , 000,000 to .
the consolidated fund. The budget has been received ,° n
tility by the business sections of the community. The ecis ^
to increase the tax on gasoline by fourpence per gal 0,1 '
that on beer by sixpence per gallon is particularly un b°^ U . £
Prof. A. H. Locker, leading economist, has stated ta
budget appears to be mainly a stop gap and that the 8°'
ment is merely deferring the evil day when it will have to
its difficulties.

MATERNITY SERVICES CONTRACTS
After much dissension, the medical profession has ^
approved by ballot the acceptance of contracts for nia ^ f[1 (
services, under the social security scheme, and the S°' cr c(5
has' been asked by the profession to legislate to make con ^
binding on all practitioners who normally undertake ma c
work. The effect will be that all mothers who desire ^
assistance will have this right, although any who o no
to take the benefit may make independent arrangements. ^
decision, however, does not dispose of the larger question. ^
is still at issue between the British Medical Assoaa^o .
the government over the inauguration of the unnersa
titioner service. A powerful coercion on the pro cssl °" j n
however, come from the public. Several letters apP c ‘ - n g
the press have pointed out that the community is n0 '' - ceJ 0 f
the social security tax hut still has to pay for t ie sc
a doctor. The writers suggest that instead of paying 0

Volume 113
'Number 16

FOREIGN LETTERS

1503

services twice. over, as at present, doctors' bills should be ignored
in future. If this- idea- “catches on," the British Medical Asso-
ciation will be forced irrevocably to obey the voice of the people
as expressed in a democratic election.

Plumbism and Chronic Nephritis
As long ago as 1892, attention was drawn to the prevalence
of lead poisoning among children in Brisbane. It was not until
1929, however, that serious attention was paid to the possible
association of plumbism and chronic nephritis. Now the com-
monwealth department of health has issued a brochure on the
subject consisting of a report by Dr. R. Elliott Murray includ-
ing details of a method for the estimation of lead in biologic
materials. At the present time about ninety persons below the
age of 30 years and approximately the same number between
the ages of 30 and SO die annually from nephritis in Queens-
land, in excess of the number that would succumb to the disease
were the death rate the same as that of Great Britain. The
death rate below the age of 30 years is about the same as
it was from 1917 to 1926, but above that age it has been steadily
tending to increase. During the same period the annual total
death rate from chronic nephritis at all ages has increased from
an average of 403.5 to 558 per million of population. Murray
has shown beyond doubt that plumbism does occur in children
in Queensland. Investigating paint as a source of lead, he
found that paint which retained its glossy hard surface would
not yield any appreciable amount of lead on being rubbed with
saliva moistened fingers. On the' other hand, when the paint
became weathered the danger rapidly became serious. He
makes the observation that a weathered paint containing a low
percentage of lead may yield more lead on being rubbed than
a paint containing a higher proportion of lead but remaining
in a better condition and suggests that the 5 per cent limit to
the lead content of paint for veranda railings, gates and fences
as enacted in 1923 may still allow dangerous amounts of the
material to become available to children after weathering has
occurred.

Considering the question whether plumbism is a factor in the
causation of chronic nephritis in Queensland, Murray concludes
that- from a consideration of the past history of cases of nephritis
and the later progress of cases of plumbism, together with the
results of biochemical examination of nephritis cases, lead poison-
ing in childhood is a major factor in the causation of the abnor-
mal Queensland incidence of chronic nephritis. Although it
would appear possible that it is the sole factor responsible, it
cannot be stated dogmatically that such is the case. It would
appear probable that any other factor which can cause renal
damage could act in conjunction with lead to aggravate the
condition. The role of climate with its possible effects on acid-
base and mineral metabolism cannot be accurately assessed, but
while it may act as an adjuvant to other sources of renal damage
there is sufficient evidence to allot to it a major role.

A National Memorial to Sir Truby King

The Royal New Zealand Society for the Health of Women
and Children, more commonly known as the Plunket Society,
has launched an appeal for a national memorial to its founder,
the late Sir Truby King. Such an appeal has the whole-hearted
support of the medical profession in New Zealand. It has
been decided that £ 2,000 of the sum obtained shall be set aside
to assist in the upkeep and maintenance of the home of Sir
Truby King in Wellington, which he bequeathed to the society.
A further f2,500 will be invested for the purpose of providing
a postgraduate course for nurses trained in the Plunket system
of child welfare, while smaller sums will be expended on a
monument and a portrait of the founder of the Plunket Society.

It is too soon after the death of Sir Truby King to assess
finally and with any accuracy his contribution to medical
science. We can, however, pay homage to his personal attri-

butes, His untiring energy and selfless devotion to an ideal
were known all over the world. He possessed a genius for
organization of a high order, and to a remarkable degree he
wielded the power of infusing others with his own enthusiasm.
He was held in great honor by members of his profession,
and their response to the appeal. .made by the council of the
Plunket Society no doubt will be spontaneous.

Medical School for Queensland

The official opening of the new medical school of the Univer-
sity of Queensland on August 11 marks the final achievement
in the campaign for the provision of facilities for medical educa-
tion in this state. When in October 1936 the Faculty of
Medicine was inaugurated, that function marked the successful
issue of representations which had their commencement as early
as the foundation of the university itself. The first actual
proposals in 1913 were interrupted by the outbreak of the great
war and shortly after its conclusion in 1922 arrangements were
made for anatomic demonstrations to be given to certain of
the dental students at the university. By slow degrees from this
small beginning grew the skeleton structure of a medical course.
In 1936 it was suggested that the inauguration of the faculty
was of such importance that even makeshift provision, so far
as buildings were concerned, would be better than delay, but
the government after due consideration decided to provide build-
ings worthy of the new venture, and the recently completed
medical school is a magnificient tribute to their recognition of
its scope and importance. The building is a dignified example
of Renaissance architecture and has been designed to incorporate
all modern improvements in laboratory and lecture room design.

COPENHAGEN

(From a Special Correspondent)

Sept. 19, 1939.

The Hospital Habit

A generation or two ago it was the rule rather than the
exception for residents of Copenhagen to be sick at home. Now
most of them, when seriously ill, prefer hospital to home treat-
ment. Support of these remarks is to be found in a study
Dr. Povl Heiberg has undertaken with the object of showing
bow the hospital habits of his fellow countrymen have changed.
He has studied his material in five year instead of one year
periods to avoid the pitfalls inherent in small figures. In the
five year period 1881-1885 only 29 per cent of all the deaths in
Copenhagen occurred in hospitals, whereas the corresponding
figure for the five year period 1931-1935 was 67 per cent. At
the end of the last century only one in every three of the impu-
tation of Copenhagen died in a hospital, whereas now two in
every three do so.

This remarkable change has not been effected in an equal
degree by the various diseases responsible for the deaths on
record. Hospital treatment for such a disease as croupous
pneumonia, for example, is not so much more common now
than it was in the five year period 1886-1890, when 26 per cent
of all the cases were admitted to a hospital. The corresponding
figure for the five year period 1931-1935 was 37 per cent. On
the other hand, only 2S per cent of all the deaths from pul-
monary tuberculosis between 1896 and 1900 occurred in hos-
pitals, whereas between 1931 and 1935 as great a proportion as
75 per cent did so. Indeed, in the case of syphilis- and gonor-
rhea the tendency seems to be away from inpatient hospital
treatment in favor of outpatient hospital treatment. Formerly,
every fifth case of scabies was treated in hospitals, whereas now,
thanks in large part to the quick efficiency' of modern treatment,
it is found necessary to provide hospital treatment for only some
3 per cent of these cases. This is just as well, for there are
still some 5,000 to 6,000 cases of scabies notified in Copenhagen
every year in spite of the compulsory treatment provided for
this disease.

1504

MARRIAGES

Jots. A. M. A
Ocr. 14 , l!li

Denmark’s Dietetic Habits

Dr. Jolianne Christiansen, who seems to have become the
uneasy dietetic conscience of her country, continues to wage war
on her fellow countrymen’s sins of omission and commission
over the dinner table. Her special aversion is Dr. Hindhede,
who did so much a generation ago to promote vegetarianism in
Denmark. The duel between these two protagonists has been
carried on outside as well as inside Denmark, and in 1934
Dr. Christiansen issued in a German medical journal a pug-
nacious article with the ominous heading Mein Kampf gegen
Hindhede. This autumn she has issued in Danish a fairly com-
prehensive summary of the faith which is in her. The Danes,
she says, are laboring under the most embarrassing handicap of
utterly misguided doctrines concerning the very elements of
nutrition. They are fed on margarine, bacon, refined sugar and
sophisticated flour, whereas what they need in the place of these
mischief-making foods are milk, eggs, cheese, meat, fish, fruit,
vegetables and wholemeal bread. The Danes in the Middle
Ages lacked vitamin C and, before the introduction of potatoes,
were subject to scurvy. The Danes of today suffer from a
host of ills because natural and protective foods have largely
been replaced by artificial foods from factories. As a race,
Danes are far too plump, and it is no mere chance that in some
Danish hospitals about 10 per cent of all the diagnoses on
admission are obesity. It is temptingly easy for the medical
profession to cope with this situation by prescribing various
vitamin preparations with a view to repairing the mistakes of
the menu, but how much more rational it would be to revise
the menu and thus to make proprietary vitamin preparations
superfluous ! When a Dane falls ill, it has heretofore been the
practice in hospital dietaries to reduce rather than increase his
supply of vitamins, and he has been fed on pappy foods instead
of on plenty of milk arid on meat soups, which are an excellent
vehicle for vegetables. Dr. Christiansen would also like to sec
her countrymen producing home-brewed beer containing plenty
of vitamins B and C. The old Danish custom of mixing home-
brewed beer with milk might well, she says, be revived.

Vitamin K Deficiency in Infancy

A good example of effective team work in Copenhagen is to
be found in the hospital for children’s diseases under Professor
Bloch, the University Biochemical Institute under Professor
Ege, and the obstetric departments A and B of the Rigshospital
under Professor Hauch and Professor Rydberg respectively.
The coordinators of this work are Drs. Dam, Tage-Hansen and
Plum. Employing the technic elaborated by Dam and Glavind
for the quantitative demonstration of prothrombin in the blood,
they have succeeded in linking up in a clinical triad the follow-
ing conditions heretofore regarded as independent of one another :
icterus gravis neonatorum, anaemia neonatorum and hydrops
congenitus. The connecting link, demonstrable in each case, is
a well defined hypoprothrombinemia. Administration of vita-
min K to the patients suffering from these conditions was so
effective in rapidly raising the quantity of prothrombin in the
blood that it seemed likely that these patients must have been
suffering from vitamin K deficiency.

Last April a 26 day old boy was admitted to Professor Bloch’s
hospital suffering from jaundice, anemia and hemorrhages.
Vitamin K deficiency being suspected, the rate of coagulation
of the blood was investigated, the content of prothrombin in
the blood being measured. It proved to be much reduced, and
the child was therefore treated with vitamin K. Within a day
of this treatment the hemorrhages ceased. This striking obser-
vation led to quantitative analyses of prothrombin in the blood
of healthy children and others suffering from such conditions
as icterus gravis neonatorum, anaemia neonatorum and con-
genital hvdrops. The conclusion drawn from these studies is
that under normal conditions there is a shortage of vitamin K

during the first few days after birth. No depot of vitamin K
existing in the baby’s body at birth, and the supply of this
vitamin depending on the lhother's milk and bacterial activity
in the intestine, this temporary shortage of vitamin K is inevi-
table and is repaired only after the baby has begun to feed and
the normal bacterial activities of the contents of the intestines
have set in.

BUCHAREST

(From Our Regular Correspondent )

Aug. 18, 1939.

More Than a Thousand Centenarians in Rumania
The Central Statistical Institute, led by Prof. D. Sabin
Manuila, has published a bulky volume with the title "Breviarul
Statistic al Romaniei.” According to tin’s book the number c!
persons in the kingdom reached in this year the figure of
19,535,398. Of these about 80 per cent, that is 15,926,178, live in
villages and the number of the urban population is only 3,609^20.
The number of children under 9 years of age is 4,822,698 and of
persons from 70 to SO is 323,355, from 80 to 90 is 61,212 and
from 90 to 100 is 8,030. The number of persons over 100 years
of age is 1,074. Since the last census in 1930 the birth rate
has fallen from 35.2 per thousand to 31.5 per thousand. The
death rate, however, did not follow the rate of decrease of the
birth rate, decreasing only from 21.2 to 1 9.8.

Marriages

Henry Franz Albrecht Jr., Troy, N. V., to Mbs &&
erine Elizabeth McArdle of Lawrence, Mass., recently.

James D. Sort, Madisonvilie, Ky., to Mrs. Margaret Jo n
son of Boston at Lexington, Ky., September 16.

Watson Wharton, Smitbfield, N. C., to Miss Ed J 1 c
Hawkins of Johnson City, Tenn., August 17.

Charles McCaw Wood to Miss Florence Swan, boti o
Maroa, 111., at Rochester, Minn., August 15. .

Samuel A. Alessandra, Dallas, Texas, to Miss tlf
Evelyn Prince of Timpson, September 1.

Ivan Vincent Bambercer, York Haven, Pa., to Miss • >'
E. Painter of York, September 20. . g

Edward Kirby Lawson, Penbrook, Pa., to Miss Bessie
Stoner of Philadelphia, August A. .... .

Ernest E. Wiesner, Brockton, Mass., to Miss Doris
of Lynn, September 8. ((e

Alban Papineau, Plymouth, N. C., to Miss J ca
Edwards of Ayden, August 30. . 0 j

Edwin E. McNiel to Miss Marjorie Robertson,
Honolulu, Hawaii, July 16. .

Eluvood W. Godfrey, Ambler, Pa., to Miss Sophia
of Wynnewood, August 28. . -

William N. Gilman, Wenona, Iii., to Miss Dorns
Lee of Normal in August. . c f

Grant Sanger to Miss Margery Edtvina Campbe ,

New York, September 30. , • >.

Alfred A. Gellhorn, St. Louis, to Miss Olga re c
Nokomis, 111., August 4. . r s t

Joseph Marcovitch, Dwight, 111., to Miss Lillian
Brooklyn, September 6. , . c .i

Walter J. Phillips, Chicago, to Miss Helen e
Cicero, Iff., August 20. Kennedy

Joseph N. Rose, Evarts, Ky., to Miss Myrtle i ■
of Harlan, recently. , £(-.

Nathan R. Abrams to Miss Edna Silverstein, 0
cinnati, August 20. f

Hans Syz to Miss Emily Sherwood Burrow,

York, August 12.

Joel Wright to Miss Onie May, both of - P ,nc '
August 6.

Volume 113
Number 16

DEATHS

1505

j!

M

Deaths

Harvey Cushing ® most distinguished of all surgeons in
operative procedures on the brain, recognized as an accomplished
author, educator, philosopher and leader, died in New Haven,
Conn., Saturday, October 7, of coronary thrombosis. He was
the fourth Cushing in a direct line to win distinction in a
medical career.

Dr. Harvey Cushing was born in Cleveland, April 8, 1869,
the ninth child in his family. His well known brother, Edward
F. Cushing, M.D., a pediatrician, died in 1911 ; his father, Henry
K, Cushing, formerly professor of obstetrics and gynecology
in Western Reserve University School of Medicine, died in 1910 ;
his grandfather Erastus Cushing died in 1893, and his great
grandfather David Cushing Jr., of Massachusetts, died in 1840.

After receiving the bachelor of arts degree at Yale in 1891,
where incidentally he also played baseball, Dr. Harvey Cushing
graduated from Harvard Med-
ical School in 189S, receiving
the degrees of master of arts
and doctor of medicine. He
entered the Massachusetts
General Hospital as surgical
intern, working with Dr. J. C.

Warren. In 1S96 he went to
Baltimore as junior assistant
in the surgical service of Hal-
sted, becoming resident sur-
geon in 1897 and developing
as instructor in surgery, assis-
tant in surgery and associate
in surgery. He made the first
roentgenograms that were
made at Johns Hopkins Hos-
pital and did experimental
studies on gallstones, the bac-
teriology of the alimentary
canal, and cocaine anesthesia.

In 1900 he studied abroad,
traveling with Drs. William
Osier and Thomas McCrae. On
this trip Dr. Cushing studied
in England, France and for a
year in Kronecker’s laboratory
in Berne. Here he carried out
some_ investigations suggested
by Ivocher on the physiologic
relationships of intracranial
tension. This work he con-
tinued in the laboratory of
Mosso in Turin, Italy, and
then for four months he
worked with Sherrington in
Liverpool studying the motor
cortex in anthropoids. Late in
1901 he returned to Baltimore
and asked for the post of
neurosurgeon in the clinic.

Here he remained until 1912,
during which time he became associate professor of surgery.
He gave the Mutter lecture in Philadelphia in 1901. He became
a member of the American Neurological Association in 1903
and president in 1923, a charter member of the American Society
of Clinical Surgery in 1903 and president in 1921, a member of
*b c American Physiological Society in 1905, a fellow, of the
American . Surgical Association in 1906 and president in 1927.
Dr. Cushing was secretary of the Section on Surgery and
Anatomy of the American Medical Association in 1906-1907.
He gave the Carpenter lecture in New York in 1906 and the
W. M. Banks Memorial lecture in Liverpool in 1909 and the
Harvey lecture in New York in 1910. During this period he
developed his marvelous technic in neurosurgery. The earlier
operations were failures, but Dr. Cushing’s courage, precise
technic and remarkable spirit began to yield success and his
fame spread widely. During this period he developed and
described the subtemporal decompressive operation and perfected
hemostasis in operations on the brain and new technics for
suture. His contributions to the physiology of the brain, the
spinal fluid and the pituitary body were fundamental.

, in 1912 Dr. Cushing became Moseley Professor of Surgery
at Harvard and Surgeon-in-Chief to the Peter Bent Brigham
Hospital. He received the master of arts from Yale in 1913,
gave the oration of surgery at the International Congress of

Medicine in London in 1913 and was made a fellow of the Royal
College of Surgeons, of the American College of Surgeons of
which he became president in 1922 and of the Institute of
Hygiene in London. He gave the Weir Mitchell lecture in
Philadelphia in 1914 and was elected at that time a foreign
member of tbe Societe de neurologie in Paris, of the American
Academy of Arts and Sciences and of the Washington Society
of Arts and Sciences.

In 1914 came the great war, during which the remarkable
service rendered by Harvey Cushing was universally recognized.
He served with distinction in the British Expeditionary Force;
he became surgical director of the United States Base Hospital
No. 5 and was appointed senior consultant of neurologic surgery
with the American Expeditionary Forces with the rank of
colonel. For these services he received the Distinguished Ser-
vice Medal of the United States, the Companion of the Bath of
England, and Officer of the Legion of Honor of France. His
war service is reflected in his recently published “Diary of a
War Surgeon.” Evidently this service in the war was a terrific

physical stress, for Dr. Cush-
ing returned to Boston in 1919
suffering from peripheral neu-
ritis, which was to handicap
him during the remainder of
his career. Nevertheless in the
years from 1919 on he worked
indefatigably. He turned to
an interest in the history of
medicine and made a complete
collection of the writings of
Vesalius. At the same time
he developed a surgical team
for neurologic surgery and
himself studied intimately the
microscopic anatomy, gross
anatomy, pathology and physi-
ology of conditions within the
brain. Young surgeons flocked
to him from all over the world.
Today his pupils have won
distinction as neurosurgeons.
In 1918 he became fellow of
the Royal College of Surgeons
of Ireland. He received the
degree of doctor of science
from Washington University
in 1919 and in the same year
the honorary doctor of laws
from Western Reserve Uni-
versity, doctor of science from
Yale and Doctor of Science
of Queen’s University, Belfast.
In 1920 he received the degree
of honorary doctor of laws
from Cambridge and in 1921
was made honorary fellow of
the Medical Society of London,
giving the chief oration in
1927. In 1921 he became a
corresponding member of the
Medical Society of Vienna and
in 1922 a Charles Mickle Fellow of the University of Toronto,
also the Cavendish Lecturer (London) and was awarded the
title of Honorary Perpetual Student of St. Bartholomew’s
Hospital, London. He also became a corresponding member of
the Medico-Chirurgical Society of Edinburgh.

After the death of Sir William Osier, Lady Osier turned
over all her data relative to her distinguished husband to Harvey
Cushing and he took up the task of preparing the famous biog-
raphy. This book appeared in 1925 in two large volumes and
was awarded the Pulitzer Prize as the best biographic writing
of the year.

In the meantime he continued his surgical operations and
received additional honors. In 1923 he became a foreign member
of the Academie de medecine of Paris and a fellow of the
Association of Surgeons of Great Britain and Ireland. In 1924
he gave the Cameron Prize Lecture at Edinburgh and was
elected a corresponding member of the Societa medico-chirurgica
di Bologna. In 1926 he received the honorary doctor of laws
from the University of Glasgow, in 1928 the doctor of laws from
Jefferson Medical College and the Doctor of Medicine from John
Casimer University of Lwow, Poland. In the following year
he was made honorary fellow of the Royal Society of Medicine
of England, of the Royal Academy of Medicine of Ireland,
master of surgery of Trinity College, London, doctor of laws

1506

DEATHS

of the University of Edinburgh and a fellow of the Royal Col-
lege of Surgeons of Edinburgh. In 1929 there was published
in his honor a. special number of the Archives of Surgery, dedi-
cated to his sixtieth birthday. A similar festschrift was later
published by Acta rncdica Scandinavica. In 1932 Dr. Cushing
retired from his posts in Boston and became Sterling professor
in the School of Medicine of Yale University, teaching neurol-
ogy, and the history of medicine and holding this position until
1937, when he became emeritus professor.

In addition to the famous “Life of Sir William Osier,” Dr.
Cushing published “The Pituitary Body and Its Disorders” in
1912, “Tumors of the Nervous Acusticus” in 1917, with Dr.
Perciva! Bailey “A Classification of the Gliomata" in 1925,
collected essays under the title "Consecratio Medici" in 192S,
“Intracranial Tumors” in 1932, and in the same year a book
on “The Pituitary Body and the Hypothalamus.”

In July 1938 Oxford University conferred on him the honorary
degree of doctor of science, on which occasion great physicians
and surgeons from all over the world assembled to honor him.
It was pointed out that his former pupils hold positions in
Brussels, Louvain, Amsterdam, Manchester, Edinburgh, Leeds,
London, Oxford and Newcastle-on-Tyne as well as in most of
the leading clinics in the United States. There are honorary
Cushing clubs in many medical schools dedicated to his work
and his memory.

Since 1931 great universities have continued to honor him.
He gave other lectures, such as the Donald Balfour Lecture of
the University of Toronto. In 1933 he was honored in Paris,
at which time he was presented with the original copy of
Clemanceau's thesis for the doctorate in medicine, written in
1865. He received also the honorary degree of doctor of laws
from Northwestern University and the honorary degree of
doctor of medicine from Budapest.

Of recent years Dr. Cushing had shown special interest in
maintaining the traditional professional status of the physician
and surgeon and he had given freely of his time and of his
efforts in this endeavor. An essay called “Medicine at the
Crossroads,” published in The Journal, May 20, 1933, page
1567, defined his point of view. In this essay he wrote: “Those
who deal with the science of society deal with something that
actually does pulsate with so short a time cycle that conditions
almost from year to year are never quite the same, so that our
theories of today are likely to need modifying tomorrow. What
this puzzled world needs perhaps is more study of the past,
fewer commissions and surveys of the present, and a greater
number of philosophically minded, self-supporting and law-
abiding persons who can see all round their particular problem
and independently devote themselves to it as do most doctors.”

In the presence of such a record and such a career, in the
light of such a character and such a man, superlatives fail.
Great epochs in medicine are marked by the names of physicians
whose careers have made these epochs. With Dr. Harvey
Cushing, surgery of the brain became for the first time scientifi-
cally established. Of him it may be truly said that he was in
all that he attempted greatest of the great.

Andrew Stewart Lobingier, Los Angeles; University of
Michigan Department of Medicine and Surgery, Ann Arbor,
1S89; member and past president of the Pacific Coast Surgical
Association; fellow of the American College of Surgeons;
formerly on the staffs of the Hospital of the Good Samaritan
and the Hollywood Clara Barton Memorial Hospital; at one
time lecturer in surgery at the University of Southern Cali-
fornia School of Medicine; professor of bacteriology and
pathology, Gross Aledical College, Denver, 1889-1892; pro-
fessor of pathology. University of Colorado School of Medicine,
Denver, 1892-1894, and professor of surgery, 1894-1902;
formerly secretary of the Colorado State Medical Society ; aged
76; died, July 31, of arteriosclerosis.

Herbert Peter Howell Galloway, Winnipeg, Man.,
Canada : Victoria University Medical Department, Coburg,
Ont., Canada, 1887; formerly associate professor of clinical
surgery (orthopedic), University of Manitoba Faculty of Medi-
cine; served during the World War; served as president of
the Manitoba Medical Association and the Winnipeg Medical
Society; member of tlie Clinical Orthopedic Society and the
American Academv of Orthopedic Surgery ; past president and
vice president of the American Orthopedic Association , fellow
of the American College of Surgeons ; aged/3 ; was the ongma
orthopedic surgeon at the Children’s Hospital ; on the staff of
the Winnipeg General Hospital, where he died, July 13, of
cerebral hemorrhage.

rtenree Samuel Bel ® New Orleans; Tulane University
of LouWana School of Medicine, New Orleans, 1893; profes-
sor of medicine at the Louisiana State University Medical

Jom. A. II. A
Oct. 14, 193)

Center ; assistant in medicine, 1894-1900, instructor in medirine,
1900-1904, assistant professor of medicine, 1904-1910, professor
of clinical medicine, 1910-1918, professor and head of (be
department of. medicine, 1918-1924, and emeritus professor of
medicine at his alma mater'; president of the Louisiana Stale
Board of Medical Examiners; past president of die Louisiana
State. Medical Society; director of the Charity Hospital ; aged
67 ; died, August 10, of coronary thrombosis.

. Lena Kellogg Sadler ® Chicago; American Medical Mis-
sionary College, Chicago, 1906; fellow of the American Col-
lege. of Surgeons; past president of the Medical Women’s
National Association and the Chicago Council of Medical
Women ; attending gynecologist to the Columbus Hospital;
attending surgeon to the Women and Children’s Hospital;
author of “How to Feed the Baby” published in 1925, author
with Dr. W. S. Sadler “The Mother and Her Child” published
in 1916 and “Psychiatric Nursing” published in 1937, and other
books ; aged 64 ; died, August 8, of carcinoma of the breast.

Milton Arlanden Bridges ® New York; Columbia Uni-
versity College of Physicians and Surgeons, New York, 1919;
assistant professor of clinical medicine at the. New York Post-
Graduate Medical School, Columbia University ;. fellow of the
American College of Physicians; served in various capacities
on the staff of the Riker’s Island Hospital of the Department
of Correction ; consulting physician to the Sea View Hospital,
Staten Island ;• author of “Dietetics for the Clinician ana
“Food and Beverage Analyses”; aged 45; died, August 19, o
chorio-cpithclioma.

George Hudson McLellan ® Lieutenant Colonel, U. S.
Army, retired, San Diego, Calif.; University of Miclusaa
Department of Medicine and Surgery, Ann Arbor, 190 /; ua>
commissioned in the medical corps of the U. S. Army 3S , .
first lieutenant in 1909 and retired as a major m V'-' ,
disability in line of duty ; served during the. Vi orW >
was appointed lieutenant colonel under the special act ot }

21, 1930; aged 55; died, July 14, of coronary occlusion ana
cerebral hemorrhage.

William Louis Clapper, St. Louis; Washington Univer-
sity School of Medicine, St. Louis, 1904; formerly sc
instructor in obstetrics, gynecology and abdominal surgep,
Louis University School of Medicine; on the staff °‘ bt. l .
Hospital ; assistant gynecologist and obstetrician to /t- 1 - .
Group of Hospitals; member of the Missouri State A
Association; fellow of the American College of Sn g
aged 61 ; died, August 4, of Parkinson’s disease.

Leo Thomas Perrault, New York; Jefferson Medical Col-
lege of Philadelphia, 190S; associate professor of c Inn <
laryngology at the New York Post-Graduate Medica ^
Columbia University; member of the Medical . Socie 5

State of New York; on the staffs of St. Lukes

Hospital St

OI ot, i>uiw- o * • < , J.

Francis Hospital, Post-Graduate Hospital and 1, Mctropo ^
Hospital ; aged 55 ; died, August 25, in Mantoloking, • •>
coronary thrombosis. . - ,

Bernhard Friedlaender ® Detroit; Baltimore i ca \T 0 rth
lege, 1898; member of the Radiological Society
America ; formerly attending obstetrician and gy 11 ti:M,hnd
the Women's Hospital, and senior surgeon at t ie t ^

Park (Mich.) Hospital; aged 68; died, August 1 ’ rene ol
ester, Minn., of thrombosis of the mesenteric vein, g< b
the intestine and peritonitis. . . . ^

Clyde I. Allen © Detroit; Johns Hopkins University „
of Medicine, Baltimore, 1921; fellow of tlie.A.meric Tlioracic
of Surgeons ; member of the American Association jr 0 rd

Surgery; for many years on the staff of the , mt Jrrhage.
Hospital ; aged 45 ; died, August 2, of cerebral
arteriosclerosis and hypertension. _

Joseph Dixon Purvis ® Butler, Pa.; University ° pad
sylvania Department of Medicine, .Philadelphia, > j(3 jj
president of the Butler County Medical Society , . died,

of the Butler County Memorial Hospital ; ag e M '/ sub-
August 3, in St. Mary's Hospital, Rochester, Mi •>
arachnoid hemorrhage. . . of

Judson Albert Palmer, Arcadia, Wis.; Urn'ersn^.
Michigan Department of Medicine and Surgery,

1890; member of the State Medical Society ot prc ;i-

served during the World War ; formerly mayor, ,j s£35 c.

dent and health officer; aged 70; died, July 7, ot l> . s ; c ; jn 5
Carl O. Hertzman, Ashland, Wis. ; College of
and Surgeons, Baltimore, 1900; member of th e s . ;1;) gs
Society of Wisconsin; city health officer ; aged /*> . jq 0? p:tak
of St. Joseph’s Hospital and the Ashland Gene ■
where he died, July 25, of chronic nephritis and u

Volume 113
Number 16

CORRESPONDENCE

1507

Carroll J. Tucker, San Diego, _ Calif. ; Indiana Uni-
versity Scliool of Medicine, Indianapolis, 1914; served during
the World War; aged 52; died, July 18, in the Veterans Admin-
istration Facility, West Los Angeles, of carcinoma of the
prostate with multiple metastases.

Edwin Jason Brewer, Shabbona, 111.; College of Physi-
cians and Surgeons of Chicago, School of Medicine of the
University of Illinois, 1901 ; member of the Illinois State
Medical Society; for many years mayor; aged 64; died,
August 6.

Ira Ayer, Sati Diego, Calif. ; Long Island College Hospital,
Brooklyn, 1892; veteran of the Spanish-American War; at
one time personal physician to the King of Siam; aged 70;
died, July 9, in the United States Naval Hospital, of myo-
carditis.

Truman Osborne Boyd ® Long Beach, Calif. ; University
of Louisville (Ivy.) Medical Department, 1902 ; past president of
the Idaho State Medical Association; aged 69; on the staff of
St. Mary’s Hospital, where he died, July 8, of lymphosarcoma.

Edmund Francis Fusco ® Elizabeth, N. J. ; Columbia
University College of Physicians and Surgeons, New York,
1934; member of the Medical Society of the State of New
York; aged 29; died, July 23, at St. Elizabeth Hospital.

Thomas Francis Gartland ® White River Junction, Vt. ;
University of Vermont College of Medicine, Burlington, 1893 ;
aged 70; died, July 7, at the Mary Hitchcock Memorial Hos-
pital, Hanover, N. H., of coronary occlusion.

Philips Josiah Edson ® Pasadena, Calif.; University of
California Medical School. San Francisco, 1924; on the staffs
of St. Luke’s Hospital and the Huntington Memorial Hospital ;
aged 42; died, July 6, in San Marino.

Gustave Adolph Fritz, Baltimore; University of Maryland
School of Medicine, Baltimore, 1915; member of the Medical
and Chirurgical Faculty of Maryland; formerly coroner; aged
48; died, July 9, of heart disease.

John Walter Fitz-Gerald ® Buffalo; Trinity Medical
College, Toronto, Ont., Canada, 1900; aged 67; died, July 12,
at his summer home at Wasaga Beach, Out., of coronary
thrombosis.

Edgar August Degenhardt ® Chicago; Chicago Medical
School, 1921 ; served during the World War ; aged 43 ; died,
August 14, at his home in Oak Park, 111., of coronary thrombosis.

Oliver H. Thompson, Marion, La. ; University of Nash-
ville (Tenn.) Medical Department, 1884 ; formerly bank presi-
dent and member of the school board ; aged 82 ; died, July 28.

Charles W. Montgomery, Washington, D. C. ; National
Homeopathic Medical College, Washington, D. C., 1894; aged
71; died, July 11, of cerebral hemorrhage and arteriosclerosis.

Ephraim Gardner Kimball, Washington, D. C. ; Columbian
University Medical Department, Washington, D. C., 1888;
aged 81 ; died, July 17, of chronic nephritis and pyelitis.

Ira De La Matter, Long Branch, Out., Canada ; Queen’s
University Faculty of Medicine, Kingston, 1911; aged 56;
died, August 3, in the Toronto Western Hospital.

Laurence A. Saunders, Los Angeles ; Louisville (Ky.)
Medical College, 1876; aged 85; died, July 24, of pulmonary
tuberculosis.

Colston L. Dine, Minster, Ohio; Medical College of Ohio,
Cincinnati, 1886; aged 81; died, August 1, of cerebral arterio-
sclerosis.

William John Hunter Emery, Porterville, Calif.; Cleve-
land University of Medicine and Surgery, 1882; aged 78; died,
July 31.

Henry Applegate Lacy ® Philadelphia ; Hahnemann Medi-
cal College and Hospital of Philadelphia, 1891; aged 75; died,
July 30.

Loyal Low Liken, Smithmill, Pa.; Western Pennsylvania
Medical College, Pittsburgh, 1901; aged 69; died, July 2.

Robert H. McLean, Lillington, N. C. (licensed in North
Carolina in 1882) ; aged 86 ; died, July 14, of myocarditis.

c ^ a ' ter J- Proper, Pleasantville, Pa. ; Starling Medical
college, Columbus, Ohio, 1883; aged 79; died, July 20.

Robert Herman Dengler, Philadelphia ; Jefferson Medical
College of Philadelphia, 1887; aged 79; died, July 19.

CORRECTION

- Lr. Fisher Not Dead. — Dr. James Coleman Fisher of
Jefferson, Ohio, whose death was reported in The Journal
September 30, page 1346, is not dead. His death was errone-
ously reported by the Decatur (111.) Hcratd-Rcz'icw. August 6.

Corresp on den ce

POTASSIUM CHLORIDE IN ALLERGY

To the Editor : — In The Journal, September 2, appeared a
communication by Dr. David Louis Engelsher in criticism of
my report on potassium chloride in allergy. Since this might
give an erroneous impression, both of the toxicity and of the
efficacy of potassium chloride, I feel that some clarification is
needed.

Dr. Engelsher has made the simple mistake, against which I
warned in my article, of administering potassium chloride in
the dry form. He says “The patients were given ten 5 grain
(0.3 Gm.) tablets of potassium chloride to be taken, when
necessary, three times a day after meals with at least one glass-
ful of water.” (By this he probably means 5 grains to a dose
rather than 50.) In my article I stressed the necessity for
administering it in dilute form, e. g., 5 grains dissolved in a
glass of water. This does not mean prescribing a 5 grain
tablet to be taken with a glass of water. It is apparent that
the severe epigastric pain described by Dr. Engelsher is due,
as I have already noted, to his method of administration. Unfor-
tunately, many of the drug houses are now marketing potassium
chloride in tablet form without clear instructions that the tablet
is to be dissolved before being taken. When properly admin-
istered, potassium chloride only rarely produces side effects.
The most important of these is the occasional aggravation of
asthma, which calls for the immediate cessation of this treat-
ment; other rare effects include diarrhea and urinary urgency.
I have not advocated the use of potassium chloride in chronic
asthma.

Answers to letters sent to a number of leading physicians in
this country indicate a wide divergence of opinion with regard
to its efficacy in allergy. Many report gratifying results, par-
ticularly in hay fever and allergic rhinitis. On the other hand,
many have found it so far completely ineffective. My results
continue to be good, although I do have failures. The only
published report so far is that of A. F. Abt, who obtained
excellent results in twenty cases. I hope that an explanation
for this sharp discrepancy of opinion will be forthcoming. Potas-
sium is neither a “cure” nor. a “cure-all”; it is apparent, how-
ever, from my results as well as from the numerous reports
which I have received, that it has given appreciable relief to a
large number of allergic 'patients.

Benson Bloom, M.D., Tucson, Ariz.

THE DEGREE OF “DOCTOR” IN
DENTISTRY

To the Editor : — The need for safeguarding the title of
“doctor” in the interest of public protection and professional
dignity was clearly pointed out by Dr. Frederick Juchhoff in
his communication “The Degree of Doctor,” published in The
Journal August 26, page 876. I need add little to support
the main thesis. Although I fully approve the spirit of the
communication, I wish to recommend a modification of the
following statement by the author to give it a sense of greater
completeness : "The statutes should prohibit the use of the
title doctor in connection with any healing art by one who
does not have a regular medical training.” By addition of the
phrase “and dental training” following “medical training,”’ the
dental profession will be given the honor of distinction that
American dentistry rightly deserves. As an Associate Fellow,
I believe that I express the sentiment of other dental members
in the Association.

From observations made in my recent study on dentistry
and dental education (Principles Underlying the Social and
Professional Background in the Education of Dentists and
Teachers of Dentistry, thesis. New York University, School

150S

QUERIES AND MINOR NOTES

Join. A. II. A.
On. 14, 193)

of Education, June 7, 1939) it is noted that in 1940 all dental
schools in the United States will require a two year prepro-
fessional course and a four year professional course of train-
ing for the practice of dentistry and the degree of Doctor of
Dental Surgery (D.D.S. or D.M.D.). The years required for
the professional training of the dentist are the same in number
as those required of the physician. As indicated by Dr. Fish-
bein, the medical course in the United States covers four years
(Fishbein, Morris: Do You Want to Become a Doctor? New
York, Frederick A. Stokes Company, 1939, p. 37). The two
preclinical years of the four year professional course in den-
tistry include a considerable portion of subject matter that is
identical in content with the first two years of the medical
course. In addition to this, almost all dental schools are affil-
iated with universities. Since the publication of Professor
Gies’s Carnegie study in 1926 the proprietary dental school of
the past has disappeared in the United States.

It is true, as shown in my report, that a large percentage
of dentists and dental educators favor maintaining dentistry as
an autonomous profession, independent of medical education.
It is, however, unanimously conceded that dentistry is a spe-
cialty of medicine (not of medical practice) and an acknowl-
edged oral health service. Dentistry has attained a place of
scientific recognition to the extent that eleven dentists have
considered it worth while to pursue their graduate studies
leading to the Ph.D. degree in hygiene, chemistry and surgery.
It has been my pleasure to take the Ph.D. degree in education,
stressing in the thesis the professional and social significance of
dental education.

I suggest that in all considerations of the degree of "doctor,”
dentistry be given its due recognition and the consideration it
deserves. After all is said and done, dentistry is an integral
part of the medical profession. It therefore behooves those
who write in defense of the title “doctor” not to overlook the
honorable degree of doctor in dentistry.

Alfred J. Asgis, D.D.S. , Ph.D., New York.

VULVOVAGINITIS IN PREGNANCY

To the Editor: — “The Significance of Vulvovaginitis in
Pregnancy” by Edward G. Waters and Eakle W. Cartwright
(The Journal, July 1, p. 30) does not cover the entire sub-
ject; certain points deserve elaboration:

1. Many, if not most, researches of recent date have used
Sabouraud’s or modified Sabouraud’s medium directly for iso-
lation of the yeastlike fungi instead of the method employed
by these authors. Their technics might explain this low inci-
dence. Surely those interested in this work would appreciate
the authority for the technic advocated in this article. Yeast-
like fungi were isolated from 32 per cent of gravid women
without vulval symptoms by Plass and his co-workers (Am.
J. Obst. & Gynec. 21:320 [March] 1931), from 23 per cent of
all pregnant women by Weinstein and Wickerham (Vale J.
Biol. &■ Med. 10:553 [July] 1938) and from 14 to 41 per cent
in different economic and hygienic groups by Woodruff and
Hesseltine (Am. J. Obst. & Gyncc. 36:467 [Sept.] 1938).

2. The relationship of pn readings to the mycosis is not
clear, since these yeastlike organisms will grow in vitro oyer
pn ranges greater than any reported readings of the ragina
(Hesseltine, H. C., and Noonan, W. J.: J. Lab. & Clin. Med.
21:281 [Dec.] 1935).

3 The reports of Hesseltine, Borts and Plass (Am. J. Obst.
& Gynec. 27:112 [Jan.] 1934), Bland, Rakoff and Pincus
(Arch. Dermal. Sr Syph. 36:760 [Oct.] 1937) and Karnaky
all agree that certain strains of monilia are capable of pro-
ducing in certain patients the clinical entity vaginal moniliasis.
These workers fulfilled Koch’s postulate. xMoreover, there is
good evidence that some women may be carriers without hav-
ing the clinical state develop, while in others moniliasis may

develop when the environment is favorable. Thus, this organ-
ism is an opportunist. So, until equally good evidence relut-
ing these observations is forthcoming, these reports would seem
to stand.

4. It is assumed that the authors made these vaginal cul-
tures at or near term. Published reports of larger series o!
oral thrush and vaginal mycosis are in direct disagreement,
indicating that with larger series the experimental errors are
reduced appreciably. The authors offer no source for the
contaminations. It is acknowledged that not all oral thrush
is contracted from the mother’s genital tract, yet it is well
established that this is the most frequent source.

5. Why credit the lochial flow as a fungicidal agent when
biopsy studies demonstrate a marked and rapid depletion of
the glycogen-like material in the vaginal epithelium immediately
after delivery (a state unassociated with vaginal mycosis).
Early in studies by other workers it was stated that alkalinity
of the lochial flow influenced the course of the mycosis, hut
now enough available data and confirmatory reports offer, ii
not establish, a more correct answer, namely a deficiency oi
nutritive materials, ff . Close Hesseltine, M.D., Chicago.

Queries and Minor Notes

Tiie answers here PUBLISHED have been PREPARED .BY C0M?E j E* V
AUTHORITIES. THEY DO NOT, HOWEVER, REPRESENT Tilt OPINIONS 0
ANY OFFICIAL BODIES UNLESS SPECIFICALLY STATED IN THE •

Anonymous communications and queries on postal cards will b

BE NOTICED. EVERY LETTER MUST CONTAIN THE WRITERS NAME
ADDRESS, BUT THESE WILL BE OMITTED ON REQUEST.

APPEARANCE OF THROAT IN INFLUENZA

To the Ed/for: — My associate, who has been practicing thirty years.

daw

to be able to diagnose grip, or influenza, by means of a k—
throat sign, namely, the appearance of a sharply den ] a [f otl r' , s w jth
shaped area of redness confined to the anterior pillars of fne i ^
its convexity facing the lost lower molor tooth. I have con ^
literature and other physicians on this subject, together vn ^ a

my own observations, and am unable to confirm this sign, jfW |[ erJi

redness oppeors apparently in many normal throats, especia J fte
Also the physician claims to be able to prognosticate the He

disease by means of the gradual fading of this circumsen onM | of

states also that this sign will appear in contacts ^ /njecterf-

srares oiso mar mis sign win -- .

temperature elevation. The rest of the pharynx is allege y
Is there anything in the literature confirming or denying

M.D., New i° r *’

Answer. — T here is no convincing evidence to

substantiate the

idea that the sign described is pathognomonic ^ ,! n ^ U | ar gc
Most observers who have had an opportunity to s 7 r j e( j a
number of cases of influenza at a given time hav -jj ars .
diffuse redness of the pharynx, soft palate and f i vr tiphoid

In addition there is observed a distinct swelling oi t l,c

follicles resembling discrete glistening oewdrop n , mUcU ;
uvula and soft palate. There is frequently a ® a *i ?_ enl ent of
over the posterior pharyngeal wall. With an en J esc rip-

lymphoid follicles in this location as well. This gc po-

tion has been termed characteristic, but to say tn
lutely diagnostic would be exceeding the facts.

RIGOR MORTIS . h„v

o the Editor :— Kindly enlighten me regarding cadaveric r '?'.' 1 oCM rt?
soon docs it set in? How long does it endure before [S , whet

What variations may be expected in warm weal or v- irl

variations may be expected in newborn infants exposea uissoU".

weather? M.V., ^

Answer. — Ordinarily rigor mortis starts bettvccu 0 f

x hours after death and develops first in the m cx trcini-
le head, face and jaws. It then extends to the UPP an( j the
es, the trunk and the lower extremities in S f < ' U j.- sl p P ejranct
rocess becomes complete in about two hours, its orc and
:curs in from twenty-four to seventy-two h°ufS r egub r
le progress of the disappearance is usually in tne
:quence. . .-t; on s and ,!I

Rigor mortis is influenced by a number ot con c xcr-

:rsons dying of convulsions or after excessive i [ rc m

on the rigidity appears quickly, often witfun ers0 ni

ic time of death. Generally in powerfully mu

Volume 113
Number 16

QUERIES AND All NOR NOTES

1509

rigor develops slowly and is retained for a long time. In those
with poorly developed musculature, as infants and emaciated
persons, the rigidity appears rapidly and is lost rapidly. Heat
accelerates the onset and speeds its dissolution. Cold also
hastens the onset but tends to retard disappearance, so that the
stiffness may be retained for days or evtn weeks. In such cases
it may be necessary to distinguish rigor mortis from stiffness
attributable to freezing of the body or to mummification.

In a newborn infant, rigor would ordinarily develop quickly
and disappear rapidly. At times in these cases the rigor is
fleeting and may be overlooked.

From these considerations it is evident that the different stages
in the process can rarely be used as definite criteria in deter-
mining the time of death. However, if rigor is found only in
the head, face and jaw muscles and the body is still warm, it
is reasonable to estimate the postmortem interval as between
three and six hours. If rigor is found in the torso and arms
and not in the legs, death probably occurred less than twelve
hours prior to its onset.

If the legs are stiff but not the torso and arms, it is probable
that the person has been dead two or three days. In a body
found stiff and cold no definite opinion can be expressed as to
the postmortem interval. In any event, estimation of the time
interval must be made with caution.

SPAS AND MINERAL WATERS

To the Editor: — Within the past few weeks I have had inquiries from
patients as to the value of the spas of Europe and America. 1. Which
are the most important ones? 2. What types of diseases do they seem
to benefit? 3. Are the springs of America as beneficial as those of

Europe? 4. Are all supervised by competent physicians? 5. Do they

have dietary regimens, exercises, massages and the like in connection?
6. Where can I obtain information as to the exact chemical analysis of
these waters? 7. About how many people frequent these places and
what percentage derive some benefit? 8. Can these salts and waters be
imported for use in the home? 9. Where can I get a copy of "Spas

and Mineral Waters of Europe?” I do not know the names of the

authors or publishers, but it was printed in 1896.

M.D., Minnesota.

Answer. — 1. Important spas in the United States include Hot
Springs, Va. ; White Sulphur Springs, W. Va.; Hot Springs,
Ark. ; French Lick, Ind. ; Mount Clemens, Mich. ; Excelsior
Springs, Mo.; Saratoga Spa, Saratoga Springs, N. Y. ; Sharon
Springs, N. Y. ; Glen Springs, Watkins Glen, N. Y., and a
number of others.

In Europe the spas in France include Vichy, Vittel, Aix-les-
Bains, Royat and many others. In Germany, Baden-Baden,
Wiesbaden, Bad Nauheim, Bad Ems, Carlsbad, Marienbad and
Bad Gastein are prominent. In England, Bath, Buxton and
Harrogate are important. In each country there are other
places where spa therapy can be carried out to good advantage.

2. In general, the use of mineral waters and spa treatment is
of some value in chronic disabling conditions, including those
affecting the heart and circulation ; rheumatic disorders ; ail-
ments of the stomach, intestinal tract, gallbladder and liver;
nervous conditions; certain disorders of the skin, and some
metabolic diseases. It is obvious that not every patient with
any of these conditions is a proper subject for spa treatment.
The most promising patient is one who does not require bed
care, who may be treated as an ambulatory patient and who can
take advantage of the many-sided program which is available
in a well equipped spa ; in fact, the regimen may be more impor-
tant than the composition of the water.

3. Treatment with mineral waters has the same effect in the
United States as in Europe.

4. Competent medical advice is available at practically all
spas; the physician referring patients for treatment at a spa
should place his patient in the care of one of these physicians,
who will outline the program. In most places the spa physician
'* ln private practice. In a few places he is associated with
the spa organization.

5. Nearly all places have arrangements for dietary regulation,
exercise and massage, the details of which should be outlined
completely by the spa physician in charge of the patient’s
Program.

, ‘‘Mineral Waters of the United States and American Spas,”
by Dr. William Edward Fitch (Philadelphia and New York,
Lea & Febiger, 1927), gives the chemical analysis of many
mineral waters.

In Europe each country has a publication listing the spas of
hi c ? untr 7> B ,e nature of their waters and the provisions avail-
able for treatment. These may be obtained from their respective
ravel or publicity bureaus in the large cities such as New York.

7 There are no available statistics regarding the actual
lumber of people taking treatment in the spas of the United
ates. It is estimated that each year from 40,000 to 50,000

patients take regular treatment at Hot Springs, Ark., and from
12,000 to 15,000 at the Saratoga Spa. These estimates indicate
that many people take spa treatment in this country. It is
impossible to give the exact percentage of those deriving benefit.
Benefit from spa treatment occurs (1) in the specific medical
ailment and (2) in the general state of health of the patient.
One cannot neglect the psychotherapeutic value of a well organ-
ized program of treatment, which, with many patients, goes a
long way in building up the morale.

8. Some mineral waters are bottled for home use and can be
obtained through the distributing agency of the company han-
dling the waters. The salts of the Carlsbad waters have been
imported for years. It must be remembered that the extraction
of salts from a mineral water gives a residue which many times
cannot be completely dissolved when added to plain water. The
artificial duplication of natural mineral waters has not been
successful because they practically all contain, in small amounts,
a certain number of mineral constituents which are not included
in the artificial preparation.

9. There is no recent book in English which gives a general
survey of mineral waters and spas. The following references
deal particularly with certain phases of this important program :

1. Wallace, A. W.: The Modern Health Resort, The Journal, Aug.
8, 1936, p. 419.

2. Fantus, Bernard: Our Insufficiently Appreciated American Spas and
Health Resorts, The Journal, Jan. 1, 1938, p. 40.

3. McClellan, W. S. : The Place of Carbon Dioxide Baths in the
Treatment of Diseases of the Circulation, Internat , Clin. 1:199
(March) 1937.

4. McClellan, W. S. : The Saratoga Spa: Its Place in the Treatment
of Rheumatic Disorders, Arch. Pliys. Therapy 18:408-473 (Aug.)
1937.

5. Kovacs, Richard: American Spas, Hygcia 17:207 (March) 1939.

Mineral waters and spa therapy, important as they are, repre-
sent only one method of treatment available to ‘the physician,
and use of these facilities should be made in conjunction with
other methods of treatment such as drugs, dietary regulation
and physical measures. Details regarding the chemical and
physical properties of the mineral water, the type of accommo-
dations, the cost of treatments and the medical supervision may
be obtained by writing to the administration of any of the spas.
“Spas and Mineral Waters of Europe” by H. Weber and F. P.
Weber was published in London by Smith, Elder and Company
in 1896 and 1898. The book is out of print, and no record has
been found of the publishing house as being active today.

OPTI-MED AND OBESITY

To the Editor : — The enclosed abstract and order blank was sent me through
the mails from Germany, apparently introducing this new proprietary
product called "Opti-Med." Inquiry and a brief search fail to reveal the
character of the ingredients. Quite obviously, the reliance on some
preparation to hinder or retard intestinal absorption to lose weight would
seem hazardous. I should greatly appreciate information concerning the
preparation with special reference to the mode of action, dangers and
reason — if any — for the inclusion of the ingredients. ,

M.D., New York.

Answer. — Opti-Med has not been considered by the Council
on Pharmacy and Chemistry and is apparently another name
for the obesity treatment marketed by the firm of Dr. Rudolf
Reiss of Berlin, under the name “Adiposettes.” The American
distributor is H. H. Beisner, New York.

The advertising for Opti-Med tablets which has recently been
sent to American physicians directly from Dr. Rudolf Reiss
(Chemical Works), Berlin, includes no adequate statement of
the composition of the tablets. In lieu of a quantitative declara-
tion of the ingredients in simple terminology the German manu-
facturer offers the following statement, which is inadequate
because no quantities are given and because two of the ingre-
dients are described in terms which apparently are designed to
conceal rather than reveal their identity : “Opti-Med contains :
Extract, fuc. vesic., extract, frangulae, lecithin, tritetraboryl-
bis-propantriolester, bis-oxyphenylphthalide.”

In Martindale’s “Extra Pharmacopeia” (London, The Pharma-
ceutical Press, 1936) “Adiposettes” are described as follows :
“Ext. fuc. vesic. 5 . 9 %, Ext. frangul. 8%, lecithin 1%, tetra-
boryl-bis-propan-triolester 30%, triphenylcarbinol-o-carbonic acid
glycolate 10%.”

From the foregoing statements it appears that the anti-fat
tablets of Dr. Rudolf Reiss (Chemical Works) contain extract
of fucus vesiculosus (bladderwrack), extract of frangula (buck-
thorn bark), lecithin, a derivative of a boric acid glycerin ester,
and a substance which is either phenolphthalein or a closely
related product. This combination of purgative drugs together
with other agents not infrequently found in anti-fat nostrums is
offered to physicians as “a valuable preparation, free from any
undesirable by-effects,” one “which effectively reduces body
weight without harm to your patient.” It is also claimed that

1510

QUERIES AND MINOR NOTES

Jour. A. M. A.
Ocr. H, 1531

“Whilst a suitable diet (and no alcohol), is — as you know — of
help, European doctors have reported successful treatments of
many cases, without changing the mode of living of their
patients/’

Since the boric acid glycerin ester is stated to be the “specifi-
cally acting” constituent that increases the oxidation of fat and
decreases the assimilation of food in the intestine, it may be well
to recall the following excerpt from Dr. F. Zernik's article ,
“New Pharmaceuticals in Germany,” in the Manufacturing
Chemist of June 1935 :

Of late the medicinal products industry lias devoted increasing aiten*
tion to slimming preparations. After numerous official warnings or pro-
hibitions had been issued against the dangerous nature of dinitrophenol or
its derivatives, interest has been diverted towards boric acid-containing
preparations. Popularity was acquired in this connection by compounds
of boric acid with urea, as well as sodium compounds of boric acid. A
representative of this group is adiposettes (Dr. RudoH Reiss , Berlin),
dragees combining purgatives with seaweed extract and a boric acid
glyceryl ester. The German Office of Health has published a warning,
pointing out that boric acid and borax, whenever administered in quanti-
ties greater than a fraction of a gram, do not belong to those preparations
entirely free from undesirable action upon human beings and that, there-
fore, the consumption of boric acid-containing preparations for slimming
purposes without medical supervision may eventually be injurious to the
health. Recently the use of boric acid slimming preparations lias been
completely prohibited in Denmark, probably for the reason stated above.”

ATTACKS OF EPIGASTRIC PAIN WITH DEFECATION

To the Editor : — A white woman aged 53 complains of recurrent attacks of
epigastric pain of severe intensity. The onset of the attacks occurred
approximately two years ago, during which time they have been irregular
as to frequency, sometimes not occurring for a period of months and again
occurring two or three times in one week. The duration is from two to
five hours. The patient's first premonition of an ensuing attack is a feel-
ing of abdominal fulness with a desire to move the bowels. The attack
comes on with severe pain; there is no abdominal tenderness and no eleva-
tion of temperature; at times there does exist a slight vertigo on arising,
and often there is a chill after the pain subsides without any elevation of
temperature after the chill. After the attack has passed, the patient feels
no ill effects whatever except fatigue and is able to be up and about
without any abdominal discomfort or gastrointestinal disturbances. There
is no nausea during the attack or after. The bowels are moved two or
three times during an attack but afford no relief. Various types of medi-
cation have been attempted to relieve the attack without any results. How-
ever, whisky on one occasion produced sleep but since that time has been
unsuccessful. Morphine, both by mouth and hypodermically, has produced
no effect on the patient. The patient gives a history of having had gall-
bladder colic five years ago, fhe nature of these attacks being entirely
different from the present ones, and the diagnosis of attacks of gallstone
colic was questioned at that time. The patient has developed a fear of
future attacks and more or less anticipates them continuously, with a
resulting depression and melancholia. The attacks, except in two instances,
have occurred just before she retires and on two occasions have awakened
the patient from sleep. During on attack, physical manifestations such as
elevation of temperature and tenderness are essentially negative. Following
a series of attacks the patient guards her diet, not because of qualitative
food dyspepsia but because of a fear of another attack, and consequently
loses considerable weight. However, if the attacks do not come as she
anticipates she increases her diet with no ill effects and gains weight,
leaving her in a happy frame of mind. The patient normally suffers from
constipation but keeps the bowels open with a mild laxative, and there is
definitely no history of constipation preceding an attack. 1 would be
interested in having your opinion as to diagnosis and treatment.

M.D., Pennsylvania.

Answer. — At this woman’s age one would think first of
definite organic disease involving perhaps the small bowel.
The fact that these attacks have persisted for two years, during
which time the patient hasn’t come to any bad end, would tend
to rule out a neoplasm or any lesion obstructing the bowel.
The tendency to gain in weight is also encouraging. Lesions
of the small bowel usually force the patient to operation within
six months after the symptoms begin. The desire to move the
bowels with attacks suggests something irritating the bowel.
Apparently there are no symptoms of intestinal obstruction.
The shortness of the attacks and the lack of physical indications
suueest more a functional disturbance, such as is seen m rare
cases of abdominal migraine. Sometimes at the menopause a
typical migraine will change and produce attacks somewhat like
those described. The absence of nausea speaks against the
presence of migraine or of a lesion in the bowel. The fact that
morphine does not work is much in favor of a functional trouble
rather than an organic one.

Something like this picture can be seen m nervous persons
after emotional debauches. The commonest cause, of course,
of severe abdominal pain in a woman of this age would be
gallstones Gallstone attacks, however, should have responded
fo morphine. Naturally one would want to examine the gall-
bladder with x-ravs to see whether it is functioning and whether
it contains stones.' It would be helpful to see ^et *£**«•«
attack the serum bilirubin goes up. The fact that attacks hare
awakened the patient from sleep indicates organ, c disease.

A remote possibility is that the patient may be responding
allergically to some food ; allergy is not so likely to begin at
the age of 51. It might be well, however, to have the patient
keep a record to see whether attacks follow the eating oi any
particular food.

It would be helpful in a case such as this to watch a barium
sulfate meal as it passes down the small intestine to make sure
that there is no obstruction anywhere. One possibility is that
the. attacks are due to an internal hernia, but in this case tie
patient would probably have come to grief before now.

In cases such as this it is generally wise not to explore tie
abdomen tinless some definite indication is found for it. It is
presumed that the knee jerks are present and that the Wasser-
man reaction is negative. The attacks do not much suggest a
"crisis.” Another lesion that has to be ruled out is a small
duodenal ulcer with perforation posteriorly. In such cases one
can generally obtain a history of ulcer many years before.
One might think also of pancreatic stones and perhaps arterio-
sclerotic changes in the mesenteric blood vessels. . Such changes
are common but generally silent. One would think of a lesion
of the spinal cord, but this probably would have brought serious
trouble in the course of two years.

STAINED LIPS FROM SMOKING

To the Editor : — Could you tell me why nicotine stoin should - collect on my
lips while smoking? It is much heavier with cigarets then wth o PP
The staining is so heavy it produces a dork brown discoloration on
kerchiefs, which wash with great difficulty. I smoked about three p
of cigarcts for a period of five years when one day I notieen
lips a dark brown stoin which would rub off eosily. I tun 0 ,.
ond then filters, without on iota of help. I changed to, pipo |

ond fhe stain is greatly improved. Nevertheless, some 5,1,1 c0 ,
have absolutely no discomfort — never have cracked or chop?
Could you suggest any treatment? M.D., New York

Answer. — This experience seems unique. None of
smokers of cigarets, dentists or physicians consulted haw n®
staining of the lips by cigarets. Tobacco . of any kin
produce a brown juice when chewed. This is not due to "
tine, which is a colorless liquid turning brown only on agv
As the color rubs off easily one should not be too col ’ ce , f
Perhaps smearing the lips with petrolatum or a w ax P ,1
would be helpful. Paper handkerchiefs, easily obtamei ,
avoid the staining of linen.

SULFANILAMIDE FOR TYPHOID CARRIERS (([

To the Editor : — Kindly send references on fhe use of s “" 01 ' j. this
typhoid corriers. What is the present consensus os to rrs . B

connection? M.D., v| 9

Answer. — One reference has been found to the use °'" rr ,; c r
anilamide in the control of the typhoid or 10 , injs)

state. A. T. Bazin ( Canad . M. A. J. 38:559 b3C illi

reported that he had been able to eradicate paratyp j
from the bile of a carrier by' intensive therapy 5 ;„ c e

amide. It would seem from the literature however j j 0 ;
sulfanilamide has not been especially effective m i. ,c carr ier
clinical typhoid and paratyphoid infections, its use in fl jth
state would not be of great value unless one was ji ain idt

urinary tract carriers. For this type of carrier c0ncen tra-
might be of some value because one can obtain nig . ^ e .
tions of the drug in the urine of treated persons p
quate, quantities of the drug are prescribed.

DILUTIONS FOR TUBERCULIN T®™®

-0 the Editor:— Each fall my associates and 1 do h5 M nside«W

using two strengths of purified protein derivative, slron gcr dil'd ’

reduce the cost of this procedure if we bought only osrv ^ „
and made up the weaker dilutions ourselves. Will r
directions for making up the proper diluting tiuia. po.

Edgar S. Krug, M.D., State Com

Answer. — S ince the second dose is 250 times doff

if the first, the simplest way to achieve the ue g sCCO rd
rom a second strength tablet would.be to u Puffer so!"'
trength tablet in 250 cc. instead of 1 cc. o , , es . Since
ion. This would yield a solution containing 4 , w ;ihin

bis is probably greatly' in excess of what wou> . (a03 ntity
be keeping limits of the diluted solution, a king dilu-

.•ould be preferable. This can be prepared by ub W

ion in two stages: e. g.. dissolve one secon < cc with 3
i 1 cc. of buffer solution, withdraw exact . • jj e puffer

terile calibrated syringe and add it to 24.9 cc. 7 - cc _ \vi-
r salt, solution. Each 0.1 cc. of the resulting
jrnisli the required first dose.

Volume 113
Number 16

EXAMINATION AND LICENSURE

1511

Medical Examinations and Licensure

COMING EXAMINATIONS

STATE AND TERRITORIAL BOARDS

Alabama: Montgomery, June 18-20. Sec., Dr. J. N. Baker, 519
Dexter A'vc. p Montgomery.

Arizona: Basic Science. Tucson, Dec. 39. Sec., Dr. Robert L.
Nugent, University of Arizona, Tucson.

Arkansas: Basic Science. Little Rock, Oct. 23. Sec., Mr. Louis E.
Gcbauer/ 701 ‘Main St., Little Rock. Medical (Regular). Little Rock,
Nov. 9-10. Sec., -Dr. I), L. Owens, Harrison. Medical (Eclectic). Little
Rock, Nov. *9*10. See., Dr. Clarence H. Young, 1415 Main St., Little

California: Written examination. Sacramento, Oct. 16-19. Oral
examination (required when reciprocity application is based on a state
certificate or license issued ten or more years before filing application in
California). San Francisco, Nov. 15. See., Dr. Charles B. Pinkliam,
420 State Office Bldg., Sacramento.

Connecticut: Basic Science. New Haven, Oct. 14. Prerequisite to
license examination. Address State Board of Healing Arts, 1895 Yale
Station, New Haven. Medical (Regular). Examination. Hartford, Nov.
14-15. Endorsrmcnf. Hartford. Nov. 28. Sec., Dr. Thomas P. Murdock,
147 \V. Main St., Meriden. Medical (Homeopathic). Derby, Nov. 14-15.
Sec., Dr. Joseph H. Evans, 1488 Chapel St., New Haven.

Delaware: Examination. Dover, July 9-11. Reciprocity. Dover, July
16. Sec., Medical Council of Delaware, Dr. Joseph S. McDaniel, 229 S.
State St., Dover.

District of Columbia: Basic Science. Washington, Oct. 23-24.
Medical. Washington, Nov. 13-14. Sec., Commission on Licensure, Dr.
George C. Ruhlaml, 203. District BHg., Washington.

Florida: Jacksonville, Nov. 13-14. Sec., Dr. William M. Rowlett,
Box 786, Tampa.

Illinois: Chicago, Oct. 17-19. Acting Superintendent of Registration,
Department of Registration and Education, Mr. Lucien A. File, Spring-
field.:

Indiana;. . Indianapolis, June 38-20. Sec., Board of Medical Registra-
tion and Examination, D.r. J. ,W. Bowers, 303 State House, Indianapolis.

Kansas: Topeka, Dec. 12-13. Sec., Board of Medical Registration
and. Examination, Dr. J. F. Hassig, 905 N. 7th St., Kansas City.

Kentucky: •_ Louisville, Dec. 5-7. Sec., State Board of Health, Dr.
A. T-. McCormack, 620 S. Third St., Louisville.

Maine: Portland, Nov.- 14-15. Sec., Board of Registration of Medi-
cine, Dr. Adam P. Leighton, 192 State St., Portland.

Maryland: 'Regular. Baltimore, Dee. 12-15. Sec., Dr. John T.
O’Mara, 1215 Cathedral St., Baltimore. Homeopathic . Baltimore, Dec.
12-13. See., Dr. John A. Evans, 612 W. 40th St., Baltimore.

Massachusetts: Boston, Nov. 14-16. Sec., Board of Registration in
Medicine, Dr. Stephen Rushmore, 413-F Slate Hou^c, Bipston.

Minnesota: Minneapolis, Oct. 17-19. Sec., Dr. Julian F. Du Bois,
350 St. Peter St., St. Paul.

Mississippi: Reciprocity. Jackson, December. Asst. Sec., State

Board of Health, Dr. R. N. Whitfield, Jackson.

Missouri: Kansas City, Oct. 26-28. Sec., State Board of Health,
Dr, Harry F. Parker, State Capitol Bldg., Jefferson City.

Nebraska: . Lincoln, Nov. 24-25. Dir., Bureau oi. Examining Boards,
Mrs. , Clark Perkins, 1009 State Capitol Bldg., Lincoln.

Nevada: Written examination and reciprocity with oral examination.
Carson City, Nov. 6. Sec., Dr. John E. Worden, 3 1 1 W. Robinson St.,
Carson City,

New Jersey: Trenton, Oct. 17-18. Sec., Dr. Eqrl S. Hallinger, 28
W. State St., Trenton.

North Carolina: Reciprocity and Endorsement. - Raleigh, Dec. 11.
Sec., Dr. W. D. James, Hamlet.

North Dakota: Grand Forks, Jan. 2-5. Sec., Dr. G. M. Williamson,
4J4 S. Third St., Grand Forks.

Ohio: Columbus, Dec. 5-7. Sec., Dr. H. M. Platter, 21 W. Broad
St., Columbus.

Oklahoma: Basic Science. Oklahoma City, Nov.' 6. Sec. of State,
Hon. 'C. C. Childress, State Capitol, Oklahoma City. Medical. Okla-
homa. City, Dec. 13. Sec., Dr. James D. Osborn, Jr., Frederick.

Oregon: Basic Science. Portland, Oct. 28. Sec., State Board of
Higher Education, Mr. Charles D. Byrne, University of Oregon, Eugene.

Pennsylvania: Philadelphia, January. Dir., Bureau of Professional
V-^nsmg, Dr. James A. Newpher, Department of Public Instruction,
358 Education. Bldg., -Harrisburg.

South Carolina: Columbia, Nov. 14. Sec., Dr. A. Earle Boozer,
505 Saluda Ave., Columbia.

South Dakota: Pierre, Jan. 1 6-17. Dir.. Medical Licensure, Dr.
^ J- Van Heuvelen, State Board of Health, Pierre.

Texas: Austin, Nov. 20-22. Sec., Dr. T. J. Crowe, 918-19-20 Mercan-
">e BId K ., Dallas.

ermont: Burlington, Feb. 13-15. Sec., Board of Medical Registra-
tion Dr. W. Scott Nay, Underhill.

iircinia: Richmond, Dec. 13. Sec., Dr. J. W. Preston, 30Vi
t'^mdm Road, Roanoke.

West Virginm: Fairmont, Nov. 6-8. Sec., Public Health Council,
I* Arthur E. McCIue, State Capitol, Charleston.

Wisconsin: Basic Science. Milwaukee, Dec. 2. Sec., Professor
Robert N. Bauer, 3414 W. Wisconsin Ave., Milwaukee. Medical. Madi-
-on, Jan. 9-11. Sec., Dr. E. C. Murphy, 314 E. Grand Ave., Eau Claire.

Delaware July Report

frr. Joseph S. McDaniel, secretary, Medical Council of Dela-
ware, reports the written examination held at Dover, July 11-13,
1939. The examination covered ten subjects and included 100
questions. Seventy-five per cent in each subject was required
to pass. Thirteen candidates were examined, eleven of whom
passed and two failed. Three physicians were licensed by reci-
procity. The following schools were represented :

o , . Year Per

School passed Grad. Cent

jeorgetown University School of Medicine (1938) 85

Diversity of Maryland School of Medicine and Col-
®ge of Physicians and Surgeons (1937) 80

Hahnemann Medical College and Hospital of Phila-
delphia (1937) 77, (1938) 78

Jefferson Medical College of Philadelphia (1937) 78, 81, (1938) 80, 81

Temple University School of Medicine...... (1938) 79

University of Pennsylvania School of Medicine (1937) 82, 83

Year Per

School failed Grad. Cent

Hahnemann Med. College and Hospital of Philadelphia (1938) 75.2

University of Pennsylvania School of Medicine (1937) 75.2

„„ Year Reciprocity

School licensed by reciprocity Gl -a d . with

George Washington University School of Medicine. ... (1933) Maryland
University of Maryland School of Medicine and Col-
lege of Physicians and Surgeons (1924) Maryland

New York Homeopathic Medical College and Flower
Hospital (1916) New York

Arizona July Report

Dr. J. H. Patterson, secretary, Arizona State Board of Medi-
cal Examiners, reports the written examination held at Phoenix,
July 5-6, 1939. The examination covered ten subjects and
included 100 questions. An average of 75 per cent was required
to pass. Three candidates were examined, all of whom passed.
Five physicians were licensed by reciprocity and one physician
was licensed by endorsement. The following schools were
represented :

School tassed Grad. Cent

University of California Medical School (1937) 81.5

l.ouisiann State University Medical Center (1938) 84.3

Baylor University College of Medicine (1938) 83.7

g c } 100 | LICENSED BY RECIPROCITY

State University of Iowa College of Medicine

St. Louis University School of Medicine

Jefferson Medical College of - Philadelphia

Vanderbilt University School of Medicine

McGill University Faculty - of Medicine

School

LICENSED BY ENDORSEMENT

Duke University School of Medicine.

Year Reciprocity
Grad. with

(1936) Iowa

(1936) .Missouri
.(1932) Penna.

.(1927) Tennessee
.(1924) California

Year Endorsement
Grad. of

(1934)N. B. M. Ex.

Georgia June Examination

Mr. R. C. Coleman, joint-secretary, State Examining Boards,
reports the written examination held by the State Board of
Medical Examiners at Atlanta and Augusta, June 7-8, ,1939.
The examination covered ten subjects and included 100 questions.
An average of 80 per cent was required to pass. Seventy-eight
candidates were examined, all of whom passed. The following
schools were represented:

School rASSED Grad. '

College of Medical Evangelists (1939) 82.5

Emory University School of Medicine ,....(1938) 83.2.

(1939) 82, 83.5, 84.6, 84.6, 84.8. 84.8, 84.9, 84.9, 84.9,

85.1, 85.2, 85.2, 85.3, 85.8, 85.9. 85.9, S6, 86.2, '86.2,

S6.4, 86.5, 86.6, 87.4, 87.9. 88, 88.1, 88.1, 88.5,- 88.7,

88.8, 88.8, 89.5, 90. 90.4. 90.6, 90.7, 94.6

University of Georgia School of Medicine (1939)

81.1, 81.5, 81.8, 82, 83.1, 83.4, 83.8, 83.9, 84, 84.2,

84.7, 84.8, 85. 85. 85, 85.2, 85.2, 85.3, 85.3, 85.7, 86,

86.1, 86.1, 86.3, 86.5, 86.9, 87.7, 87.8, 91.2

Harvard Medical School (1935) 85,

Columbia University College of Physicians and Surgeons (1939)

Cornell University Medical College (1937)

New York Medical College and Flower Hospital (1937)

University of Oregon Medical School (1937)

Deutsche Universitat Medizinische Fakultat, Prag (1911)

Per

Cent

87.8

88 . 2 ,

80.9,

.85.3

90.3

84.3

88.4

85.4
84.2

Twenty physicians were licensed by reciprocity and two physi-
cians were licensed by endorsement from January 5 through
July 6. The following schools were represented :

SchoQl LICENSED BY RECIPROCITY

Northwestern University Medical School

University of Illinois College of '' ” ’

University of Louisville School of
Tulane University of Louisiana S

(1935) Alabama, (1935), (1937) Louisiana

University of Michigan Medical School

New York University College of Medicine

Jefferson Medical College of- P

Medical College of the State of
University of Tennessee Col ■*

(1936), (1937,2) Tennessee

Vanderbilt University School of Medicine

(1935), (1936) Tennessee

University of Wisconsin Medical School

School LICENSED BY ENDORSEMENT

Western Reserve University School of Medicine...
Vanderbilt University School of Medicine

Year Reciprocity
Grad. with
(1927) Missouri
“• California
Kentucky

(1936) Minnesota
(1935) New York
1 S. Carolina
S. Carolina

(1900) Utah,

.(1933) Wisconsin

Year Endorsement
Grad. of .
(1935)N. B.M. Ex.
(1934} N'. B. M. Ex.

1512

BOOK NOTICES ■

Jobs. A. M. A.
Oct. 14, 1939

Bool; Notices

The Structure anti Composition ot Foods. By Andrew Xi. Wlnton,
PhD., and Kate Barber Wlnton, Fh.D. Volume IV: Supar, Sirup,
Honey, Tea, Coffee, Cocoa, Spices, Extracts, Yeast, Baking Powder.
Cloth. Price, $9. Pp. 580, with 134 illustrations. New York: John
Wiley & Sons, Inc.; London: Chapman & Hall, Limited, 1939.

The present book completes this notable series of four volumes
on foods. It includes four parts, or sections, on sugar, syrup
and other saccharine products, on so-called alkaloidal products,
on spices and extracts and other flavoring materials, and on
leavening agents such as yeast and baking powders. There is
also a chapter of addenda to volumes ii and in of the series.
It is in the sections on food adjuncts particularly that the
value of the authors’ method of presentation is apparent. There
is presented not only the usual description of chemical com-
position but also a discussion of each subject from the botanic
point of view, illustrated by numerous excellent drawings of
cell structures. Many of the spices can be better identified by
determination of the morphologic characteristics of material
under examination than by chemical analysis. Although the
botanic method of description and classification has been empha-
sized, the chemical presentation lias not been neglected. The
book is suitably indexed. It is the kind of book one may turn
to with confidence to find information on inquiries such as
What is the composition of maple syrup from different parts of
the country ? What is caramel ? What enzymes have been
found in honey? What products have been found in coffee,
tea and cocoa? What is the nature of oil of peppermint?
What alkaloids have been found in pepper? What is the differ-
ence between paprika and pimiento? What are the constituents
of bakers' yeast? How are baking powders classified? This
volume is a fitting conclusion to the encyclopedic series. The
set comprises a veritable mine of information about the struc-
ture and composition of foods and food adjuncts, written by
experts who have had a lifetime of experience in the field.

Traits d'ophtalmologie. Fubll6 sous ies auspices de la Society frau-
gaise d’opIUaltnoIogle. Par JIM. P. Ballliart, Ch. Coutela, E. Redalob, B.
Velter. Bend Onfray: Secretaire general. Tome I: Histoire, cmbryoiogle,
anatomic. Par JUI. L. Cerise et nl. Clotli. Pp. 1,042, with illustra-
tions. Paris: Jtasson & Cie, i939.

This is the first of an eight volume treatise on ophthalmology
sponsered by the French Society of Ophthalmology with com-
pletion promised in less than a year. There are 103 collabora-
tors from France, Belgium and Switzerland. A general table
of the entire material to be covered is in the beginning of the
first volume and an alphabetical index of all the volumes is
promised for the end of the eighth volume. At the end of each
chapter is a moderate sized but comprehensive bibliography
embracing the modern literature in all languages. A rather
interesting and useful novelty is the printing on each page of
just where the bibliography pertaining to the subject matter
of that page is to be found.

The three fairly modern compilations of ophthalmology are
the Graefe-Saemisch Handbuch (which has taken forty years
for completion), the Kurzes Handbuch der Ophthalmologie and
the American Encyclopedia of Ophthalmology. The new French
traite does not follow the pattern set by any of these but
branches out boldly on a new path of its own. That path con-
forms to the advances of the recent decades, even though each
collaborator has been allowed full sway to handle his subject
matter as he has seen fit. If the clinical parts of the traite
maintain the standards set by the first volume, the ophthalmo-
logic world will have something new and valuable.

The first volume opens with an elaborate table of contents
preceded by the names, titles and locations of the collaborators.
Then comes a short and somewhat inadequate history of ophthal-
mology by Villard of Montpellier. The general development
of the visual apparatus was written by Leplat of Liege, is well
done, and has some original illustrations of embryos from the
collection of the University of Liege. This is followed by a
chapter on the embryology of the different parts of the ocular
apparatus by Dejean of Montpellier. Although not lengthy,
the material is well presented and well illustrated. A short
chapter on comparative embryology and phylogenesis of the

visual apparatus by the same author follows. Then comes a
long. and' detailed description of the anatomy and histology of
the_ orbit and the ocular adnexa by Winckler oi Strasbourg.
This is well illustrated with many photographs of original
dissections and diagrams of intra-orbital contents. This chapter
is particularly good, for it contains much material that Carnot
be found elsewhere. The anatomy and histology of the lacrimal
system and of the vascular system of the ocular apparatus was
written by Jayle of Marseilles. The crowning section of the
volume, however, is the chapter on the anatomy and histology
of the eyeball by Redslob of Strasbourg. Every ophthalmolo-
gist, no matter how experienced, can read that with profit.
Then follow the shorter chapters on the anatomy of the optic
pathways by Lhermitte of Paris, the anatomy of the oculomotor
nervous system by Van Gehuchten of Louvain, the anatomic
pathways for ocular sensibility by Cerise and Thurel of Paris,
the anatomy of the sympathetic and parasympathetic nervous
system of the ocular apparatus by Tournay of Paris and com-
parative anatomy and physiology by Rochon-Duvigneaud oi
Paris. The last two and somewhat longer chapters on heredity
and teratology are by Van Duyse of Ghent.

In a review of this character it is of course impossible even
to try to evaluate each individual chapter. Suffice it to say
that a high standard of excellence is maintained throughout the
volume, which occupies a somewhat unique place in ophthalmic
literature. The volume is printed on rather thin paper, accord-
ing to our standards, and the type is somewhat fainter and
smaller than we are accustomed to use. The illustrations are
uniformly excellent, the majority being in black and white.
However, the few colored illustrations give great promise for
the volume that will cover diseases of the fundus. In producing
this eight volume work the French Society of Ophthalmology
is making a distinct contribution to modern ophthalmology-
For all libraries and readers of French, this encyclopedia is a
necessity.

You're the Doctor. By Victor Heiser, JI.D. Clotli. Price, $2.50. PP-
390. New York: W. W. Norton & Company, Inc., 1939.

This is a rambling, somewhat discursive, book on health which
discusses many phases of the subject, few of them adequate y
and many of them superficially. Readers of An American
Doctor’s Odyssey will be disappointed. The book contains some
interesting anecdotes based on the author’s worldwide experi-
ence and travels but it lacks the vivid and interesting quan |CS
of his odyssey. . .

On page 84 his first paragraph oil vitamin C mentions ^
most concentrated source as paprika, but paprika cannot
used in significant amounts to make a real contribution o
vitamin C to the diet, as can oranges, lemons, grapefruit, tom
toes and raw cabbage; he mentions only tomatoes specific* )
and singles out no fruits or vegetables as exceptionally 5°
sources of vitamin C, except boiled potatoes.

On page 201, in a brief paragraph on hernia, he says P c
tive cure is usually simple and recently, under certain con i 10 •
some have been effected medically without aid of the s^S
by injecting irritating substances.” This is misleading, ^
safety of injection methods depends on the careful selec ion
cases and the technic of a well qualified surgeon.

On page 250 he credits the supervision of small priva e
pitals to municipal health departments and makes no men
of the American Medical Association Council on Medica
cation and Hospitals, the American College of Surgeons \ o
American Hospital Association; all these have con
infinitely more to improvement of hospital standar s
United States than has any health department, excep
as a few of the larger municipalities may operate t lei
hospitals. Even these have been known to be unaceep a
professional agencies adhering to'high standards.

On page 253 he says that outbreaks of measles mu nc. i
pressed quickly by injecting serum. Health officials .

have overlooked the availability of a quick means of su /’ j, 35

measles epidemics; the truth is, of course, that mortal! : y
been curtailed by the use of convalescent serum but n
there been available an adequate supply of this prepara ;j
never has any considerable epidemic been suppressed >

On page 261, after recounting how be procured the ^Tfor
tion of many agencies in a proposed new health prog

Volume 113
Number 16

BOOK NOTICES

1513

Halifax, lie says “Only after an hour and a half conference did
the Halifax Medical Association agree.” With reference to no
other agency docs the author use this implication of reluctance
when, as a matter of fact, an hour and a half seems hardly a
long conference if it results in the enlistment of cooperation for
an entirely new health program for an important seaport like
Halifax.

These statements arc chosen at random in support of the
reviewer's .opinion that the hook is poorly organized and
unbalanced. It is of course an assemblage of essays written
from time to time for a variety of publications.

A Cerebral Atlas Illustrating the Differences Between the Brains of
Mentally Defective and Normal Individuals with a Social, Mental, and
Neurological Record of 120 Defectives During Life. By Richard J. A.
Berry, M.D., F.R.S.E., F.R.C.S.E., Director of Medical Services to the
Incorporation or National Institutions for Persons Requiring Care and
Control, Stoke Tark Colony, Bristol. Cloth. Brice, $35. Bp. 425, with
441 illustrations. New York, Toronto & London: Oxford University
Tress, 193S.

The study conducted by Dr. Berry and his associates has
consisted of the correlation of clinical observations with physio-
logic and anatomic evidence. He has compared the brains of
idiots, imbeciles, moral defectives and feebleminded persons with
those of normal persons. He has compared them as to actual
size by the brain product method, lie has compared them as to
weights of the right cerebral hemisphere and he has compared
the planimeter cortical areas as determined on the flat by
dioptrographic tracings. He has also compared as to morpho-
logic changes grossly and microscopically the brains of feeble-
minded persons with those of normal persons.

In determining the actual size of the brain by the brain
product method, he multiplied the length by the breadth and
the height of the brain by dioptrographic tracings and for prac-
tical purposes used the same measurements on the head and
assumed that the proportion of brain size is about fi6 per cent;
that is, the brain is about two thirds the size of the head. In
estimating the weight of the brain, the right cerebral hemisphere
alone of both normal and defective persons is stripped, mounted
in formaldehyde-saline solution and weighed after the removal
of all superfluous fluid either inside or outside the brain. Sur-
face areas of the brains of normal and feebleminded persons
were calculated by dioptrographic tracings. Comparisons of
respective areas in normal and diseased brains were made to
bring out the morphologic differences.

Dr. Berry’s atlas is of inestimable value, since each series of
photographs is accompanied by a thorough history and neuro-
logic examination in the case prior to death of the patient, as
well as computations as to the actual size of the brain product
and the weight of the right cerebral hemisphere and cortical
areas. The photographs in every instance illustrate the gross
morphologic changes.

In summary the author states that, during its growth from
birth to adult, the average brain increases in weight by roughly
1,000 Gm. According to Donaldson, it does so by an increase
of its non-nervous constituents and by an enlargement of its
nerve elements :

These latter changes are dependent on the increase in the mass of the
cell body and cell outgrowth, especially the axons, and in the acquisition
of the medullary sheath. Calculation shows that the absolute mass of the
medullary substance is the chief source of increase in weight during this
period. The weight increase in the nerve element proper is due to the
enlargement of those cells which at birth are small, the addition of nerve
cells being excluded since their formation ceased at birth.

The author further states that if, therefore, a defective brain
is found to weigh less than a comparable normal brain — the two
having been weighed under strictly similar conditions — to be
appreciably smaller and to possess a corpus callosum (through
which all medullated neopallial commissural axons must pass)
smaller than normal, it is a reasonable inference that the brain
is deficient in its number of fully developed and properly func-
tioning cortical neurons and hence is incapable of achieving that
type of mental reaction which distinguishes man from the
animals. On the whole, the brains of idiots are 10 per cent
smaller than the brains of normal persons :

The chief differences between defective brains and a normal one of the
type described may be summarized briefly as follows. In a defective
brain there is:

1. A considerable reduction in size and weight.

**■ A tendency for the persistence in the convolutional pattern of certain
prenatal development features.

3. A greater variation than occurs normally in the gyri and sulci
bordering the central sulcus of Rolando — that is, in the important effector
and receptor areas.

4. A lack of full development in the opercula, particularly in the
frontal one, which frequently fails to cover the insula.

5. A diminution in the cortical amount of the triangular parietal area
— that is, of the area concerned with the association of incoming impulses
from the somesthetic, acoustic and visual areas.

6. On the medial surface the corpus callosum appears to be frequently
diminished in size, notably the genu and splenium.

7. The visual areas exhibit more variation in pattern and extent.

8. Lastly, the sulci generally appear to be shallower in the defective
brain than in the normal.

Hammarberg, in his classic studies of normal and idiot brains, long ago
pointed out that even comparatively small diminutions in the development
of the cortical cells were sufficient to reduce the intelligence to moderate
imbecility. Any of the variations just described as of frequent occur-
rence in the defective brain have a precisely similar effect.

The reviewing of this work has been exceedingly interesting
and instructive. The author has presented comparisons of defec-
tive brains with those of the normal brain as no other author
has done. The presentation of the clinical symptoms due to
morphologic changes in the brain elucidates the problem of the
mentally defective. The atlas not only is of value to the anato-
mist and physiologist but should be an excellent reference work
for every neurologist and psychiatrist.

Alcoholics Anonymous: The Story of How More Than One Hundred
Men Have Recovered from Alcoholism. Cloth. Price, $3.50. Pp. 400.
New York : Works Publishing Company, 1939.

The seriousness of the psychiatric and social problem repre-
sented by addiction to alcohol is generally underestimated by
those not intimately familiar with the tragedies in the families
of victims or the resistance addicts offer to any effective treat-
ment. Many psychiatrists regard addiction to alcohol as hav-
ing a more pessimistic prognosis than schizophrenia. For many
years the public was beguiled into believing that short courses
of enforced abstinence and catharsis in “institutes” and “rest
homes” would do the trick, and now that the failure of such
temporizing has become common knowledge, a considerable
number of other forms of quack treatment have sprung up.
The book under review is a curious combination of organizing
propaganda and religious exhortation. It is in no sense a
scientific hook, although it is introduced by a letter from a
physician who claims to know some of the anonymous con-
tributors who have been “cured” of addiction to alcohol and
have joined together in an organization which would save other
addicts by a kind of religious conversion. The book contains
instructions as to how to intrigue the alcoholic addict into the
acceptance of divine guidance in place of alcohol in terms
strongly reminiscent of Dale Carnegie and the adherents of the
Buchman (“Oxford”) movement. The one valid thing in the
book is the recognition of the seriousness of addiction to alcohol.
Other than this, the book has no scientific merit or interest.

Milk Supplies and Their Control In American Urban Communities of
Over 1,000 Population in 1936. By A. W. Fuchs, Senior Sanitary Engi-
neer. and L. C. Frank, Senior Sanitary Engineer. From the Division
of Public Health Methods, National Institute of Health. Prepared by
direction of the Surgeon General. U. S. Treasury Department, Public
Health Service. Public Health Bulletin No. 245.- Paper. Price, 10
cents. Pp. TO. Washington, D. C. : Supt. of Doc., Government Printing
Office, 1930.

This pamphlet provides the results of a study conducted by
the U. S. Public Health Service on the production and con-
sumption of fluid market milk, the volume and price of various
grades of milk sold, the legal requirements and the extent of
both pasteurization of milk and of the testing of milk cows
for tuberculosis or infectious abortion, state and local milk
control organization and personnel, and the inspection, sampling
and bacterial quality of local milk supplies. The information
which forms the basis of the report was secured by means of
the questionnaire method and by correspondence, and there was
made available information from more than 2,500 municipalities.
It was found that nearly 75 per cent of the market milk in the
municipalities studied was pasteurized and that 99.4 per cent
was from tuberculin tested herds. It is pointed out that since
1923 there have been phenomenal progress in abortion testing
in cattle, extensive progress in tuberculin testing and consider-
able progress in pasteurization. It is interesting to note from
this survey that the daily per capita consumption for the entire
country is estimated to be 0.06 pint of fluid market milk, 0.035
pint of cream and 0.031 pint of buttermilk, or a total of 0.73

1514

BOOK NOTICES

Jour. A. M, A.
Oct. 14, 1939

pint. The total milk consumption was lowest in the Southern
states and highest in New England. It is estimated that 36 per
cent of the municipalities had a milk ordinance. Control of
milk sanitation work was a function of the health department
in twenty-two states, of the department of agriculture in twelve,
jointly of health and agricultural departments in ten, and of
some other agency in four. Some degree of local milk control
was exercised in about one third of all municipalities. Milk
supplies for the larger cities apparently are subjected to greater
control than those of smaller municipalities. The information
provided by this pamphlet should be valuable to all who are
interested in statistics on the sanitation and consumption of fluid
milk.

Electrocardiographic experimentale: Application A la physlo-pathologlo
du occur, dualitc du occur, arythmies. Tar lc Dortour E. de Somcr, pro-
fesseur de pathologic generate a l’Untvcrslte dc Ganil. Preface du Prof.
Dr. Wenckebach. Paper. Tp. 142, with 122 illustrations. Tarls :
Afasson & Cie, 193S.

In this brochure the author presents data on which he
attempts to outline his ideas regarding the genesis of the elec-
trocardiogram. There is little reference to tile literature, the
presentation is polemic, the views expressed are unorthodox,
the evidence is unconvincing and the method of recording the
electrocardiogram is unconventional. The spacing of the book-
let into three separate parts containing respectively the text,
the illustrations and the legends makes it extremely difficult
to follow the abstruse presentation. Apparently the author is
convinced of the dualistic theory of the origin of the heart
beat, namely that there is one pacemaker for the auricles and
another for the ventricles. This view has cropped up before
and will probably appear again, but it has few advocates, and
none apparently among the leading students of this subject.

Annual Review of Biochemistry. James Murray Luck, Editor. James
H. C. Smith, Associate Editor. Volume VIII. Cloth. Price, $5. Pp. C7G.
Stanford University P. O., California : Annual Reviews, Inc., 1939.

The eighth volume of these now indispensable reviews of
annual advances in biochemistry is the first since the establish-
ment of the companion volume known as the Annual Review of
Physiology. It is the conviction of the editorial board that the
publication of two sets of reviews will considerably ease the
trials of the authors. To the present commentator it seems to
be a mistake to separate two closely allied subjects such as
biochemistry and physiology, and one criticism of the articles in
the present volume is that the physiologic aspects are too often
omitted. Perhaps this is necessary, but it is unfortunate to
establish any line of demarcation when none exists. The diffi-
culties presented to the reader because of emphasis on chemistry
may be exemplified perhaps by the following sentence, which
appears in an authoritative review of the alkaloids : “The
alkamine retronecine, the basic fragment from the hydrolysis
of senecionine, retrosine, jacobine, squalidine, trichodesmine and
seneciphylline, is converted by hydrogenation to retronecanol,
CH,r,NO.”

The subjects in the present volume include biologic oxidations
and reductions, proteolytic enzymes, nonproteolytic enzymes,
polysaccharides and lignin, x-ray studies of the structure of
compounds of biologic interest, the chemistry of the acyclic
constituents of natural fats and oils, the chemistry of proteins
and amino acids, the chemistry and metabolism of the com-
pounds of sulfur, carbohydrate metabolism, lipid metabolism,
metabolism of proteins and amino acids, mineral metabolism
(calcium, magnesium and phosphorus), hormones, choline as a
dietary factor, the water-soluble vitamins, the fat-soluble vita-
mins, metabolism of brain and nerve, the alkaloids, chemical
aspects of photosynthesis, mineral nutrition of plants, growth
hormones in the higher plants, animal poisons, ruminant nutri-
tion, immunochemistry and the biochemistry of yeast. There
is an author index and a subject index.

' It is apparent from the list that some topics are so broad
that much more space should be provided for their appropriate
presentation. There is still too much mere cataloguing of
papers without discussion or even mention of the results obtained
Thus in a discussion of molecular weight determinations of
proteins there appears the sentence “Sumner Gralen and
Eriksson-Quensel (1, 2, 3) studied the crystalline proteins,
urease, canavalin, concanavahn A, and concanavahn B, from

the jack bean.” The only way the reader can find out what
values were found is to refer to the papers cited as numbers 1,
2 and 3. There is almost a page devoted to the discussion o!
molecular weight determination of proteins, and, although some
values are recorded, it would be much more satisfactory to the
reader if all the values were listed in a table. There are excel-
lent tables of coenzyme specificity of dehydrogenases and tables
of utilization of amino acid derivatives for growth.

Erniihrungslehre: Grundlagcn und Anwendung. Bearbeltet ion B,
Bley it et at. Ilerausgegehen von Frofessor Dr. Wilhelm Stepp, lllrektor
der 1. Mcdlzlnlschen Kltnlk der Unlversltat Miinchen. Cloth. Priee.
3fi marks. Pp. G22, with 34 Illustrations. Berlin : Julius Springer, 193L

This is a modern textbook on nutrition written in German
by seventeen contributors in addition to the editor. It is interest-
ing to note the many references to American work as compared
with the relatively few citations in some of the standard German
textbooks of twenty or thirty years ago. In the discussion of
energy requirements the work of F. G. Benedict, Du Bois and
Boothby and their collaborators is discussed at length. The
recent work of W. C. Rose, Brand, Lewis, du Vigneaud and
others on the nutritional significance of the amino acids, includ-
ing the recent work on the homologucs of cystine, is presented.
The expression “protective food” has been introduced into the
German language as "schutzstoffe.” Discussion of some sub-
jects, such as mineral metabolism, is brief, as is necessary
perhaps because of the nature of the book. The chemistry o
the vitamins is presented fully but briefly. Each chapter con-
tains a selected bibliography. The references presented in the
discussion of nicotinic acid and pellagra are not the most
important papers. An interesting chapter by Schittenhelm dis
cusses undernutrition and overnutrition and the mehlnair
schadcn” of Czerny and Keller. The subjects in the SK *1™
on avitaminosis and hypovitaminosis are well presented. *
final section is an interesting discussion of nutrition as a pu J c
health problem, in which evidence regarding the requirement
of different peoples is gathered together and discussed in '
light of current information.

Principles of Healthful Living. By Edgar F. Van Bus i . (l) ,

Professor of Hygiene and Health Education, Stephens College. ,|y
Wilson (J. Snilllie, M.D., Professor or Public Health, Cornell un
Medical College. Cloth. Price, S3. Pp. 38G, with Illustrations.
York: Dial Press, 1938. ^

This is a good textbook on hygiene at the college level,
is also a good reference book for the home, assuming 13 .

education of the family is of high school level or above. ^
not sufficiently appealing in style or treatment for t,e nl ° ^
less casual reading of those who are mildly intercstec ^
seriously concerned in making a study of health an >5 ^

It deals in a comprehensive manner with the structure an ^
tions of the body and its environment, placing a high y es .^ ro _
emphasis on preventive medicine and at the time gi' ln S ^
ductory information with relation to the principal c h 5 £ a3es r .

afflict man. It does not encourage self medication 11 e 0 j

ages what the author calls “reflective thinking as a me ^
evaluating advertising claims with relation to iea ^
attempts to develop a critical attitude toward such c aim _ ^

out at the same time discrediting honest commercia P r an( ]

It should make a good basis for any course m US' ^

healthful living or for collateral reading and reference.
critical sections relating to diet, the use of narcotics jm
lants, personality development and mental hygiene 1 . ( [ f
those places where faddism might easily have crep [nan y
eminently sound. The book is attractively pnnte , '' turcSl
simple and clear diagrams illustrating the anatomic cc i] cn t
and is embellished with numerous photographs 0 ^ | )35

quality, sharply reproduced and intelligently empoje
i good bibliography and an excellent index.

A banana: Frulo be tobo o ano allmento-mfdkamento-^ I ^

Vicente Henrlques de Gouvela. Besumee en franca s
ivitli 18 illustrations. Funchal, Portugal: The Author,

This is a discussion in Portuguese, with a Fre f nC |j I( f l ^nan 3 -
ibout the composition and nutritional value ot . • a | jjtcra-
Unfortunately no references are provided to the o E
:ure and the monograph itself presents no new fac s.

Volume 113
Number 16

BUREAU OF LEGAL MEDICINE AND LEGISLATION

1515

Bureau of Legal Medicine
and Legislation

MEDICOLEGAL ABSTRACTS

Corporations: Group Health Association, Inc., Held
Not Illegally Engaged in the Corporate Practice of
Medicine or in the Insurance Business. — Group Health
Association, a corporation not for profit, was organized under
the laws of the District of Columbia providing for corpora-
tions for "benevolent, charitable, educational, literary, musical,
scientific, religious, or missionary purposes, including societies
formed for mutual improvement, or for the promotion of the
arts.” It undertook to provide medical and hospital services
to its members and their dependents on a monthly prepayment
basis. According to the published report, its membership is
"limited to employees of the government in certain of the
administrative branches.” It entered into a contract with the
Home Owners Loan Corporation whereby the latter agreed to
pay §10,000 in consideration of the association's providing for
two years from Nov. 1, 1937, “substantially complete medical
and hospital service to such employees of the Home Owners
Loan Corporation as care to join it on a reasonable monthly
payment basis.” The United States District Attorney for the
District of Columbia, claiming that the association was illegally
engaged in the practice of medicine in violation of the Healing
Arts Practice Act, notified the association that unless it sus-
pended immediately its activities he would file a bill for an
injunction or institute proceedings for the involuntary disso-
lution of the corporation. The Superintendent of Insurance
for the District of Columbia contended that the association
was engaged in the business of insurance in violation of the
insurance laws of the District of Columbia. The association
thereupon filed a bill of complaint in the district court of the
United States for the District of Columbia against the district
attorney and the superintendent of insurance. The defendants
moved that the bill of complaint be dismissed.

Group Health Association, said the district court, was not
practicing medicine in the sense that it itself prescribed for
the sick. It was the contention of the association that it entered
into contracts only with duly licensed physicians who them-
selves attended its members and if necessary prescribed for
them. The court could see no reason why an individual or
a group of individuals may not contract with a physician, or
a group of physicians, for medical services for a stipulated
period at a fixed compensation without violating the Healing
Arts Practice Act. It seemed to the court that such a group
of individuals might incorporate themselves for their own
mutual benefit for the same purpose and that such a corpora-
tion, not for profit but for tbe mutual benefit of its members,
would not be engaged in the practice of medicine or would
not be holding itself out as doing so. While a corporation
can act only through its agents and employees, the physicians
■with whom Group Health Association contracted to render
medical services were, in the opinion of the court, independent
contractors, for the association “does not in any way undertake
to control the manner in which they attend or prescribe for
their patients.”

While the court expressed itself as having more difficulty
with the contract between the association and the Home
Owners Loan Corporation, it concluded that the medical and
hospital services which the association agreed to furnish- to
the members of that corporation were substantially the same
as those furnished to its own members. No profit was to be
made for the association or its members.

The purpose of the Healing Arts Practice Act, the court
continued, was to protect the public from quacks, the ignorant
and incompetent. The activities of the association in no way
tended to commercialize the practice of medicine, as the court
viewed them ; the association was not in the business of
making money by furnishing medical services to any one who
might come along. The court did not believe that the cases
bearing on the right of a corporation to practice law were

closely analogous, “they being based on the common law and
governed by the courts independently of any statute.” For
the reasons stated, the court held that the activities of the
association did not constitute a %'iolation of the Healing Arts
Practice Act.

The contention of the superintendent of insurance that the
association was unlawfully engaged in the business of insurance
was based on tbe following provision of the insurance laws
of the District of Columbia :

Every corporation . . . transacting business in the District of

Columbia, which collects premiums, dues, or assessments . . . and which
provides for the payment of indemnity on account of sickness or accident,
or a benefit in case of death, shall be known as “health, accident, and life
insurance companies or associations."

This provision, the court pointed out, does not include all
"insurance” companies but only those which provide for the
"payment of indemnity on account of sickness” ; it does not
include necessarily contracts “to indemnify,” but is limited to
those which provide for tbe “payment” of indemnity. The
word “payment,” the court continued, as ordinarily used means
the payment of money, and the court could find no reason to
believe that the word “is used in a different sense in the
statute or that it is equivalent to ‘indemnity.’ ” In the opinion
of the court, the association was not engaged in the business
of insurance within the meaning of the quoted provision of
tbe law.

Accordingly, the district court overruled the motion to dis-
miss the bill of complaint . — Group Health Ass’u v. Moor ct al.,
24 F. Supp. 445.

Malpractice: Volkmann’s Paralysis Allegedly Result-
ing from Improper Application of Plaster of Paris Cast.
— Dewey Dark Jr., a boy aged 6 years, suffered greenstick
fractures of both the ulna and the radius of the left arm on
Thursday, March 4, 1937. Dr. Brown, a local physician, was
called in but, since in his opinion it was necessary to “x-ray”
the arm before administering any treatment, the child was
taken to Dr. McAdams in a neighboring town. Dr. McAdams,
after studying roentgenograms, reduced tbe fractures and applied
a plaster of paris cast “next to the flesh,” bending the elbow
just before tbe cast hardened, which caused tbe cast to wrinkle
at the elbow. The following day the arm began to swell, but
Dr. Brown did not believe that the cast needed loosening.
Saturday and Sunday nights Dr. Brown administered hypo-
dermics anci on Sunday loosened tbe bandage. When the child
was taken back to Dr. McAdams on Monday the physician
removed the dressing and drained and sterilized blisters which
had formed on the top of the arm and on the hand. Accord-
ing to his testimony, at that time the pulse was good, there
was no blueness in tbe fingers and the child could move his
band. The father testified, however, that at that time “inside
the elbow it was black.” Although the physician urged the
father to hospitalize the child, the father failed to do so for
two more days, in the meantime bringing the child to Dr.
McAdams each day. The child was hospitalized Wednesday,
the 10th, at which time he had a temperature of 103 F. Dr.
McAdams removed the splint and the dressing and elevated the
arm on a pillow. While the child was in the hospital, accord-
ing to Dr. McAdams, the "temperature went down to practi-
cally normal, swelling was much better, the blisters looked
better, he bad a good pulse, and movement in his wrist and
fingers” and he was free of pain. Over Dr. McAdams’s objec-
tions the father removed tbe child from the hospital on March
12 and dismissed Dr. McAdams from tbe case, informing the
physician that “he could get the boy attended to nearer home,”
mentioning a Dr. Cooper and saying nothing concerning Dr.
Brown. Consequently Dr. McAdams gave Dr. Brown no
instructions for treatment. Apparently, however, the father
placed tbe child under Dr. Brown’s care from then until March
22, when he was taken to the Dr. Cooper just referred to.
When Dr. Cooper came into the case he found that the arm
was swollen twice the normal size, the child had a high tem-
perature, there was “no circulation” and the tissue was slough-
ing off in a spot about 2 inches long by 1^4 inches wide. May
16, on Dr. Cooper’s advice, the child was taken to Dr. Speed,
a bone specialist in Memphis. Roentgenograms, Dr. Speed

1516

SOCIETY PROCEEDINGS

Jour, a. M. A.
Oct. 14, 191)

testified, while showing a fracture of both bones of the fore-
arm, destruction of one bone, osteomyelitis of this bone and to
a certain extent other bones, showed excellent apposition of
the bones at the points of fracture. Apparently Volh-mann’s
paralysis had developed, the fingers had become stiff and the
arm was useless, and subsequent 'procedures by the specialist
were fruitless.

The father and the child subsequently sued Dr. Brown and
Dr. McAdams for malpractice. The substance of their com-
plaint was that “there was a want of skill on the part of
McAdams and Brown, who acted jointly in applying the treat-
ment — that the cast was applied too tightly, and when it was
bent to accommodate the arm in a sling, wrinkles formed in
the interior of the cast and, when it set or hardened, these
wrinkles bruised the flesh when swelling occurred — a condition
brought about through failure of the physicians to place yield-
ing or resilient material between the flesh and the cast.” From
a judgment for the plaintiffs the defendants appealed to the
Supreme Court of Arkansas.

The determining questions, as the Supreme Court viewed the
controversy, were whether or not the cast was applied too
tightly and whether or not it was good medical practice to
place the cast in contact with the skin. From the fact, said
the Supreme Court, that wrinkles did form in the cast at or
near the elbow, it cannot be concluded that the infection com-
plained of was caused thereby, and the evidence adduced justi-
fies no such conclusion. Dr. Speed testified that the disability
of the child was due to Volkmann’s paralysis, which can result
from a number of different causes : It might be the result of
a direct injury to the blood vessels of the arm when the blood
supply is cut off to the muscles; it might be due to hemor-
rhage or swelling within the fasciae covering of the arm, or it
might be due to stricture due to splinting or pressure. He was
unable to tell the original cause of the trouble but, in view
of the testimony with regard to the circulatory condition — the
presence of radial pulse, which indicates that blood is being
supplied to the parts, and the movement of the fingers — he
believed that when the child left the hospital on March 12
“there had been no serious or permanent interference, and with
proper care from then on the condition should have improved,
and the patient should have recovered.” Dr. McAdams, in his
opinion, handled the case well “throughout the treatment of
the fracture, both regarding the x-raying of it, the reduction
of the fracture, the apposition of the bones, the type of immob-
ilization which was used, and the instructions which were
given with regard to the kind of precautions necessary.” Dr.
Speed saw no objection “if the arm is almost straight to bring-
ing it to right angle position after the splint is applied.”

Six other expert witnesses, called on behalf of the plaintiffs,
testified that the methods Dr. McAdams used were proper.
Dr. Govar, another physician witness called by the plaintiffs,
testified that it was optional with the physician whether splints
or a cast be used to accomplish immobilization but that he
wouldn’t deem it advisable to place plaster of paris casts against
the skin because “if a person is hairy the hair will join the
cast, and if the skin is tender you may get a burn.” No
physician, said the court, testified for the plaintiffs that direct
application of the cast to the skin would be improper from a
professional standpoint. Dr. Govar’s aversion to plaster of
paris was based on the possibility that hairs on the arm might
become attached to the cast and if the skin is tender you
may get a burn.” There is no testimony in the record that
the blisters caused infection or that the deep-seated malady
was produced by plaster of paris burns, and Dr. Speed testi-
fied that direct application was generally approved. There is
no testimony in the record to show that the cast was too
tight when "first applied. There is testimony that within a
short time swelling occurred and that proper treatment prob-
ably would have been to loosen the tension. Dr. McAdams
cannot be charged with such failure for he had no opportunity
to act. The plaintiffs’ entire case is predicated on the physi-
cian defendants’ negligence and want of skill when the opera-
tion was performed. . . . ._

Our conclusion, continued the court, is that the plaintiffs
failed to support their allegations with substantial evidence.
This is a case in which a layman took chances and experi-

enced misfortune of a tragic nature. If the doctrine res ipsa
loquitur applied, the judgments might be sustained. But it
does not. Medicine and surgery are inexact sciences, and
physicians arc not guarantors of results. Our view is that
permanent injuries to the child were occasioned by the father’s
own negligence or error of judgment in not leaving the patient
with Dr. McAdams when it became apparent that infection
had developed.

The judgments in favor of the plaintiffs were reversed and
the causes were dismissed .— Brozen ct a!, v. Dark (Ark.), ID
S. W. (2d) 529.

Compensation of Physicians: Liability of Third
Person for Medical Fees. — Aileen Yaffe was injured while
riding in the automobile of one William Yaffe. After the
accident William sent her to a hospital in an ambulance and
telephoned the plaintiff, a physician, and employed him to treat
her. The plaintiff rendered medical services to the patient for
four and one-half months. About two and one-half months
after the accident Simon Yaffe, the stepfather of the patient
and the father of William, visited the patient at the hospital
and at that time had an interview with the plaintiff. The
plaintiff claimed that Simon requested him to continue his
services and told him to endeavor to get William to pay as much
of the bill as lie could but that he, Simon, and his wife would
be responsible for the bill. Simon, his bookkeeper and his wife,
who were present at the interview with the plaintiff, denied (hat
he had made any such agreement. The plaintiff then brought
suit against Simon, William and Aileen, the defendants, for
$2,750 as payment for his services. As a defense, Simon pleaded
that the alleged contract was void under the statute of frauds
because it was not in writing. From a judgment in favor of
the plaintiff against all the defendants, Simon appealed to the
Supreme Court of Arkansas.

The evidence, said the Supreme Court, showed that Simon
merely promised the plaintiff that he would take care of the 1
if William did not. The undertaking on the part of Simon,
therefore, was collateral and not original. It was an u" u-
taking on his part to pay the debt of another if the origin a
debtor failed to pay the same. In the judgment of the cour ,
therefore, the undertaking was within the statute of frauds an ,
because it was not in writing, was void. Accordingly
Supreme Court reversed the judgment as to Simon and
missed the cause as to him . — Yaffe of. Pickett (Ark.), 121 J-
(2d) 93.

Society Proceedings

COMING MEETINGS

American Academy of Pediatrics. Cincinnati,. November

Clifford G. Grulee, 636 Church Street, Evanston, IH.» Secre >■ a,
American College of Surgeons, Philadelphia, Oct. 16-20. Vr. i

Besley, 40 East Erie St., Chicago, Secretary. n jwfnald

American Public Health Association, Pittsburgh, Oct. 17-20.

M. Atwater, 50 West 50th St., New York, Executive Secrewry. Df
American Society of Tropical Medicine, Memphis, Tenn., Nov. l

E. Harold Hinman, Wilson Dam, Ala., Secretary* < ^ pr,

Association of American Medical Colleges, Cincinnati, Oct. ^

Fred C. Zapffe, 5 South Wabash Ave., Chicago, Secretary. jf 0 „
Central Association of Obstetricians and Gynecologists, Kansa »

Nov. 2-4. Dr. W. F. Mengert, University Hospitals,

Secretary. . r) r r. D.

Central Society for Clinical Research, Chicago, Nov, 3-4.

Thompson, 4932 Maryland Ave., St. Louis, Secretary. Hvde C.

Gulf Coast Clinical Society, Mobile, Ala., Oct. 26-27. D

Rouse, 56 St. Joseph St., Mobile, Ala., SccretaO; Artober 1&

International Society of Medical Health Officers, Yittsburgn,

Dr. Leon Banov, 32 Mill Street, Charleston, S, C., Secre > •
Inter-State Postgraduate Medical Association of North ’Freeport.

Oct. 30 -Nov. 3. Dr. W. B. Peck, 27 East Stephenson *

111., Managing Director. , . 0ct . 2 6*28.

National Society for the Prevention of Blindness, New « Director.

Mr. Lewis H. Cams, 50 West 50th St., New \ ork. General ^
New York State Association of Public Health Eauorat » Albany,
Nov. 3. Miss Mary B. Kirkbride, New Scotland i ••
Secretary. _ n. J. D*

Omaha Mid-West Clinical Society, Omaha, Oct.

McCarthy, 107 S. 17th St., Omaha, Secretary. Portland, Ore*.

Pacific Coast Society of Obstetrics and Gynecology, Secre^D'-

Nov. 8-11. Dr. T. Floyd Bell. 400 29th St., Oakland, 1 C J».
Southern Medical Association, Memphis, Tenn.. Nov. JJ'-

Loranz, Empire Bids., Birmingham, Ala., Secrctary. _ £ Ah©

Southern Surgical Association, Augusta, Ga., Dec. a-/. *

Ochsner, 1430 Tulane Ave., New Orleans, Secretary - Marshal

Tri-States Medical Society of Texas, Louisiana and ! ' SeC retai7*

Texas, Nov, S-9. Dr. Robert K. Womack, Longview, i exas.

Volume 113
Number 16

CURRENT MEDICAL LITERATURE

151 7

Current Medical Literature

AMERICAN

The Association library lends periodicals to members of the Association
and to individual subscribers in continental United States and Canada
for a period of three days. Three journals may* be borrowed at a time.
Periodicals are available from 1929 to date. Requests for issues of
earlier date cannot be filled. Requests should be accompanied by
stamps to cover postage (6 cents if one and 18 cents if three periodicals
are requested). Periodicals published by the American Medical Asso-
ciation are not available for lending but may be supplied on purchase
order. Reprints as a rule are the property of authors and can be
obtained for permanent possession only from them.

Titles marked with an asterisk (*) are abstracted below.

American J. Obstetrics and Gynecology, St. Louis

38: 187*370 (Aug.) 1939. Partial Index

Treatment of Hemolytic Streptococcus Infections During Pregnancy and
Puerperium with Sulfanilamide and Immunotransfusion. C. A.
Chandler and C. A. Janeway, Boston. — p. 187.

•Toxemia of Pregnancy: Types, Etiology and Treatment. M. B. Strauss,
Boston. — p. 199.

Obstetric Management of Patients with Toxemia. \V. J. Dieckmann and
I. Brown, Chicago.— p. 214.

•Macrocytic Anemia of Pregnancy and Anemia of Newborn. J. A. Ritter
and \V. J. Crocker, Philadelphia. — p. 239.

Treatment of Early Abortion. C. E. Galloway and T. D. Paul, Evanston,
111.— p. 246.

Studies on Reconstruction of Fallopian Tube: Preliminary Report of
Original Technic. J. R. Gepfert, New York. — p. 256.

•Treatment of Dysmenorrhea with Testosterone Propionate: Biologic
Effects of Testosterone Propionate in Sexually Mature Woman. U. J.
Salmon, S. H. Geist and R. I. Walter, New York. — p. 264.

Tubal Sterilization by Madlener Technic. E. von Graff, New York. —
p. 295.

Typhoid Fever in Pregnancy: Probable Intra-Uterine Transmission of
Disease. A. W. Diddle and R. L. Stephens, Iowa City. — p. 300.

Water Exchange and Salt Balance in Hyperemesis Gravidarum. F. L.
McPhail, Great Falls, Mont. — p. 305.

Effect of Temperature on Vitality of Spermatozoa. A. I. Weisman,
New York. — p. 313.

•Control of Pain with Local Anesthesia After Repair of Episiotomies.
G. W. Hunter, Fargo, N. D. — p. 318.

Severe Menorrhagia as Only Symptom of Essential Thrombocytopenic
Purpura Cured by Splenectomy. S. L. Israel and T. H. Mendelt,
Philadelphia. — p. 339.

Interstitial Pregnancy Following Salpingectomy. I. Forman, Philadel-
phia. — p. 344.

Interstitial Pregnancy: Five Months’ Gestation, with Observation of
Phenomenon of Rupture at Time of Operation. A. J. Kobak, Chicago.
— p. 346.

Neglected Sign for Roentgenologic Diagnosis of Intra-Abdominal Der-
moid Cyst. G. Danclius, Chicago. — p. 348.

Toxemia of Pregnancy. — Strauss declares that the term
“toxemia of pregnancy” has served for generations and still
serves as a diagnostic waste basket to cloak ignorance. Medi-
cal prepossession with mysterious and unidentified “toxins”
has prevented intelligent study of the various disorders com-
bined under this misnomer. Writers have wisely refrained
from defining what toxemia is. To each the word carries
certain connotations ; rarely does it mean quite the same thing
to any two. There remains one simple method of dividing
this heterogeneous group of "toxemic” women into at least
two main classes, and that is by studying the state of affairs
antecedent and subsequent to the “toxemia." Such study
reveals that about 80 per cent of the women designated as
having “toxemia” actually have chronic vascular or renal dis-
ease before and after the gravid state, and an additional 5 per
cent have sucli disease in acute form. The remaining 15 per
cent of such women have had no demonstrable abnormality
before pregnancy or after the pregnancy in which abnormalities
called “toxemia" occurred. Further, these women under proper
management will have subsequent uneventful pregnancies. It
is this group for which the designation “water-retention
toxemia’.’ seems appropriate. A low sodium intake is one
means of eliminating undue water retention. The development
of water-retention toxemia may be prevented by maintaining
the pregnant woman’s plasma proteins at a normal level by
an adequate diet and avoiding excessive sodium ingestion.

Macrocytic Anemia of Pregnancy and of Newborn. —
Ritter and Crocker studied the relationship between anemia of
die newborn and the hematologic picture in the mother and
believe that the anemia of both the mother and the infant is
due to a dietary' deficiency. Only one case has been encoun-
tered in the maternity service of the Philadelphia General
Hospital. The response of the mother to liver therapy was
inadequate and her severe reactions to transfusions precluded

their further use. The reticulocyte response was poor both
during pregnancy and after parturition. Therefore, either a
specific need for the liver was not indicated or an inadequate
dose or an impotent extract was used. Nevertheless the mother
did improve after delivery, when there was a cessation of
vomiting and diarrhea and better utilization of a balanced diet.
The deficiency factor which produced the anemia in the mother
may possibly have been likewise deficient in the infant. It
appeared that the maturation of the erythron was arrested at
a fetal level because of the infant’s inability to utilize a factor
which it could not obtain in utero. In fact, there appears to
have been little response to combined therapy and transfusions
seemed only to carry the infant over until such a time as its
own erythropoietic system could function at a more mature
level. The infant’s reticulocyte response was definitely poor
in spite of marked anemia. Once a higher level of maturation
of the infant’s red blood cells was attained, probably condi-
tioned by dietary intake of the deficient factor, steady improve-
ment was noted. Oddly enough there was not an “adequate”
reticulocyte response in the recovery phase. The authors can
only say that the erythropoietic system was either depressed
or inhibited in some inexplainable manner and improvement
occurred only when tills was overcome. Why such factors
should work selectively on the erythropoietic system does not
seem explainable except by some mechanism such as produces
pernicious anemia in adults.

Treatment of Dysmenorrhea with Testosterone Pro-
pionate. — Salmon and his associates used testosterone pro-
pionate in the treatment of thirty women suffering from
dysmenorrhea. The level of testosterone tolerance was estab-
lished at approximately 500 mg. Administration of upward of
500 mg. resulted in the appearance, in some of the cases, of
masculinization phenomena and evidence of estrogen deficiency.
Normal cyclic phenomena (clinical and morphologic) returned
spontaneously in all cases within two months after treatment.
With doses of 300 mg. or less neither androgenic nor estro-
genic deficiency effects were produced. Symptomatic relief of
twenty-six of the thirty women was achieved. The suggestion
is made that the biologic effects of testosterone propionate (in
doses of 500 mg. or more) in women is brought about by
inhibition of the gonadotropic factors of the hypophysis with
consequent suppression of ovulation, estrogen and progesterone
formation and menstruation, as well as by inactivation of the
circulating estrogens and estrogen stores in the body. The
therapeutic effects of smaller doses are probably the result of
partial inactivation or modification of the action of the estrogens
and progesterone. The theory is advanced that functional dys-
menorrhea may be caused by an androgen deficiency.

Local Anesthesia for Pain of Episiotomies. — Reports
of the successful use of soluble anesthetic solutions in rectal
surgery with the purpose of relieving patients from postopera-
tive pain have suggested to Hunter the use of this type of
medication following episiotomy and other perineal repair. The
results with twenty-five patients and twenty-five alternate
patients taken as controls were encouraging. Two types of
solutions were used: procaine base 1.5 per cent, butesin 6 per
cent, benzyl alcohol 5 per cent and oil of sweet almond, the
other solution being an aqueous one containing 1 per cent
piperidinopropanedio diphenylurethane hydrochloride. Follow-
ing repair of the episiotomy or perineal laceration, 10 cc. of
warmed solution is drawn into a dry Luer Lok syringe. The
solution is injected slowly into the deeper tissue, care being
taken that it does not go immediately beneath the skin or mucous
membranes. Following injection, massage of the parts assures
an even distribution of the anesthetic. The needle is inserted
about one-fourth inch on each side of the incision and the
solution is injected fanwise. The injection is made while the
patient is still under the effects of the general anesthetic given
during repair. The water soluble solution was used for ten
patients and they were free from pain until the third or fourth
postpartum day, at which time the effects of the anesthesia
had apparently disappeared. They then experienced as much
pain as the controls. The oil soluble anesthetic, however, kept
patients for the most part entirely free from distress. Healing
did not appear to be impaired and no general toxic effects
were observed.

1518

CURRENT MEDICAL LITERATURE

Jour. A. M. A
Ocr. M, 1919

American Journal of Public Health, New York

29: 821-982 (Aug.) 1939. Partial Index
Care of Premature Infants. Ethel C. Dunham, Washington, D. C. —
p. 847.

Effectiveness of Different Systems of Collecting Vital Statistics Data.

J. V. DePorte, Albany, N. Y. — p. 856.

Infection of Air: Bacteriologic and Epidemiologic Factors. W. I**,
Wells, M. W. Wells and S. Mudd, Philadelphia. — p. 863.
•Paratyphoid Fever in Massachusetts. R. F. Fcemster and G. W.
Anderson, Boston,: — p. 881.

Relation of Coroner’s Office to the Bureau of Vital Statistics. S. R.
Gerber, Cleveland.- — p. 889.

Analysis of Subsequent Course of Diagnosed Cases of Tuberculosis.
Ruth R. Puffer, H. C. Stewart and R. S. Gass, Nashville, Tenn. —
p. 894.

Effects on Health of Gases Produced by Electric Arc. L. W. La Tow-
sky, Philadelphia. — p. 912.

Comparative Study of Mouse and Guinea Pig Inoculation Methods in
Diagnosis of Rabies. S. E. Sulkin and J. C. Willett, St. Louis — p.
921.

San Francisco’s Hotels Are Examined for Cross Connections, j. C.
Geiger, A. B. Crowley and G. E. Arnold, San Francisco. — p. 927.

Paratyphoid Fever in Massachusetts. — Fcemster and
Anderson state that a sudden increase in paratyphoid fever
occurred in Massachusetts in 1937. From a level of about six
cases a year the number reported rose to 267. The cases
reported in 1937 fall readily into five groups. There were four
food-borne outbreaks (220 cases), and the remainder (forty-
seven) were sporadic cases ; these occurred before the outbreaks
and were widely scattered throughout the state. It has been
impossible to trace any connection between these outbreaks.
People infected in the first outbreak may have carried the
organism to many other parts of the state, but so far no such
individuals have been found. The fact that twenty with positive
stools and eleven others with positive agglutination tests were
entirely without symptoms emphasizes the importance of sub-
clinical infections in this disease and illustrates why its control
may be difficult. The persistence of the organism in the stools of
convalescents adds an additional problem. Almost half of those
who showed positive stools were still carrying the organism at
the end of five weeks, one eighth at the end of nine weeks and
others continued positive until the twenty-eighth, thirty-second
and forty-ninth weeks and there were five permanent carriers.
In the first nine months of 1938, sixty-six cases were reported.
Six small outbreaks, forty-eight cases, occurred in families or
in groups eating a common meal. The other eighteen cases
were sporadic.

Archives of Dermatology and Syphilology, Chicago

40: 345-520 (Sept.) 1939

Factor Analysis of Acne Complex with Therapeutic Comment. J. H.

Stokes, Philadelphia, and T. H. Sternberg, Peoria, III. — p. 345.
Management of Intractable Urticaria. E. F. Traut, Chicago. — p. 368.
Nodular Myxedema Complicating Thyrotoxicosis: Report of Case. F.
Handley and J. G. Downing, Chelsea, Mass. — p. 374.

* Pigmentation Following Use of Iron Salts. C. E. Reyner, Detroit. — •

p. 380.

Staphylococcus Ambotoxoid: Experience with Its Use in Treatment of
Acne Vulgaris and Other Pyogenic Dermatoses. L. E. Anderson,
Springfield, Mass., and J. H. Stokes, Philadelphia. — p. 382.

Multiple Pigmented Nevi: Report of Case. H. L. Arnold Jr., Ann
Arbor, Mich. — p. 386.

Hemosiderin Histiocytoma of Skin. J. C. Bernstein, Baltimore.— p. 390.

* Mouse Brain Antigen: Intravenous Use in Diagnosis of Lymphogranu-

loma Venereum. D. A. Decker, Allentown, Pa.; O. Canizares and
R. F. Reider, New York.— p. 397.

Recurrent Herpetiform Dermatitis Repens. S. Ayres Jr. and N. P.
Anderson, Los Angeles, p. 402.

Dermatitis Due to Sulfur-Meat Complex: Report of Case. J. C. Bern-

stein, Baltimore. — p. 414. .

Patterned Alopecia About Calves and Its Apparent Lack of Significance.

F. Ronchese and R. R. Cl, ace, Providence, R. I.-p. 416
Epidermodysplasia Verruciformis (Lewandowsky and Lutz). M. Sulli-
van and F. A. Ellis,' Baltimore.— p. 422.

Pigmentation Following Use of Iron Salts - Reyner
reviews the reports of the eight cases of (permanent) pigmen-
tation from the use of iron salts in the treatment of ivy poi-
soning He cites an additional case of pigmentation in which
complete removal of the iron deposits was effected by ultra-
violet irradiation (with a water-cooled lamp). Heretofore such
pigmentation has been considered permanent.

Diagnosis of Venereal Lymphogranuloma-Decker and
his associates find that the intravenous injection of 0.1 cc. of
mouse brain antigen is a reliable procedure for corroborating
Te results of the intradermal Frei test in the diagnosis of

venereal lymphogranuloma. When they injected 0.1 cc. of
mouse brain antigen into thirty-five patients with venereal
lymphogranuloma of the inguinal type, thirty gave a positive
anti five a doubtful reaction. All twenty-one patients with
venereal lymphogranuloma of the genitorectal type gave a posi-
tive reaction. Of seventy control subjects given an injection
of 0.1 cc. of mouse tirain antigen, five gave a doubtful and the
rest a negative reaction. A patient who had had a bubo of
venereal lymphogranuloma incised four years before and bad
apparently had no recurrence gave a typical reaction to tbe
intravenous injection of 0.1 cc. of Frei antigen (mouse brain)
intravenously. This would support the view that the reaction
to intravenous injection behaves similarly to that to intrader-
mal injection, remaining positive after active signs of the dis-
ease are no longer present.

California and Western Medicine, San Francisco

51: 73-144 (Aug.) 1939

Sulfanilamide and Sulfapyridinc in Treatment of Various Infections
C. S. Keefer, Boston.— p.* 81.

Congenital Malformations of- Rectum and Anus: Their Surgical Irea-
ment. L. R. Chandler, San Francisco, — p. 84. ,

The Patient’s Concept of Maternity Care as Obtained from op 31
Sources. G. \V. Coon, Riverside. — p. 92. , ..

Present Status of Artificial Fever in Treatment of Syphilis. • *’
Epstein, San Francisco. — p. 94.

Santiago Ramon y Cajal. J. B. Doyle, Los Angeles.— P- 97.

Cure of Gonorrhea: Immunologic Problem. E. W. Beach, a

'Herpes Zoster: Treatment with Thiamin Chloride. M. J- Goodm
Eureka. — p. 105.

Thiamin Chloride for Herpes Zoster.— Since the benefi-
cial influence of thiamin chloride in neuritis and its P rc ' en ’
of certain degenerative nerve changes is acknowle ge ,
since it has been established that the prominent ea ur
herpes zoster is a neuritis with degenerative changes,
man treated five such cases with subcutaneous ainutns
of thiamin chloride with gratifying results. In compart
results obtained in these cases with similar ones trea
local applications and salicylates the author fin s ^
former treatment is a logical and more satisfactory m ,
combating herpes zoster. The pain is relieved more P ’
the lesions clear up at an earlier date and the tola i - ^

time is notably decreased. In one instance a onge
(than six or seven injections of 3,000 units of thiamin
daily or every other day) of treatment was require • resu j 15
(71) of the patient may have been a factor. 1 ..

obtained suggest that further investigation in > 1,5
warranted.

Canadian Medical Association Journal, Montr

41: 111-222 (Aug.) 1939. Partial Index ^

-Use of Vitamin K and Bile Salts in Prevention ° Report- -■

orrhagic Diathesis in Obstructive Jaundice. Prel.mi 1
R. Townsend and E. S. Mills, Montreal, p. • rt |,.. r oidisin. ^
Menorrhagia, with Special Reference to Occult H>P

V. Sliute, London, Ont. — p. 115. r Miller,

•Intestinal Protozoa of Man in Saskatchewan.

Orleans. — p. 120. i • A T Grace,

Surgical Procedures in Pulmonary Tuberculosis.

Ont.— p. 124.

Appendicitis. G. Murray, Toronto, p. 134. white Cell arid

Relative Value of Different Essential Phases in . Kelowna, In-
ferential Count in Diagnosis of Appendicitis. A - * ^

Use of Fascia Lata in Treatment of Fallen Metatarsal

Shouldice, Toronto.— p. 142. menificance. J* &

Human Electro-Encephalogram and Its Clinical g

Goodwin and G. E. Hall, Toronto, p. 146. jj jIcCoUtuL

Early Diagnosis of Expanding Lesions of Brain.

Saskatoon, Sask. — p. 151. n«t— P* 1^**

External Hydrocephalus. A. E. Harbeson, Kings.o ’

Rare Cause of Fatal Hematemesis. R. D. Roach, Moncton,

173. . r children.

Relation of Achlorhydria to Nutritional Anemia o

son, Vancouver, B. C. — p. 176. . <r umc r

Significance of Indigo, Cyanogen and Thiocyanate
J. E. Davis and H. E. Schmitz, Chicago.— p.

Vitamin K and Bile Salts for Hemorrhagic
— Ten cases of obstructive jaundice are presen e efC low'
and Mills in which the plasma prothrombin e ' , ; n di-

and in which there was an abnormal tendency f-> ,.; tam in K

cated by prolonged clotting times. Administration o

Volume 113
Number 16

CURRENT MEDICAL LITERATURE

1519

and bile salts restored the clotting time to normal. One failure
: w ith no adequate explanation is recorded. No abnormal bleed-
ing followed operation on patients treated with vitamin IC and
bile salts. 'In one case there was a further disturbance in the
plasma prothrombin after operation with an abnormal tendency
to bleed. Prophylactic therapy is suggested as a safeguard. It
is suggested ' that the tendency to give patients with jaundice
a low fat diet predisposes to IC avitaminosis, which may be
accentuated further by the frequently accompanying nausea and
vomiting.

Intestinal Protozoa of Man. — As information regarding
the incidence of intestinal parasitic infection in Canada is lack-
ing, Miller obtained data on the incidence of such infection in
Saskatoon, Sask., by examining the stools of 254 persons.
Ninety-seven of these, or 38.2 per cent, were positive for intes-
_ ... final parasites. • Only protozoan parasites were found. No
“■ helminth eggs were recovered from the' stools, although one
immature Ascaris, passed by a 6 year old child, was sent in
by a local physician. Seven species of Protozoa u'ere found.
■ Five of these belonged to the class Rhizopoda and the two
remaining species belonged to the class Mastigophora. Of the
254 stools examined 149 were from hospitalized and nonlios-
pitalized clinical patients, forty of whom, or 26.8 per cent,
showed parasitic infections. Only five of the infected persons
harbored more than one parasite, and these were all double
infections. An infection incidence of 39.7 per cent was obtained
in a group of fifty-eight healthy persons. Multiple infections
were found in two persons. In forty-seven orphan asylum
», children the incidence of parasitic infections was approximately
- 72 per cent. Multiple infections were quite common in this

group, and of the thirty-four infected children eight had triple
infections, eleven had double infections and the remaining fifteen
harbored only one species. Endamoeba coli was found most

- often in all three groups. In the orphans this was followed by

- Endolimax nana, then Endamoeba histolytica. The observations
. . of Fantham and Porter together with the present results, the
. author states, tend to demonstrate that parasitic infection is

widespread throughout Canada and that even climates as severe
. as those found in western Canada are tolerated by this parasite.
Therefore competent .’stool examinations should play an impor-
tant part in diagnosing otherwise unexplained diseases of the
large intestine.

Florida Medical Association Journal, Jacksonville

26: 57-108 (Aug.) 1959

Puerperal Infection versus the General Practitioner. \V. C. Roberts,
Panama City — p. 67.

Five Hundred Consecutive Major Operative Gynecologic and Obstetric
j' Cases. F. Richards, Jacksonville. — p. 72.

Menace of State Medicine. R. F. Godard, Quincy. — p. 77.

Jellyfish and Portuguese Man-af-War .Stings. E. J. Thomas, Miami
. - Beach. — p. 83.

Present Status of Cancer Therapy. E. M. Hendricks, Fort Lauderdale.
— p. 87-

: '' Relation of Sympathetic Nervous System to Health and Longevity. T.
hi. Rivers, Kissimmee. — p. 90.

S 1

Journal of Immunology, Baltimore

37: 85-178 (Aug.) 1939

Studies on Serum Complement of Guinea Pigs Infected with Trypano-
- :•/ ~ soma Equiperdum. I. Horner, Pecs, Hungary. — p. 85.

i-' • onadotropic Inhibitory Substance and Precipitins in Blood of Monkeys
eceiving Gonadotropic Hormone Preparations. R. K. Meyer and
.* C’rc Madison, Wis. — p. 91.

jq 3 Formula for Diphtheric Toxin Broth. J. H. Mueller, Boston.

» t °l'? J Tophysectomy on Immunity and Hypersensitivity in Rats

min -Brief Description of Operative Technic. N. Molomut, New
l' \ork.— p. in.

is integration of Bacteria by Mechanical Means: I and II. P. H.

r, . nE ?, e T r *' r ‘ and J. S. Forrester, Philadelphia. — p. 133.

V' Comparative Reactions After Intracutaneous Injection of

I Mechanically Disintegrated Bacteria and of Heat Killed

-p, , Organism Suspensions. J. S. Forrester and P. H. Langner Jr v
Philadelphia.— p. hi.

. !' Structure of Hemolytic Streptococci of Lancefield Group A;

>/ Y ac * • -f nter forence of Blood Group A Substance in Culture
f' K-*; UmS vfV lt k Chemical and Serologic Studies on Streptococcus Haemo-
&V Grn, c . Henle and Gertrude Henle, Philadelphia.— p. 149.

'Ipp* yrJ* Specific Agglutinins in Rabbit Serums for Human Cells:

-V: ™ u ?e Specific M Agglutinins. K. M. Wheeler, P. B. Sawin
Y' M ’a V* • Stuart * Providence, R. I.— p. 159.

P,f5i ltlnogen of Rhesus Monkeys. K. M. Wheeler and C. A. Stuart,
1 V/ 1 °vJdcnce, R. . I.— p . 3 69 .

Journal of Investigative Dermatology, Baltimore

2 : 151-230 (Aug.) 1939

Clinical and Experimental Study of Interstitial Keratitis. J. V. Klauder,
with assistance of E. R. Gross and H. F. Robertson, Philadelphia. —
p. 157.

Notes on Anatomy and Pathology of Skin Appendages: I. Wall of Intra-
Epidermal Part of Sweat Duct. H. Pinkus, Eloise, Mich. — p. 175.

Cultural Characteristics of Pit} rosporum Ovale: Lipophylic Fungus.

Rhocla W. Benliam, New York. — p. 187.

•Further Studies on Therapy of Acne Vulgaris with Modified Liver
Extract. W. Marshall, Appleton, Wis. — p. 205.

Experimental Use of Lipocaic in Treatment of Psoriasis: Preliminary
Report. C. D. Stewart, D. E. Clark, L. R. Dragstedt and S. W.
Becker, Chicago. — p. 219.

Liver Extract for Acne Vulgaris. — Marshall used boiled
liver extract in the treatment of fourteen cases of acne vulgaris
and obtained satisfactory results. Tbe subcutaneous injection
of liver extract, 0.4 cc., is given so that a sufficient amount of
the probably specific vitamin (probably vitamin H, termed the
X factor by Boas and the skin factor by Gyorgyi) may be bad.
The author says this reservedly, although he is not acquainted
with any other material in the extract which would increase its
dermatologic potency on boiling. Since the seborrhea seemed
to be the first component of the acne complex to improve, it
appears that one may be dealing with a human counterpart of
status seborrhoeicus in experimental animals. When injectable
liver extract is boiled for thirty minutes, its acne-improving
factor seems to increase. When this boiled extract is given to
patients already under routine liver therapy, their improvement
appears more rapid.

Journal of Nutrition, Philadelphia

18 : 105-216 (Aug.) 1939

Vitamin Bi Content of Human Milk as Affected by Ingestion of Thiamin
Chloride. Agnes Fay Morgan and Edna Gavin Haynes, Berkeley,
Calif.— p. 105.

Comparative Toxicity of Fluorine in Calcium Fluoride and in Cryolite.
Margaret Lawrcnz, II. II. Mitchell and W. A. Ruth, Urbana, III. —
p. 115.

Comparison of Toxicity of Fluorine in Form of Cryolite Administered
in Water and in Food. Margaret Lawrenz, H. H. Mitchell and W. A.
Ruth, Urbana, III. — p. 127.

•Average Values for Basal Respiratory Functions in Adolescents and
Adults. N. W. Shock and M. H. Soley, Berkeley, Calif. — p. 143.

Dietary Requirements of Guinea Pig, with Reference to Need for a
Special Factor. M. D. Cannon and Gladys A. Emerson, Berkeley,
Calif. — p. 155.

Minimal Vitamin A and Carotene Requirement of Rat. H. Goss and
H. R. Guilbert, Davis, Calif. — p. 169. *

Conditions Affecting Content of Chick Antidermatitis Vitamin in Yeast.
W. H. Peterson and C. A. Elvehjem, Madison, Wis. — p. 181‘.

Influence of Massive Doses of Vitamin Bi on Fertility and. Lactation.
B. Sure, Fayetteville, Ark. — p. 187.

Basal Metabolism of Connecticut State College Students. E. Charlotte
Rogers, Storrs, Conn. — p. 195.

Average Basal Respiratory Functions. — In an attempt to
determine the range in values of basal respiratory functions in
normal adolescents and adults and to indicate changes that take
place during adolescence, Shock and Soley recorded the res-
piratory rate, the respiratory volume per minute, the tidal
volume, the concentration of oxygen and carbon dioxide in the
expired air, the oxygen consumption and the alveolar carbon
dioxide tension of fifty normal boys, fifty normal girls, forty-six
normal adult men and forty normal adult women. In the chil-
dren the tests were begun at the ages of 11 or 12 years and
were repeated at intervals of six months over a period of five
years. The adults ranged in age from 27 to 43 years. The
adults were chosen from staff ■ members and from university
students who were presumably healthy (although no systematic
medical examination was given) and' in view- of their sedentary
activities the average values for metabolic- test's, may ; be some-
what lower than for the general population.; In- the adult group
as many as sixty tests were made in. triplicate only on two suc-
cessive days on each subject. The authors tabulate the results
of these studies and in conclusion state that the following was
found to prevail: 1. In boys the minute respiratory volume
increases between the ages of 12 find 14 years, owing to an
increase in body size. 2. In boys the respiratory rate decreases
between the ages of 14 and 16, the tidal volume increases, the
concentration of oxygen in the expired air decreases and the
expired carbon dioxide increases. 3. In girls the respiratory
volume and tidal volume increase between the ages of 12 and
14 years. 4. The composition of the expired air in girls
changes between the ages of 14 and 16 as it does in the boys,

1520

CURRENT MEDICAL LITERATURE

J OCR. A. !f. A
Oct. 14, Hi!

but the change is not so clearly defined. In boys there is a
significant increase in alveolar carbon dioxide tension between
the ages of 12 and 14 years. No significant change in alveolar
carbon dioxide tension was found in girls. 5. The average
oxygen consumption per minute increases from the age of 12
to 16 years in both sexes. In respect to body size there is a
decrease in oxygen consumption. 6. Most respiratory functions
of girls of 16 are similar to those of adult women. 7. Sixteen
year old boys breathe more rapidly and have a smaller tidal
volume, higher concentration of oxygen and lower concentra-
tion of carbon dioxide in the expired air and a lower total
oxygen consumption than adult men.

Journal of Pharmacology & Exper. Therap., Baltimore

<56:379-508 (Aug.) 1939. Partial Index

Effects of Various Agents on Metabolic Rate in Experimental Hyper-
thyroidisfti. W. C. Cutting and G. B. Robson, San Francisco. —
p. 389.

Role of Molecular Oxygen in Antispirocbctal Activity of Arsenic and
Bismuth Compounds in Vitro. H. Eagle, Baltimore. — p. 423.

Effect of Sulfbydryl Compounds on Antispirocheta! Action of Arsenic,
Bismuth and Mercury Compounds in Vitro. H. Eagle, Baltimore.—
p. 436.

Comparison of Actions of Prostigmine and of Guanidine on Activity of
Choline Esterase in Blood Serum. Ann S. Minot, Nashville, Tenth —
p. 453.

Action of Syntropan on Gastrointestinal Tract. B. B. Chirk, E. B. S.
Shires Jr., E. H. Campbell and C. S. Welch, Albany, N. V. — p. 464.
* Studies in Absorption, Distribution and Elimination of Alcohol: IV.
Elimination of Methyl Alcohol. H. \Y. Haggard and L. A. Greenberg,
New Haven, Conn.- — p. 479.

Elimination of Methyl Alcohol. — Widmark is of the
opinion that methyl alcohol is largely destroyed in the body
and that the loss is at a uniform rate regardless of the amount
present or the concentration in the blood. Haggard and Green-
berg, to the contrary, state in summary that they find that:
1. More than 70 per cent of the methyl alcohol is eliminated
in the expired air. 2. The elimination follows the principle
defined for volatile substances which are largely nonreactive.
3. The amount eliminated in unit time is determined by the
concentration of alcohol in the blood and the volume of pul-
monary ventilation. 4. The curve obtained from the concen-
trations of inethyl alcohol in the blood during elimination is
not a straight line but an exponential curve. 5. The Widmark
value P held by him to be a constant is not a constant but
a variable influenced by all factors which influence the amount
of methyl alcohol eliminated in unit time in the expired air.

Journal of Thoracic Surgery, St. Louis

8:581-696 (Aug.) 1939

Disease of Aberrant Intrathoracic Lung Tissue. S. O. Freedlander and
P. W. Gebauer, Cleveland. — p. 581.

Beck Operation (Heart) : Report of Two Cases. A. L. Lockwood,
Toronto. — p. 598.

Treatment of Pulmonary Tuberculosis by Temporary Elimination of
Number of Intercostal Nerves. F. Torek, New York. — p. 607.
Patient Support for Thoracoplasties and Other Thoracic Operations.

W. L. Howard, Battle Creek, Mich. — p. 613.

Partial Thoracoplasty (with Extrafascial Apicolysis) and Contralateral
Oleothorax. A. H. Aufses, New York. — p. 615.

Extrapleural Apicolysis. A. R. Judd, Glen Gardner, N. J. — p. 62 2.
Tboracoplastic Collapse of Acute Progressive Tuberculosis: Report of
Five Cases. H. Meltzer, Ninette, Man. — p. 627.

Immediate Effect of Scaleniotomy on Size of Apical Tuberculous Cavities.

J. H. Gibbon Jr., Philadelphia. — p. 633.

Interposition of Colon Following Right Phrenic Nerve Interruption.
C. Muschenheim and J. B. Amberson Jr., New York.— p. 638.

•New Technic for Phrenic Crush. L. W. Frank, Louisville, Ky.— p. 644.
Technic of Extrapleural Pneumothorax. F. S. Dolley, J. C, Jones, Los
Angeles, and Jane Skill en, Olive View, Calif.— p. 646.

Penetrating Gunshot and Stab Wounds of Thorax: Report of Eighty-
Seven Cases. C. R. Steinke, Akron, Ohio.— p. 658.

Gunshot Wound of Chest of Patient with Artificial Pneumothorax.

E. F. Parker Jr., Nashville, Tenn.—p. 666. „

Experimental Lobectomy Using Bronchial Plugs. S. R. Rosenthal, E. H.

Lambert, W. Van Hazel and P. H. Holinger, Chicago.— P. 66$.
Catheter for Bronchospirometry, P. W. Gebauer, -Cleveland, p. 674.
Bronchiogenic Carcinoma of More Thar. Five Years Duration Treated
by Radiotherapy: Report of Case. F. R. Harper, Denver.— p. 6S3.

Phrenic Crush.— Frank states that, after crushing of the
main phrenic nerve for 1 cm., resection of large segments of
any accessory nerves and division of the nerve to the subcla-
vius muscle, only SO per cent of his cases were successful as
evidenced by a total paralysis of the diaphragm. Of the 50
per cent which were unsatisfactory, half showed only partial
paralysis of the diaphragm ; in the others an apparent paralysis
was first produced and diaphragmatic movement became rees-

tablished in an average time of three months. As all fa
operations had been most carefully done, it became evifd
that other connections entering the phrenic nerve be! on- fa
clavicle must exist. Therefore the author developed the Id-
lowing technic: The usual transverse incision for exposure cf
the phrenic nerve is employed. The accessory phrenic nerves
are divided. The nerve to the subclavius muscle is resected
as before. The phrenic nerve is then crushed for approxi-
mately 1 cm. and drawn upward into the neck for from 3.5 to
4 cm. It was thought that, by drawing the nerve upward
any filaments entering the phrenic nerve below the clavicle
might be torn and hence the resulting paralysis of the dia-
phragm would last a much longer time. The incision is clod
with subcuticular suture of fine silk with a split shot on each
end of it. Since January 1935 the author has performed fa
foregoing operation on 246 patients and in every one complete
paralysis of the diaphragm ensued. Following this type d
operation the diaphragm remained paralyzed on an average a
from ten to twelve months. Diaphragmatic movement to
began, although that structure itself remained elevated. 11*
amount of diaphragmatic excursion increased, and within ta
two to three months the diaphragm returned to its nonffli
position and full normal respiratory movement.

Kansas Medical Society Journal, Topeka

40: 317-360 (Aug.) 1939

What the General Practitioner Should Know About Ear, Nose and ra>
Diseases. L. J. Birsner, St. Louis. — p. 317. « ^

Newer Knowledge of Central Vegetative Nervous System.
Grinker, Chicago,— p. 321. , . „ ,, ior ,-j

’Recovery from Subacute Infectious Endocarditis, it. n. . j

L. H. Lcger, Kansas City, Mo. — p. 324. TiMtuCt

Dermatitis Venenata: Practical Aspects and Innocuous

It. L. Sutton Jr., Kansas City, Mo. — p. 325. , _ q )S

Treatment of Actinomycosis with Sulfanilamide: R*P or

M. T. Sudlcr and C. B. Johnson, Lawrence. — p. 330. . „}

Coarctation of Aorta: Case Report. E. R. Schwartz, -

G. M. Tice, Kansas City. — p- 330. „ „ vdiK,

A County-Wide High School Tuberculin Testing Plan. K. *'•
Marion, and W. M. Tate, Peabody. — p. 332.

Recovery from Subacute Infectious Endocarditis.^.
Major and Leger report their second case of su acu «
tious endocarditis in which recovery occurred fol 1
anilamidc and sulfapyridine therapy. It must be ;e P .y
Chat occasionally patients with subacute infectious en ^
recover spontaneously. However, the authors fee (o
instance, as in the previous one, recovery was ^
therapy employed. Also in both patients, the re a i
duration of the illness was probably a decisive far or -

Medical Annals of District of Columbia, Wash’ £

S: 223-254 (Aug.) 1939 ^ ^

Supervised Obstetrics in a General Hospital: ^ e T ' Iet w as bingt° n -"'"'
Garfield Memorial Hospital, 1938. R. B- Nelson J •*

223. , „ , .,. c , n A Bronchi*

Therapeutic Use of Iodized Oil in Chronic Bronc - 227. .

sis. W D. Tewksbury and E. R. Fenton, Wash
African Sleeping Sickness: Comparison with Denae _ ccC , ar j f \\n-
with Epidemic Encephalitis. E. de Savitsch ana

ington. — p. 231.

235.

Benign Paranoid Reactions. E. Klein, Washing ton. j f(
Argentaffinoma of Ileum: Report of Case. J. U.
ington. — p. 242.

Michigan State Medical Society Journal, Lansing

3S: 645-740 (Aug.) 1939 Aan '

Pioneer Sanitarians in Michigan. E. E. Kleinschmi ,

p. 659. . . Fr»«*

•Incidence of Idiopathic Hypertension in tne

MacCraken, Detroit.— p. 668. TheravY oi Pne 0 *' - '

Specific Therapy of Pneumonias: IL Serum

J. G. M. BiUlowa, New York.— p. 670. MacCtffc 3

Idiopathic Hypertension in the Young- j^n to
wonders whether the tendency on the part 0 disease c ‘

regard malignant or idiopathic hypertension prcss cr f

the forties may not be due to . the fact t w ^ KOl {j.

of younger persons are taken infrequent!). of .ye?

as one becomes older intercurrent conditions exf resJ

toms develop which take one to the physician hyped 61-
purpose of "having the blood pressure taken. ( j, c pat-*
sion is then discovered and attributed to the ag e a , [su-
whereas an earlier examination might P 0551 ' ;,y. D l " ?

disclosed a beginning hypertension ot less

CURRENT MEDICAL LITERATURE

1521

Volume 113
Number 16

consideration of this phenomenon, as an examiner for more
than 10,000 women between the ages of 20 and 30 applying
for positions as teachers, the author observed among other

■ things a distinct variation in blood pressure. While the blood
pressure of most of the women ranged around 120 mm. of

■ mercury systolic and less, about one in twenty showed a rise
, of from 20 to 30 mm. or more. These rises in systolic pres-
sure were not psychic as a rule but rather persistent over a
series of tests. In only about 0.1 per cent was any causative
factor isolated, though in each case a careful urinalysis was
made and further tests when possible. In the 500 cases only

.' meager histories and routine examinations were obtained. Only
twenty returned for reexamination following illness or some
other form of leave of absence but these consistently showed
the total absence of symptoms and gradual increase in tension.
'The absence of any “follow-up” in the majority of these cases
lowers the value of the information, but the author believes
that the presence of this factor in so many otherwise normal
persons opens a field for conjecture and investigation.

New Orleans Medical and Surgical Journal

92:61-112 (Aug.) 1939

Unification of Medical Profession for Protection of the Public. L. J.
Menville, New Orleans. — p. 61.

. i Present Concept of Cancer. J. T. Nix, New Orleans. — p. 65.

Metrazol Therapy in Psychotic Excitements. E. N. Carmouche, S. J.

Phillips, Pincville, La., and D. H. Duncan, Shreveport, La. — p. 67.
Pneumococcic Pneumonia: Treatment with Type Specific Serum. C. D.
Head Jr., New Orleans. — p. 73.

Theophylline Ethylenediamine (Aminophyllin) in Bronchial Asthma.

B. G. Efron and P. Everett, New Orleans. — p. 77.

Methods Used in Induction of Labor. M. B. Pearce, Alexandria, La.
— p. 79.

Undulant Fever: A Problem in Every Physician’s Practice. W. H.
Browning and J. S. Shavin, Shreveport, La. — p. 81.

. Trigeminal Neuralgia. D. H. Echols, New Orleans. — p. 87.

Fractures of Malar Bone and Zygoma with Eye, Ear, Nose and Throat
Complications. M. F. Meyer, New Orleans. — p. 90.

Aneurysm of Splenic Artery: Report of Case, with Special Reference to
Certain Aids in Diagnosis. J. G. Pasternack and J, R. Shaw, New
Orleans. — p. 94.

- New York State Journal of Medicine, New York

39: 1525-1636 (Aug. IS) 1939

Compensation for Eye Injuries: Its Past, Present and Future in New
York State. A. C. Snell, Rochester. — p. 1531.

Rationale and Results of Maggot Therapy in Chronic Osteomyelitis. J.

Buchman, New York. — p. 1540.

Acute Osteomyelitis. C, T. Harris, Rochester. — p. 1554.

*Su!fapyridine in Treatment of Pneumonia: Report of 100 Cases. B. R.
Allison, Hewlett.— p. 1558.

Newer Concepts ol Bacillary Dysentery and Other Types of Intestinal
‘ Infection. J. Eelsen, New York. — p. 1562.

Treatment of Varicose Veins and Varicose Ulcers: Experiences in 800
• ! Cases. P. H. Rakov, Syracuse. — p. 1569.

Diarrheal Diseases: Report of Findings in 220 Consecutive Cases.
W. Z. Fradkin, Brooklyn. — -p. 1578.

. jUicroscdimeter for Erythrocyte Sedimentation Test. H. Voilmer, New
York.— p. 1583.

Renal Sympathectomy. J. S. Ritter and L. A. Shifrin, New York. —

; P. 1587.

Pilonidal Sinus and Its Treatment. I. Silverman, Brooklyn. — p. 1598.

V Carcinoma of Bladder: Open Surgical Treatment. A. Harris, Brooklyn,
e — p. 1603.

Meningococcic Meningitis: Treatment of Case with Meningococcus
Antitoxin. A. M. Tunick and A, A. Goldbloom, New York. — p. 1608.
. Skin Reactions: VIII. Treatment of Hay Fever Coseasonally by Elec-
trophoresis of Active Constituent of Ragweed Extract: Preliminary
Report. H. A. Abramson, New York. — p. 1611.

. Jejunal Carcinoma: Report of Case. W. W. Jetter, Taunton, Mass. —
'J P. 1614.

Coronary Occlusion in Young Adults: Review of Literature with Report
of Case Aged 26. A. S. Ferguson, Newburgh, and J. R. Lockwood,
Highland. — p. 1618.

, Tonsillectomy in the Diabetic Child. A. H. Terry Jr., New York. —
P. 1622.

<’ Sulfapyridine for Pneumonia. — Since January 1939, Alli-

son points out, 100 cases of pneumonia have been treated at
i the Nassau Hospital. Every patient with pneumonia admitted

' to the hospital was given sulfapyridine whetlier or not a

1 1 Pneumococcus was found in the sputum. If a patient was

desperately sick on admission or did not respond promptly to
i the drug, serum also was given. The sputum was examined
.( at least once in ninety-seven cases. A pneumococcus was

- found in seventy, and twenty-seven were negative for pneumo-

The types of pneumococci found were I, III to VIII,
f XI ’ XIV to XXIII, XXVIII and XXIX. Blood counts and
urinalyses were done in all cases. The severity of illness of

these 100 patients was comparable to any similar series of
patients with pneumonia admitted to the hospital during recent
years. Sixty-one patients were admitted before the fourth day
of the disease, twenty on the fourth day and nineteen after
the fourth day. Forty-two cases occurred in children less than
10 years of age, nine of these occurring during the first year.
The average number of days spent in the hospital was 13.8.
Four of the 100 patients died, one infant and three adults.
Six of the seventy blood cultures performed were positive ;
three were type I, two type VIII and one was unidentified.
One of the patients with type I pneumococci, with a very
heavy growth, was addicted to alcohol, had hypertension and
made a dramatic recovery. One, with a heavy growth, died
in twenty-four hours in spite of 400,000 units of serum and
sulfapyridine. The third patient recovered after 300,000 units
of serum and 46 Gm. of the drug. Both patients with type III
pneumococcus recovered. The unidentified case also resulted
in recovery. An initial dose of 2 Gm. of the drug followed
by 1 Gm. every four hours was given in most of the adult
cases. Of the fifty-eight adults, twenty-eight received a total
of less than 15 Gm., fifteen received from 15 to 25 Gm., ten
from 25 to 40 Gm. and five more than 40 Gm. The average
total dosage was 19 Gm. The author’s impression is that small
doses, certainly much smaller than the 25 Gm. originally sug-
gested, will prove sufficient in many cases. In children a daily
dose of 0.2 Gm. per kilogram of body weight, reduced to 0.1
Gm. after the first twenty-four hours, is suggested. Children
seem to tolerate the drug so well that in some cases much
larger amounts were given. The average total dosage for
children was 7 Gm. This total dosage was well tolerated by
eacli of the nine infants. As a rule, the temperature in an
interval of from twelve to thirty-six hours showed a marked
drop and with it the pulse and respiratory rate. The general
appearance and sense of well being of the patient showed a
corresponding improvement. The temperature response seems
to be a good index of the extent of improvement. Twenty-two
of the twenty-seven patients in whose sputums no pneumococ-
cus was found showed a prompt response to treatment. It is
possible that further sputum examinations would have revealed
pneumococci ; otherwise such a high percentage of prompt
responses in nonpneumococcic pneumonias would not be
expected. There were no serious toxic signs in any of the
cases. The mortality rate at the Nassau Hospital for all
pneumonias during the last four years was 19 per cent in
1935, 20.9 in 1936, 18.1 in 1937 and 11 per cent in 193S.

Northwest Medicine, Seattle

38:273-316 (Aug.) 1939.

Personality Traits and Mental Hygiene. A. C. Ivy, Chicago. — p. 275.
•Hodgkin’s Disease with Herpes Zoster and Varicella. M. B. Marcellus,
Bayocean, Ore. — p. 279.

Etiology of Herpes Zoster and Varicella. R. T. Henson, Coeur d’Alene,
Idaho. — p. 283.

Gastrojejunocolic Fistula. C. R. Movvery, Spokane, Wash. — p. 283.

Spasmus Nutans. J. M. Cronin, Klamath Falls, Ore. — p. 286.

Blood Examinations in Lead Poisoning. T. E. P. Gocher, San Rafael,
Calif.— p. 289.

Venereal Disease Control in Oregon. S. D. Allison, Portland, Ore.
— p. 291.

Hodgkin’s Disease with Herpes Zoster and Varicella.
— Marcellus reports a case with the simultaneous coincidence
of Hodgkin’s disease, herpes zoster and varicella. The vesic-
ular eruption of varicella had a localizing effect on the herpes
zoster. Unlike some of the others formerly reported, this
patient showed the clinical characteristics of varicella with
symmetrical lesions which had thin and easily ruptured vesicles,
containing clear fluid at first which later became pustular; the
eruption spread rapidly and formed typical crusts; the mucous
membranes were involved and from the history there might
have been exposure to varicella, during leave from the hospital
the first day of which was just fourteen days prior to the
vesicular eruption, and the characteristic fever immediately
preceding an almost typical eruption strongly suggested vari-
cella or variola, but it is believed that, as he had been suc-
cessfully vaccinated, the latter may be ruled out. This case
undoubtedly represents the simultaneous existence of slowly
progressive Hodgkin’s disease, proved beyond a doubt by sev-
eral biopsies at different laboratories all of which agreed, and

1522

CURRENT MEDICAL LITERATURE

Jons. A. M A
Oct. 14, mi

herpes zoster closely followed by varicella, with no recur-
rences of either cutaneous eruption after the patient was dis-
charged from the hospital following the recovery from ,the
cutaneous lesions.

Psychoanalytic Quarterly, Albany, N. Y.

S : 279-408 (July) 1939

Discovery of Eilipus Complex: Episodes from Marcel Proust. G. Zit-
fioorg, New York.- — p. 279.

Problems of Psychoanalytic Technic. O. Fenichcl, Los Angeles. —
p. 303.

Sublimation. Frances Deri, Los Angeles. — p. 325.

Significance of Theatrical Performance. R. Sterba, Detroit. — p. 335.
Experimental Demonstrations of Psychopathology of Everyday Life.

M. H. Erickson, Etoise, Mich. — p. 338.

Associative Anamnesis. F. Deutscli, Boston. — p. 354 .

Public Health Reports, Washington, D. C.

54: 1467-1508 (Aug. 11) 1939

Plague ill the Western Part of the United States: Infection in Rodents,
Experimental Transmission by Fleas and Inoculation Tests for Infec-
tion. C. R. Eskey and V. H. Haas. — p. 1467.

Observations on Infectious Agent from Amblyomma Maculatum. R. R.
Parker, G. M. Kohls, G. W. Cox and G. E. Davis. — p. 1482.

Radiology, Syracuse, N. Y.

33: 131-200 (Aug.) 1939

Roentgen Kymographic Study of Alterations in Pathologic Heart During
Valsalva and Muller Tests. A. C. Morclli, Montevideo. Uruguay;
translation by M. Wright. — p. 131.

Rational Radiotherapy. G. W. Grier, Pittsburgh. — p. 148.

'Cystic Disease of Lung. L. R. Santc, St. Louis. — p. 152.

Treatment of Polycythemia Vera with Roentgen Ray. I. I. Kaplan,
New York. — p. 166.

Intestinal Movements in Ileocecal Region. A. E. Barclay, Oxford,
England. — p. 170.

Radiology in Teaching of Anatomy. I. C. C. TchnperofT, London,
England. — p. 177.

Megaduodenum and Duodenal Obstruction: Criteria for Diagnosis. M.
Sturtcvant, New York.— p. 185.

'Reducing Toxic Period in Hyperthyroidism. S. C. Barrow, Shreveport,
La.— p. 189.

Roentgen Ray Treatment of Skin Cancer. C. W. Perkins, Norwalk,
Conn. — p. 191.

X-Ray Study of Lungs of Workmen in Asbestos Industry, Covering
Period of Ten Years. A. W. George and K. D. Leonard, Boston.—
p. 196.

Ulcer Niches with Stopper-Shaped Vascular Defect. A. Akerlund,
Stockholm, Sweden. — p. 203.

Biology of Bone Metastases. J. Borak, Vienna, Austria; translation by
F. J. Lust, New York. — p. 208.

Further Notes Concerning Traumatic Subdural Hematoma. S. W. Gross,
New York. — p. 213.

Aneurysm of Pulmonary Artery. F. M. Grocdel, New York. — p. 219.
Roentgen Diagnosis of Abdominal Effusions. R. A. Rendicli, B. Ehren-
preis and T. Frattalone, Brooklyn. — p. 233.

Cystic Disease of Lung. — Saute refers to abnormal con-
fined collections of fluid within the lung as cysts and to air-
filled cavities as pneumatoceles. One of the most common
types of lesion referred to as cystic disease is seen as multiple
thin-walled pneumatoceles, clustering about the larger bronchial
branches in the hilar regions and adjacent areas, giving rise
to the condition referred to as cystic bronchiectasis. When
the cavities are small and their walls are thick the term honey-
comb has been applied to their appearance. Fluid cysts and
pneumatoceles of the lung arise as results of definite derange-
ment in' the lung structure. These derangements can be either
congenital from faulty embryologic development or acquired
from infection and fibrosis. The factors which primarily influ-
ence the degree of inflation of such pneumatoceles, in which
free bronchial connection is present, are the relationship of
the resistance of their walls to the resistance of normal alveolar
structure supplied by a bronchiole of equal size to the opening
supplying the cavity. The pressure in the ppeumatocele cannot
exceed atmospheric pressure. On x-ray examination there
should be no deviation of the mediastinum at any time. In
instances in which a simple check-valve opening permits
entrance of air on inspiration but checks it on expiration, the
pneumatocele will enlarge in size until an equilibrium is estab-
lished; the pressure within the pneumatocele cannot become
greater • than that of the atmosphere at maximal inspiration
but may exceed this at expiration, also causing the mediastinum
to be in normal position on maximal inspiration but displaced
to the opposite side on expiration. Pneumatoceles which con-
tinue to expand showing higher than atmospheric pressure at
all times during the respiratory cycle would seem to require

the. addition of some unusual pumping force to account h
their expansile character. Fluid cysts may result only nfa
the defect involves a bronchial structure which still retain;
secretory power. Pneumatoceles arising from the alveoli'
structure as a result of emphysematous involvement stall
not be preceded by fluid cysts, since they are not lined t;
secretory epithelium.

Reducing Toxic Period in Hyperthyroidism— For son
years Barrow lias believed that the dosage oi x-rays giten ia
the treatment of hyperthyroidism, even by those of wide experi-
ence, is insufficient for the best interests of the patient. Ai
the mysteries and intricacies of the ductless gland system unfold
it is well to hear in mind the possibility that there may k
other functions of the thyroid than those now recognized.
Surgical removal of the thyroid or proper irradiation oi fo
gland alone will restore the patient to normal. However, to
organ of the body should be removed because of dysfunction
or excess function when it is possible- to correct its function'll?
processes. The depressant action of' x-rays in all conditions
ciiaracterized by hyperfunction or excess cell activity is recog-
nized. The only argument which has been advanced against
roentgen therapy for hyperthyroidism is the time usually con-
sumed in bringing the patient to a nontoxic state. Small dosage
at long intervals seems to be the practice generally followed.
The object of the surgeon has been to remove with one stroke
the source of toxicity, the thyroid gland. Why not, tliR
suppress this toxicity as 'abruptly by radiation? Following the
use of comparatively large doses of x-rays in extremely tone
cases of hyperthyroidism, the author lias never seen any >
effects. On the contrary, by the application of rather intensive
dosage only good results have been seen, the most toxic
becoming nontoxic in from four to ten weeks rather tmn t
from six to nine months (the usual time required xv’itli sw
doses of x-rays). If the metabolic rate is high, plus J ,
more, the application of 750 roentgens weekly, the dose
over three areas, right and left anterior lateral and P 05 ’"'"
with a kilovoltage of about 130 and 3 mm. of aluminum
is the minimal dosage indicated. This may be repeate r
six to eight times at intervals of seven days, with no > c
on the skin. The metabolic rate should be checked ear i f
and the doses should be spaced at longer intervals or ec •
as the metabolic rate falls. The metabolic rate swW .
reduced to zero before treatment is discontinued; otlcr " W
exacerbation will inevitably follow. The fear of
following irradiation is hardly to be considered when n ^
is applied intelligently. Intense radiation given over ^
void area in cases in which tile thyroid is norma ' ,

shown any bad effects on the gland. Under circums a
which it is difficult because of distance or other causes
weekly applications, still more intensive dosage may c
at intervals of fourteen days (200 kilovolts, 0.75 mm. o ^
filtration, with 1,200 roentgens distributed over t,ire .||
This technic may likewise he repeated with safety u ^
require as many applications, because the metabo tc r
rapidly. In the treatment of all cases, foci of 11 \ v jil
be removed, iodine withheld and quinine used b c ” J(
of course, restrained activity as indicated. Two c *
presented indicating the conditions existing, in two tyP 1 ‘
of hyperthyroidism, with the treatment given and le
obtained.

Texas State Journal of Medicine, Fort Worth

35: 259-324 (Aug.) 1939

am

11. J- Sun* r ’ •

Use of Liver and Iron in Treatment of Anemia- R-
land. — p. 266.

General Considerations of Toxemias of Pregnancy.

York.— p. 270, # ,. TTfnar

Operation for Chronic Dislocation of Inferior Radio

J. L. Taylor, Houston. — p. 278. - - . ,i Ratio n2 ‘ c

Chronic Leg Ulcers: Discussion of Pathogens®* f ^

Treatment. R. S. Fillmore, Jacksboro. P- 28 1* An?*""

Progress in Biliary Tract Surgery. C. A. ^

p. 286. t Rectum*

Use of Electrocoagulation in Treatment of Tumors

Hayes and If. B. Burr, Houston, p. 29— Control.

Sterility Treated 5y Uterotubal Insufflation with

Martin, Dallas. — p. 295. , r . - !on _n. 200. ,,

Artificial Pneumoperitoneum. B. O. Lewis, G *’ j r.

Sonic Aspects of Public Health Control of >P
New Orleans. — p. 305.

Volume 113
Number 16

CURRENT MEDICAL LITERATURE

1523

FOREIGN

An asterisk (*) befntc a title indicates that the article is abstracted
below. Single case reports and trials of new drugs arc usually omitted.

In the author’s series the electro-encephalogram has always
been normal when the encephalogram was normal, but further
work is necessary before the reliability of the method can be
assessed accurately.

British Journal of Radiology, London

IS: 449-504 (Aug.) 1939

Report on Skiagraph ic Terminology in Pulmonary Disease. The Joint
Tuberculosis Council. — p. 449.

Asymmetry of Skull in Relation to Subdural Collections of Fluid.
J. Hardman. — p. 455.

Short-Distance Low-Voltage X*Ray Thcrap}. P. A. Flood and D. W.
SmHhers. — p. 462.

Effect of Gamma Radiation oti Cells in Vivo: Part II. A. Glticksmnnn
and F. G. Spear. — p. 4S6.

Radium Implant Rcconstructor. II. M. Farkcr and \V. J. Meredith.
— p. 499.

British Medical Journal, London

2: 155-208 (July 22) 1939

Pharmacologic Actions and Therapeutic Uses of Some Compounds Related

to Adrenalin. J. A. Gunn. — p. 155.

* Electro-Encephalogram as Aid in Clinical Neurology. R. A. Krynanw.

— p. 160.

Seasickness. R. J. Blackliam. — p. 163.

Acute Phlegmonous Gastritis in Pregnancy. T. Barnett and D. P.

Harris. — p. 167.

Cobalt as Factor in Control of Nutritional Anemia. H. II. Corner. —

p. 169.

Electro-Encephalogram as Aid in Clinical Neurology.
— From experience to date in the examination of intracranial
tumors, although the electro-encephalogram is surprisingly
accurate in localization in most cases, Krynauw states that the
additional help given by ventriculography should not be dis-
pensed with when operation is contemplated. Information as
to the depth of a neoplasm, its absolute size and its relation to
the ventricles, basal ganglions and the like can be obtained at
present only by adequate air studies; and such information is
essential in planning the scope of an operation or deciding on
the operability of a tumor. Electro-encephalography by itself
is no short cut toward the establishment of the anatomic
and pathologic diagnosis of intracranial lesions. Considerable
interest is attached to the study of the epilepsies by this method.
Nevertheless it is in the epileptic group that the greatest diffi-
culty occurs in the evaluation of results. In many cases of the
group known as “idiopathic grand mal” there is constant elec-
trical flux, sometimes generalized and arising from the whole
cortex but often arising from one or more foci. In some cases
the changes resemble closely those found in association with
expanding lesions. In some cases, too, there is a tendency
toward a frequent shift of the focus. These remarks apply only
to those cases of epilepsy in which there is a “resting focus”
of electrical flux ; that is, changes which can be detected between
the actual fits. These changes are constant in that individual
and do not bear any time relation to the actual fits. There is,
however, evidence that before a fit, perhaps for hours, a day
or even longer, there is an accession in the electrical changes.
On records taken at such times, bursts of waves of increased
amplitude and varying rate appear not at all unlike the “larval”
attacks of petit mal described by Lennox and his associates.
There are many cases that clinically appear to be idiopathic
grand mal in which the author has not been able to detect any
abnormality of tlie electrical rhythm. Why this should be so
is difficult to decide, but from his experience there seems to
be some relation between the resting focus and cortical degenera-
tion. In cases in which numerous minor seizures occur there
is an almost constant electrical flux with occasional sudden
bursts of increased activity which have been described as
larval or subclinical seizures, and then again the actual petit
mal attacks with even greater alterations of amplitude. The
pyknolepsies are said to fall into this group. It has been claimed
that in the so-called traumatic epilepsies there is never any
evidence of a resting focus of electrical abnormality. The
author’s experience supports this, for many cases with fits after
a head injury have yielded negative observations on electro-
encephalography. However, he has records of several cases of
gross localized cortical damage in which alterations of potential
were observed, similar to those found with expanding intra-
cranial lesions. In such cases he has assumed an underlying
area of gliosis. In patients in' whom the onset of fits occurs
u> later life after the age of 40 , the possibility of an expanding
lesion should be ruled out, and air studies are often called for.

Irish Journal of Medical Science, Dublin

No. 163: 289-336 (July) 1939

Combating Tuberculosis in a Swedish City. A. Wnllgren. — p. 289.
Method and Significance of Blood Alcohol Estimations. J. McGrath. —
p. 304.

Sarcoma of Prostate in Children. I. Fraser. — p. 330.

Lancet, London

2: 171-236 (July 22) 1939

Mechanism of Diabetes Mellitus. H. P. Himsworth. — p. 1 71 .

"Ureteric Catheterization in Pyelitis of Pregnancy. V. \V. Dix and
H. Evans.- — p. 176.

Vertebral Fractures Complicating Convulsion Therapy. H. A. Palmer.
— p. 181.

Importance of Bronchoscopy in Unresolved Pneumonia. J. E. G.
McGibbon, E. T. Baker-Bates and J. H. Mather. — p. 183.

Surgical Conservation of Hearing. A. Tumarkin. — p. 189.

Angina in Pernicious Anemia with Electrocardiographic Changes and
Abdominal Aneurysm. S. Vatcher. — p. 192.

Histiocytic Medullary Reticulosis. R. B. Scott and A. H. T. Robb-Smith.
— p. 194.

Ureteral Catheterization in Pyelitis of Pregnancy. —
During a period of four years Dix and Evans state that eighty-
four cases of pyelitis of pregnancy were admitted to the London
Hospital, and of these only seven required ureteral drainage :
five because of failure to respond to alkali therapy and two
because of excessive vomiting, making the administration of
alkali impossible. Nine ureteral catheterizations were carried
out. In one instance the second catheterization was necessary
because the first catheter was removed by a nurse when tlie
patient returned to the ward, and in another the second catheter-
ization was performed three and a half months after the first
during a recurrence of pyelitis. In no case was it necessary
to use an anesthetic. Catheterization of the ureter during preg-
nancy is not easy and should be carried out only by the expert.
If it should ever be necessary for the relatively inexpert to
attempt catheterization in the later stages of pregnancy, an
anesthetic should be given to minimize the difficulties. When
the ureteral orifice has been identified and the catheterization
has begun there should be no difficulty, and the fact that the
catheter has reached the renal pelvis will be at once evident
from the rapid flow of urine, which is considerably in excess
of that from a ureteral catheter of the same size passed into
a normal pelvis. In cases in which there has been a complete
block at the pelviureteral junction the flow may be rapid. It
is advisable to pass as large a catheter as possible. The sizes
used have been 10 and 12. Great care must be taken, in with-
drawing the cystoscope, to avoid displacement of the catheter.
The catheter is attached to the leg and the urine is allowed to
drain into a bottle. The catheter was usually left in place for
three or four days. However, equally good results might be
obtained if the catheter remained in place for only one or two
days, although there would perhaps be a slightly increased risk
of recurrence. It should be removed at once if urine ceases to
run freely and gentle syringing fails to reestablish the flow.
The effect of catheterization and drainage alone on the seven
patients was so good that no additional treatment was needed
except the continued administration of citrate. Premature induc-
tion of labor should rarely, if ever, be necessary, even in severe
pyelitis of pregnancy. One case of postpregnancy pyelitis was
also treated successfully by catheterization.

Medical Journal of Australia, Sydney

2: 155-192 (July 29) 1939

Health of Fetus, or True National Insurance: Review of Certain
Aspects of Fetal Environment. R. Fowler. — p. 155.

Review of Experience with Cyclopropane. G. Troup. — p. 164.
Anesthesia for Specialist Nose and Throat Services. R. H. Orton.— p.
168. **
Anesthesia in Acute Intestinal Obstruction. G, Brown. p. 170.

£>outn Atncan Medical Journal, Cape Town

13: 507-534 (July 22 ) 1939

Diagnos’s and Treatment of Common Anemias. J. F. Brock.— p 509
Bladder Neck Hnnary Obstruction. S. McMahon.— p. 517. P "

Surgical Treatment of Cholecystitis am! Gallstones. N. Garber — p 520
TtOierculos^s of Temporal Bone -in Infants and Young Children." IL

1524

CURRENT MEDICAL LITERATURE

Jour. A. M. A
Oct. H, 1933

Journal Beige d’Urologie, Brussels

12:197-276 (Aug.) 1939. Partial Index
•Amicrobic Pyuria. J. A. WeytJandt. — p. 197.

Cicatrizations of Tuberculous Renal Lesions Revealed by Retrograde

Ureteropyelography. M. Chevassu. — p. 202.

Case of Crossed Ectopic Kidney: Remarks on the Surgical Treatment.

R. Gouverneur. — p. 211.

Two Cases of Acquired Vesical Atresia. F. H. de Bcaufond. — p. 215.

Amicrobic Pyuria. — Weytlandt directs attention to cases of
cystitis and pyelocystitis in which the urine is free from micro-
organisms. He thinks that in cases of this type it is necessary
to consider first the possibility of renal tuberculosis even in the
absence of acid-resistant bacilli. Another factor that must be
considered is that during infections with colon bacilli there are
periods in which no organisms are found in the urine even if
cultures are made. The cases mentioned so far are false cases
of amicrobic pyuria, but there are also cases of true amicrobic
pyuria. In this connection the author mentions first cases of
leukocyturia that are caused by mechanical or chemical irrita-
tion. Then there is a group of pyurias in which all cultures,
including those for tubercle bacilli, remain sterile and in which
even inoculations into guinea pigs produce negative results.
The author says that it was Soderlund who in 1922 first called
attention to this type of pyuria, which can be considered as a
separate disease entity. The number of cases which have been
reported since then is small, but this amicrobic pyuria is never-
theless of practical importance. Those who know it will doubt-
less have occasion to diagnose it. Moreover, this disorder, which
formerly was extremely chronic and annoying is now curable,
Wildbolz having discovered that it yields promptly to treatment
with neoarsphenamine. In view of the fact that this form of
amicrobic pyuria was first described by Soderlund and was first
successfully treated by Wildbolz, the author suggests that it be
designated Soderlund- Wildbolz disease. The etiology of the
abacterial pyuria is still unknown, but in view of the curative
effect of neoarsphenamine it is suggested that an infectious
process is involved but that the causal agent is not necessarily '
a spirochete. The author describes the history of the case of
amicrobic pyuria which he himself observed. The disorder
began with hematuria, which was followed by cystitis. The
urine contained large numbers of leukocytes but no micro-
organisms. Syphilis could be ruled out on the basis of the
negative outcome of several serologic tests. When treatment
with methenami ne, phenyl salicylate and sulfanilamide had failed,
the author resorted to intravenous injection of ISO mg. of neo-
arsphenamine. The first dose having produced considerable
improvement, the patient was given two additional injections
of 300 and 450 mg., respectively, at intervals of five and six
days. The author thinks that two injections will suffice in most
cases.

Presse Medicale, Paris

47: 1221-1228 (Aug. 9) 1939

•Condition of Adnexa in Uterine Fibroinyomas and Their Surgical Con-
sequences. A. Chalier. — p, 1221.

Adnexa in Uterine Fibromyomas.— Chalier cites prognos-
tic and physiologic considerations which indicate that operative
treatment is advisable for the majority of patients with uterine
fibromatosis, but he also stresses that the idea of conservation
should be foremost in the mind of the surgeon, since the majority
of women who require treatment for uterine fibromatosis are
'of the age group between 28 and 50; that is, they are women
who are in the period of genital activity, and the majority still
menstruate. As regards the problem of conservation, attention
must be given particularly to the uterine adnexa, and the first
question which presents itself is the anatomic condition of the
adnexa in patients with uterine fibromyoma— in how many
cases of uterine fibromatosis the adnexa are diseased. In order
to throw light on this problem, the author carefully inspected
the adnexa of 212 patients who received surgical treatment for
uterine fibromas. He found the adnexa diseased in 161 of the
719 cases more than three fourths. Most frequent were the
purely ovarian lesions, which were observed in 104 of the 212
patients Purely tubal lesions were comparatively rare, exist-
nir in eleven of the women. Mixed tubo-ovanan lesions were
detected in fortv-five cases. The author discusses to what extent
it was possible to employ conserving methods in the surgical

treatment of these 212 patients. As regards the uterus, conserr-
ing operations could be employed in only twenty-four ol the
cases. These include six supra-isthmic hysterectomies, three
hysterectomies of the fundus and fifteen myomectomies. In the
other 188 cases the uterus had to be mutilated: total hysterec-
tomy in thirty-eight and supravaginal hysterectomy in the other
150. Conservation of one or both of the adnexa was possible
in ninety-eight, nearly 50 per cent of the cases. From this the
author draws the conclusion that in spite of the frequency and
severity of the adnexal lesions associated with uterine fibroma
it is possible to preserve all or part of the ovarian apparatus
in nearly 50 per cent of the cases.

Revue Neurologique, Paris

72:1-136 (July) 1939

* Basophil Adenoma of Hypophysis. A. Austregesilo, I. Costa Rodrigues
and A. R. de McHo. — p. I.

Intradural Fibrolipoma of Medulla. J. Jabotinski. — p. 15.
Oligodendroblastoma Involving Corpus Callosum: Consideration of Syn
drome of Corpus Callosum. O. Sager and I. Bazgan.—p. 32.

Basophil Adenoma of Hypophysis. — Austregesilo and his
associates studied the clinical, endocrine and roentgenologic
aspects of a case of Cushing’s disease in which the diagnosis
could be confirmed by anatomopathologic examination. The)
give a detailed description of the history of the patient, a woman
aged 44. Since 1914, when she had entered a psychiatric hos-
pital for the first time, she had become extremely obese ana
hairy. In 1937 she presented severe obesity, hirsutism, viriliza-
tion and anomalies of the menstrual cycle. Her face was row
and moon shaped. Her organic resistance was reduced an
she was easily fatigued. Her mentality was oligophrenic.
Roentgenography of the sella turcica showed normal outlines.
After describing the results of the humoral examinations, s
authors show that these, like the clinical syndrome, in
basophil hypophysial hyperhormonism with involvement o
other endocrine glands. The necropsy disclosed in the a *
portion of the prehypophysis an adenomatous formation, t ie s
of a small pea, which at some points was separated from
glandular parenchyma by a thin capsule, whereas at other po
there was no separation. The cells of the adenoma sl °
basophil granulation. The authors point out that toe P* ,
docs not present the complete symptomatology of u . s ,| ie
disease, but they also show the multiple variations t0 !' C c ' t ; K .
clinical aspects are subject as a result of the plurien °
metabolic deviation, according to whether there is a 0 (

or an inhibiting preponderance of certain groups 0 ^

hypophysial secretion. They also direct attention to “ ^
tions between the hypophysis and the diencephalon. ie > ^
that the incomplete clinical forms of Cushings disease
most frequent, but because of the difference in symptom
the clinical diagnosis of these forms presents difficu ties.

Schweizerische medizinische Wochenschrift, Ba

G9: 757-780 (Aug. 26) 1939 j, u0M

The Labyrinth Does Not Represent the Organ of Equilibrium i
Subjects. S. Erhen. — p. 757. Wriri.— P- ~ iS '

Aspects of Bronchial Carcinoma, hi. Dressier and A. 7 67.

New Model of Hash's Magnet. O. Haab and A. S>c»n«« •

“Panic: Nature, Causes and Treatment. E. Bircher. P- J9J3 1°

Alcoholism in .Medical Clinic of Geneva During the
1936. M. Roch.— p. 772.

. nirclier P° im

Panic: Nature, Causes and Treatment. ^ injuries
out that during catastrophes treatment of the ■ - ans 35 >>
is as important and as much the duty of the p ) n J0 the
that of the physical injuries, and so he directs a ^ a |so
problem of panics which occur not only during '' t j iea teri,
in the course of earthquakes, mine accidents, ire mcleoro |ogi c
shipwrecks, explosions, devastations causer y .. ses and
catastrophes, volcanic eruptions, famines, epiacnii sma |l or
so on. Panic is a fear neurosis which deve ops [car

large number of persons under the influence j t j n 3

brought on by a catastrophe. This emotion ™ ,j orl| whirr 1
sudden impairment of the consciousness an 1 ^ stuporc’*-

leads to senseless excitement or, more rare - ’ • destroyer-

inhibition. The thin upper layer of consciousne 0 f tnc

by the unexpected catastrophe and the strong ^ bee 011 ;-,
subconsciousness come suddenly to the_ sur a 0 f «s»

dominant. The most important of these instinc

Volume 113
Number 16

CURRENT MEDICAL LITERATURE

1525

preservation. If this instinct becomes manifest in a mass, the
phenomenon of mass fear results, which may degenerate into
wild, uncontrolled flight. At the onset not all the members of
the group are necessarily in the grip of this fear. It is enough
that some, usually those having a psychopathic constitution, the
unstable, succumb to the threat and in a mysterious, epidemic
suggestion, everybody, even the strongest, is carried along. The
author further discusses various types of panic, military, eco-
nomic and so on, and points out that panics are observed also
among animals. He thinks that the attitude toward life plays
a part in the development of panics ; that Asiatics and Moham-
medans, whose attitude is more fatalistic, are less likely to be
influenced by catastrophes than are Europeans, for instance.
Some peoples seem to be more predisposed to panics than are
others, but none are entirely immune to them. The degree of
reactivity may differ, but culture or civilization does not have
much effect in this respect, for panic is an atavism toward the
primitive, perhaps even to the animal. The greater the discipline
among a people, the lesser is the danger of panic. Declining
and weakened peoples are more subject to panic than are others.
In the therapy of panics, personalities with self possession,
resolute determination and clear vision are most important, for
they alone will know how to overcome the panic by the power
of suggestion. Psychologic education of the masses and
strengthening, of the authority arc important in counteracting
the tendency toward panics. Discipline which comes from within
and which is based on conviction or a great idea is stronger
than that which is imposed from the outside.

Zeitschrift fur klinisclie Medizin, Berlin

130:439-576 (July 27) 1939. Partial Index
Indication lor Blood Transfusion in Internal Medicine and Its Thera-

peutic Effect. H. Toussaint. — p. 439.

Effects of Tobacco on Teeth. L. H. Strauss and J. Fockcler. — p. 468.
•Hereditary Biology of Pernicious Anemia. O. Kaufmann and K.

Thiessen. — p. 474.

Dependence of Surface Tension on Hydrogen Ion Concentration. C. J.

Keller and O. Kunzel. — p. 507.

Structural Changes in Granulocytes After Administration of Aminopyrine.

H. Bernigau. — p. 517.

Changes of Red Blood Picture After Gastric Resection. Magdalene

Dreher.— p. 525.

Significance of Typical and Atypical Bundle-Branch Block for Estimation

of Working Capacity. L. H. Strauss and F. Bolt. — p. 560.

Heredity in Pernicious Anemia. — Citing reports from the
literature, Kaufmann and Thiessen show that it cannot be
doubted that hereditary factors play a part in the pathogenesis
of pernicious anemia. In order to obtain more information
about this problem, they made studies on the relatives of patients
with pernicious anemia. Their material comprises forty-eight
family groups, in which 168 persons were examined. Speci-
mens of gastric juice of an additional twenty-three relatives
were examined, and anamnestic data of a number of other
relatives were obtained by means of questionnaires. Summariz-
ing the results obtained in these studies, the authors say that
they detected the multiple occurrence of pernicious anemia in
eight of the forty-eight families, that is in 16.7 per cent. Once
it occurred in uniovular twins, once in three sisters, twice in
mother and son, twice in brothers, once in brother and sister and
once in cousins. That they detected multiple familial occur-
rence of pernicious anemia more frequently than did other
investigators is ascribed by the authors to the fact that most of
their patients with pernicious anemia were of an advanced age
so that an existing predisposition in siblings and other rela-
tives had time to become manifest. The multiple familial occur-
rence of pernicious anemia is so considerable that accident cannot
explain it and heredity must be assumed. The authors also
observed the concurrence in the same families of pernicious
anemia and essential hypochromic anemia. They say that the
familial concurrence of these two forms of anemia has been
reported so frequently that a. common hereditary factor must
j>e assumed. A pathogenic connection of the two disorders is
indicated also by the repeated observation of a transition of
essential hypochromic anemia into pernicious anemia. The
multiple appearance in their material of anacidity, of subacidity,
of hematic symptoms resembling those of pernicious anemia, of
soreness of the tongue and of atrophy of the lingual mucosa is
regarded by the authors as further evidence of the transmission

of hereditary factors of pernicious anemia. They gained the
impression that the increased incidence of anacidity or sub-
acidity in the families of patients with pernicious anemia is of
especial significance because its hereditary transmission appar-
ently is dominant. Their statement that the results of their
investigation indicate hereditary origin in about half of their
cases does not signify that in the other cases signs of hereditary
transmission were entirely absent; cases in which there were an
increased color index and hypersegmentation but normal gastric
secretion were not grouped with those in which hereditary origin
was certain. They consider it possible that heredity plays a
part in all cases of pernicious anemia. On the other hand, they
think that there may be purely exogenic, nonhereditary cases
of pernicious anemia.

Nederlandsch Tijdschrift v. Geneeskunde, Amsterdam

83: 3573-3684 (July 15) 1939. Partial Index
Nerve Injuries in Fractures of Lotver End of Humerus. L. D. Eerlaml.
— p. 3574.

Determination of Hormones in Urine of Patients with Tumors of Testes,
Especially with Chorionepithelioma. E. Dingemanse and E. Lariueur. —
p. 3582.

Leptospirosis in Atjeh. G. F. Kotter. — p. 3590.

"Action of Subcutaneously Administered Carbon Dioxide Gas in Angio-
spastic Disorders. J. C. Mom. — p. 3595.

Suppurating Pulmonary Cyst Treated by Lobectomy: Case. H. W.
Hoefnagcls. — p. 3598.

Subcutaneous Carbon Dioxide in Angiospastic Dis-
orders. — Mom points out that carbon dioxide stimulates the
respiration as proved by the administration of oxygen-carbon
dioxide mixture in cases of asphyxia. He discusses particularly
the stimulating effect of the subcutaneously administered gas on
the terminations of the vagosympathetic nervous system in the
skin. Having observed that Romeuf employed this treatment
with success in vasomotor disturbances, such as intermittent
claudication, acrodynia, acrocyanosis and Biirger’s disease, the
author also decided to try it. He injects each time from 40 to
SO cc. of the gas under the skin of the arm or leg. If neces-
sary, from 300 to 400 cc. can be injected in one session at
different sites. The use of a manometer is desirable so that the
pressure of 2 meters of water (about 150 mm. of mercury) is
not exceeded. A patient who is resting requires from four to
sixteen hours for resorption, an ambulatory patient several hours.
The vasodilator effect of this treatment produces a better blood
perfusion of the treated area.

83: 3769-3872 (July 29) 1939. Partial Index
Psittacosis in Amsterdam Detected with Aid of Complement Fixation

Reaction. A. Charlotte Ruys, A. L. Noordam and H. Vervoort.

p. 3776.

•Effective Insulin Suppository. B. Brahn and T. Langner. — p. 3784.
Ambulatory Feeding with Jejunal Tube in Patients with Gastric and
Duodenal Ulcers. R. A. Hoekstra. — p. 3791.

Treatment of Adiposity. J. Groen. — p. 3799.

Effective Insulin Suppository.— Brahn and Langner say
that rectal administration of insulin has not been possible here-
tofore because insulin is destroyed by tryptic ferments. The
authors decided to find a way to protect the rectaliy administered
insulin against destruction (1) by adding acid in order to pro-
tect it against tryptic digestion and (2) by adding substances
that increase surface tension so as to increase the rapidity of
absorption. In numerous experiments on animals and human
subjects the authors demonstrated that suppositories consisting
only of insulin and cocoa butter (theobroma oil) are ineffective
in animals as well as in- human subjects. However, by adding
acid it was possible to make the insulin effective and protect
it against tryptic influences. The authors experimented with
hydrochloric acid and with several organic acids such as lactic
acid, acetic acid, citric acid, tartaric acid and palmitic acid.
They found most effective a mixture of lactic and palmitic acids.
Because the latter acid has a melting point of 60 C., it must
be mixed with cocoa butter in a ratio of 15:85, thus bringing
the melting point to about 33 C. Further experiments proved
that the addition of saponin increases the efficacy of insulin
suppositories. Experimenting with various types of saponin,
the authors found that saponaria saponin, although harmless in
oral administration, is dangerous in rectal administration. Other
saponins were found to be harmless, however. Following rectal
application of the insulin suppositories prepared by the authors.

1526

CURRENT MEDICAL LITERATURE

Join. A. Jr. A
Oct. R m

the effect on the blood sugar is rapid, the maximum being
reached in from thirty to forty minutes. After that the action
decreases rapidly. Increasing the insulin dosage not only inten-
sifies the action but also prolongs its duration.

Acta Medica Scandinavica, Stockholm

100 : 485-606 (July ]) 1939 '

•Role of Hypophysis in ' Pathogenesis of Total Alopecia. E. Kylin and
E. Dicker. — p. 485.

Reticular Cells in Human Bone Marrow and Genesis of Monocytes.
N. G. Nordenson. — p. 507.

Effect of Ingestion of Food on Plasma Proteins. J. B. Rennie. — p, 545.

Determination of Urine Fluorescence and Its Diagnostic Value, Especially
in Carcinomas. F. I. Simon. — p. 553.

Carbohydrates in Diabetes Therapy With or Without Insulin. M.
Lauritzen. — p. 559,

Angina Pectoris and Pressoreceptor Regulation. S. Wassermann and
H. Weber.— p. 589.

Hypophysial Deficiency in Alopecia. — Kylin and Dicker
report the clinical analysis of alopecia in twenty-nine persons
(thirteen male and sixteen female) ranging in age between
S and 61 years. A hereditary tendency was established for nine
of the fifteen patients questioned with regard to familial occur-
rence. Two cases are given in detail and their mcndclian sig-
nificance pointed, out. The disease, characterized by partial or
total loss of hair at all areas of the body, did not affect the
general health, left basal metabolism and blood pressure nearly
always normal, occurred in six cases synchronously with the
first menstruation, was accompanied by dental caries in four-
teen, by brittleness of the nails and cutaneous -modifications in
fifteen, by constipation in half of the cases and -by the appear-
ance of anxiety, frequent headaches and constant chilliness and
asthenia in 50 per cent at its first manifestation. With endo-
crine abnormality clearly in evidence, the authors were led to
eliminate the direct pathogenesis of the sexual, adrenal, thyroid
and parathyroid glands and to concentrate on the hypophysis
as the causative factor. In this they were supported by the
clinical evidence of a previous case’ incorporated in the paper.
Therapy of the cases studied was twofold: (1) oral doses of
hypophysial (anterior lobe) extract, which resulted in three
complete cures, two partial cures and one negative issue; (2)
grafting of two whole calf hypophyses, yielding two complete,
four partial and two negative issues. (The previous patient was
therapeutically managed both ways and cured after intervention
of pregnancy and recidivation of alopecia.) The authors buttress
the paucity of their cases arid cures by reference to those of
other therapists. They regard the amelioration or success
obtained with other endocrine medicaments as confirmatory of
their own, in view of the dominance of the hypophysis in the
endocrine system. Among the conclusions of the authors the
following may be mentioned : 1. Complete alopecia affects both
sexes at all age levels, with the greatest incidence at the age
of 23 to 25 years. 2. Total alopecia is heritable and obeys the
mendelian laws. 3. The hypophysis plays an important part,
though it cannot at present be determined whether the whole
gland is involved or, only one of its parts and whether the
gland affects pilosis directly or through other endocrine glands.

4. Grafting with whole calf hypophyses gives just as good results
as oral or parenteral administration of hypophysial extract.

Nordisk Medicin, Helsingfors

8:2051-2132 (July 8) 1939. Partial Index
Hospitalstidende

‘After-Examination of Patients with Uncomplicated Concussion of Brain,
with Special Regard to Importance of Duration of Primary Rest in
Bed. S. With.— p. 2057.

Icelandic Mud for Mud Packs. K. Hannesson. — p. 2072.
After-Examination in Concussion of Brain. — With
asserts that brief individualized confinement to bed in uncom-
plicated concussion of the brain does not seem to give less
favorable results either as to the time when the patients, are
able to resume their full work or as to the number of patients
whose injuries are permanent than in corresponding groups
treated with prolonged rest in bed, nor is the tendency to graver
permanent injuries greater. He reviews the 394 cases (272 of
mild, ninety-seven of moderate, twenty- five of grave concussion)
treated in Sundby Hospital from 1924 to 1934 with individualized
confinement to bed according to the duration of the symptoms.

In 257 cases (65 per cent) the rest in bed was for less than

one week, in ninety-five (24 per cent) from one to 'two weeks,
m thirty-one (8 per cent) from two to three weeks, in eight
(2 per cent) from three to four weeks, in three (1 per cert)
four weeks or more. He examined 328 patients (S4 per cent)
in their homes ; 9.6 per cent could not be traced and 64 per
cent had died, presumably not from accident. Permaitt
sequelae were found in 16.1 per cent (severe sequelae in sic
cases, moderate in eight, slight in seven, very slight in twenty-
seven) . The tendency to permanent injury, he says, increases
with .age. There was no demonstrable connection between lie
severity of the acute symptoms and the occurrence of permanent
sequelae. Work was resumed within one month after discharge
by 66 per cent of the patients and within from one to three
months by 18 per cent. Less than 3 per cent were permanently
disabled. Of 250 without permanent injury, 57 per cent were
wholly free from symptoms one month after discharge, 11 per
cent in all three months after discharge. In the remaining
27 per cent the general postcommotional symptoms disappeared
more slowly.

Finska Lakaresallskapets Handlingar

Significance of Focal Infection in Rheumatic Fever. If. Savolfn.—
p. 2077. _

Experiences with Ttiree Carcinoma Reactions. L. Fnruhjetm.— p.
‘Sedimentation Reaction in Ischialgias. H. Hording. — p. 2086.

Sedimentation Reaction in Ischialgia.— Hording made
sedimentation tests three or four times, at intervals of one««h
in 198 cases of grave ischialgia. An increased sedimentation
reaction was established in fifty-two cases (26.3 per cent). “
eighteen the increase was transient ; in eleven of these t 1
ischialgic symptoms had originated in connection with an tor-
tious disorder; seven were considered cases of
ischialgia. In thirty-four cases there was a constantly increase
sedimentation reaction, in sixteen explainable by simultaneous
general disorder, in eighteen without demonstrable cause.
the cases connected with infections, unlike those in the 0 <■
groups, there was no history of earlier ischialgic s >' ra|>
Neuritic symptoms were present equally often in the cases ^
normal and those with increased sedimentation,, and J"*
mentation was not increased more often in the bilateral ®
the unilateral cases. No connection was demonstrable ew^
rise in temperature and increased sedimentation. Since »o ^
results the author assumes that one fourth of the casc ^
ischialgia are, at least in part, combined with disorder o ^
or general nature which causes increased sediments > / ^
considers the sedimentation reaction important because
therapeutic possibilities.

Norsk Magasin for Laegevidenskapen
Seven Cases of We it’s Disease. O. Svaar-Seljesxter.— P- 20S9._

ter p. 2089. . ,

After-Exam" 3 '

Course of Pulmonary Tuberculosis in Children: attter-ivxani p
Patients Discharged from Reknes Children's Sanatori
1932. T. J. Olsen. — p. 2095. „ n c dkhtr"

"Vertebral Fracture in Metrazol Shock Treatment. A.

P- 2101. HemorrtaS 0 13

What Was Cause of Death? Epidural Hematoma or
Brain Stem? O. Berne r.- — p. 2104. .

Vertebral Fracture in Metrazol Shock.— Dcdk^ ^
that while fractures, usually of the neck of the em
jf the scapula and the pelvis, have been describe te( j of

,vith metrazol shock, he has found but one uistanc t ),; s treat
tompression fracture in the vertebral column due <oir’

nent. In a short time he has observed such ra ' s \ m ilit
;rave, in six of eighty cases treated in his hospt a , ^

ractures have been noted in other hospitals since enileptk
>een called to them. These fractures do not occu v ; 0 ] f ]it
ratients because the tonic stage is not so long a ton*

the metrazol attacks; the injury occurs . ur ^ et3riUS . Tl*

The fractures resemble those seen

.ressed, «'!“■

OgV,. -L in- iiuciuiw * -n

iterior part of the vertebra is almost always c° P - rern3 ;rJ
it injury to the spinal cord, and the posterior P
tact. There is a slight gibbus. The fracture kyl* 0 '

itween the third and the ninth thoracic verte ra > c [ Ur esttf

s is most marked. The author now avoids t ies sca pub.
acing a firmly folded blanket under the region ^
moving the pillow and having the patient s trc c u ou [j!c ha-
iring the metrazol seizures, not allowing turn - or parts

If up during the attacks. The most expose poi icrk r

the vertebra are thus kept apart and the s
rts receive most of the pressure.

The Journal of the
American Medical Association

Published Under the Auspices of the Board of Trustees

Vol. 113, No. 17

Copyright, 1939, by American Medical Association

Chicago, Illinois

October 21, 1939

THE MANAGEMENT OF EXOPHTHALMIC
GOITER IN A GENERAL HOSPITAL

RICHARD LEWISOHN, M.D.

B. S. OPPENHEIMER, M.D.

AND.

SOLOMON SILVER, M.D.

NEW YORK

It is a well known fact that the surgical treatment of
exophthalmic goiter in centers highly specialized in
thyroid surgery may be carried out with a practically
negligible mortality. In spite of many serious complica-
tions of this disease (hypertension, arteriosclerosis,
diabetes and auricular fibrillation) the mortality is much
lower than in chronic appendicitis or inguinal hernia
when the latter diseases are associated with cardiac or
other complications. This low mortality, however, is
usually not maintained in general hospitals, where
mortality figures are often from five to ten times higher
than in special thyroid clinics. These clinics with a few
thousand goiter operations a year have naturally -devel-
oped an almost perfect organization both medically and
surgically. It has been claimed that a similar organ-
ization cannot be maintained in a general hospital.
Undoubtedly this statement is correct unless an organ-
ization within a general hospital is created for the
proper management of this group of cases. That an
efficient organization for the handling of thyroid cases
can be created in any general hospital without great
difficulty is proved by this report.

Most general hospitals have a number of surgical and
a number of medical services. If the cases of thyroid
disease are distributed or rotated among these different
services, it is impossible to establish the organization
necessary for the proper management of these cases.
In other words, grouping the cases is the first step in
an attempt to reduce the mortality and improve the
results. Naturally, grouping requires continuous serv-
ices. Rotating the services (two or three groups of
men being in charge of the service during a calendar
year) is incompatible with the development of a high
standard of efficiency.

The present organization at this hospital was estab-
lished in 1931. It was decided to concentrate the
diseases of the thyroid gland in one medical (Oppen-
heimer) and one surgical '(Lewisohn) service. Patients
sent in by members of the other medical service (Baehr)
were admitted to the Baehr service and were operated
on by the same surgical unit. They are included in
this survey. However, patients sent to the wards of
the hospital by members of the other three surgical

Erom the Mount Sinai Hospital.

groups were operated on in their respective services.
They comprise a very small number and are not
included in this statistical review.

ORGANIZATION AND MANAGEMENT

The patients were usually admitted to the medical
wards of only one medical service, where they were
seen by the medical members of the group. Whenever
possible the patients were placed in a small back room
containing only two or four beds and were not placed
in the large general ward. They were encouraged to
believe that a special interest was being taken in them
by the group, and frequent opportunities were offered
them for a detailed discussion of their real or fancied
complaints. Any one who has handled these patients
knows how important it is to be a “good listener.”
Since many of the patients were very apprehensive, as
little as possible was done in the way of study until they
had become accustomed to the hospital atmosphere.
Psychotherapy of the most simple and practical sort
was carried out, and the patients came to feel that they
had a friend in the medical adviser. If patients were
obviously in fear of surgery we usually answered their
early questions regarding the necessity of surgical treat-
ment by saying that the type of treatment would depend
on the results of the “tests.” As confidence developed,
most of the patients were told of the advantage of
surgery and they readily signed consent for operation.
In some cases it was considered unwise to deal directly
with the patient, and consent for the operation was
obtained from a responsible relative and the operation
done without the patient’s knowledge, avertin with
amylene hydrate being used as a basic anesthetic after
the patient had been prepared by daily enemas of an
inert substance for some time before the scheduled
operation.

The patients were put to bed and kept there for at
least several days. After that, lavatory privileges were
allowed the less sick. All were given unlimited diets
and encouraged to take extra nourishment between
meals. No special effort was made to restrict protein
or favor fat in the diet, and supplementary vitamins
were rarely given. Relaxation packs were used only
infrequently, but they sometimes seemed to help excited
patients. The usual sedative was phenobarbital in doses
of from 0.03 to 0.06 Gm. three times a day. If cutaneous
rashes developed we usually substituted chloral hydrate
and bromide for the barbiturate.

The occasional patient who remained very agitated,
and particularly if diarrhea developed, was often helped
by opiates, usually in the form of powdered opium in
doses of 0.06 Gm. three or four times a day. We have
no fear of opium medication in these patients for short
periods, and it seems to exert a particularly beneficial
effect in some instances.

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Volume. 113
Number 17

EXOPHTHALMIC GOITER— LEW ISO HN ET AL.

1529

At the outset let us state our position clearly. In
general the continuous, or even intermittent, adminis-
tration of iodine to all patients with exophthalmic goiter
over long periods of time is unwise and may even be
dangerous. We feel that there is a clear difference in
the reaction to iodine of a sufferer from exophthalmic
goiter who has never received the element, if compared
to one who has been under its effects for some time.
One can almost predict a direct, immediate and sig-
nificant amelioration of the course of the disease if the
patient ; has never been given iodine. This is true
whether the illness is of long or short duration, of
moderate or severe intensity. Almost all these patients
can be quickly improved to a point at which operation
is safe. How different is the situation when one is
faced by a patient who has had iodine for weeks or
months. Experience has taught us how little more we
can usually -expect from the further administration of
iodine. A failure to respond to the standard regimen
plus iodine always leads one to suspect previous recent
iodiriization, and this suspicion is often confirmed. We
do not pretend to explain this phenomenon, although
theories have been advanced (Marine), but the clinical
fact is obvious that good responses are the rule in
patients who have not had iodine, and are less frequent
in iodinized subjects.

We are aware that there are competent observers who
have long disagreed with this point of view. These men
believe that iodine always consistently lowers the basal
metabolic rate and the tempo of the disease and that
those cases in which it apparently fails to do so are
merely examples of spontaneous alteration in the sever-
ity of the disease which would be even more marked if
iodine were not administered. As a result of this con-
cept they favor the administration of iodine and still
more iodine to patients failing to improve under its use,
hoping that the disease will ultimately spontaneously
regress and that this regression will be accelerated by
the iodine. If this point of view is correct, there should
be no essential difference in the reaction of iodinized and
uniodinized patients. In fact, we should expect, accord-
ing to this concept, failure to respond in a considerable
number of cases in which the natural tendency of the
disease was toward greater severity. This should be
true particularly in hospitalized patients, for it is hardly
likely that ward patients would regularly seek hospital
care while their condition was improving. Yet a study
of these cases reveals scarcely a single example of failure
to respond favorably to iodine by untreated patients, and
frequent failure to respond by iodinized patients. It
seems very strange that the “spontaneous” course of the
disease was almost always favorable in patients who
had received no iodine and unfavorable in iodinized
patients. It is our opinion that these alterations were
not spontaneous but induced by the iodine and that the
iodine was unable to induce the favorable change if it
had already been given for a period of time.

It has been our practice to continue the use of iodine
for a period of about ten to fourteen days in patients
who have received it before admission. If their condi-
tion improves sufficiently to warrant operation, this is
performed. If this period brings no improvement or if
deterioration sets in, we discontinue all iodine for at
least six weeks. This sometimes leads to a considerable
aggravation of symptoms in the first or second week,
and we give heavy sedative medication at that time.
After a six weeks period we again use iodine as in our
routine and we usually see a direct and favorable
response and can proceed with surgery.

SURGICAL CONSIDERATIONS - .

This paper deals with the general management of
exophthalmic goiter. For this reason we shall not dis-
cuss in detail the finer points of this surgical technic.

In 80 per cent of the cases the operation was finished
in one stage ; in 20 per cent a two stage operation was
performed. In about a dozen cases the originally pro-
posed second stage was not done, as the condition of
the patient was very good when seen in the follow-up
clinic. In very severe toxic cases the two stage method
was definitely planned before the patient came to the
operating room. In other cases we were guided in our
decision as to the one stage or two stage procedure by
the report of the anesthetist or the general behavior of
the patient or by encountering exceptional technical dif-
ficulties (for instance, excessive bleeding) during the
operation.

When in doubt we have employed the two stage pro-
cedure. It is impossible to fix definite rules with regard
to the question which cases should be selected for the
one stage and which for the two stage operation. While
some very severe cases of exophthalmic goiter are
definitely labeled suitable only for a two stage operation,
others are on the borderline. It is perfectly reasonable
to assume that we might have achieved just as good
results if we had confined the two stage procedure to
about 10 per cent of the cases instead to 20 per cent.
However, it is very often impossible to predict which
cases may present a postoperative crisis. Thus to
be on tbe safe side and to prevent if possible this alarm-
ing and usually fatal complication, we have selected the
two stage operation when in great doubt.

There are several different methods for thyroid-
ectomy. Some surgeons split both ribbon muscles ;
others get a good view of the operative field by simple
retraction of these muscles. In this series the right rib-
bon muscles were usually divided. After the right lobe
had been resected following the ligation of the right
polar vessels and division of the isthmus, it was easy
to dislodge the left lobe from its bed and proceed to
the resection of the left lobe without division of the
left ribbon muscles. Minute and careful hemostasis is
of the utmost importance. We have usually drained
the operative field and were thus able to minimize the
postoperative collection of serum in the wound.

The patient is moved from the operating room to the
surgical wards ; not into the large ward, however, but
into an adjacent small room for one or two patients.
Except in very mild cases special nurses (day and
night) supervise the postoperative treatment during the
first one to three days. Immediately after the operation
and during the next few days the patient is visited at
frequent intervals by the medical and surgical staffs.
Staff visits should not, however, be paid indiscriminately
in order to avoid interference with the patient’s rest.
The room is kept dark and quiet. No visitors are
allowed during the first few days. The patient is given
plenty of fluid. A tracheotomy set and a suction
apparatus are at the bedside. The suction apparatus is
used to prevent the collection of mucus in the pharynx.
Catheterization is done every .ten hours unless the
patient voids spontaneously. Methenamine and acid
sodium phosphate are given if catheterization is neces-
sary. The patient receives 6 minims (0.4 cc.) of
Magendie’s solution every six hours. The nurse is
instructed to watch for and report to the house surgeon
any bleeding, cyanosis, dyspnea or swelling of the face
or neck. The total intake of fluid and output of urine

1530

EXOPHTHALMIC GOITER— LEWISOHN ET AL.

are charted. A steam inhalation apparatus is kept at the
bedside; two-thirds cc. of compound solution of iodine
is given as soon as the patient reacts. If a patient has
not reacted after five hours, the compound solution of
iodine is given by rectum. The patient receives an addi-
tional 2 cc. of compound solution of iodine in 1 ounce
of water by mouth during the first twelve hours. If this
is vomited, another dose is introduced by rectum. After
the second day the compound solution of iodine is
reduced to two-thirds cc. a day. The temperature is
taken immediately after arrival from the operating room
and every four hours thereafter. A rise of temperature
above 102 F. and a rise of pulse rate above 130 beats a
minute must be reported immediately by the nurse.

If any alarming symptoms occur, both medical and
surgical attendants are immediately notified by the house
surgeon and respond for a consultation. We feel that
this close cooperation between the two staffs has been
of great help to the patient and has improved our results
considerably.

Naturally, the operations were performed by a num-
ber of surgeons. In fact, we are presenting the combined
results of thirteen different surgeons. The majority of
the patients (247) were operated on by the attending
surgeon or by one of his two associate surgeons; the
rest (113 patients) were operated on by ten adjunct
surgeons. In this hospital we have the group system in
the surgical service. The junior surgeons rotate among
these groups, staying one year in each group. Naturally
their experience in this special thyroid group is limited.
For this reason one of the senior members of the staff
assisted them at the operation. No patients with exoph-
thalmic goiter were turned over to the house surgeons
for operation.

No polar ligations were performed in this series.
Undoubtedly polar ligation in the group of very sick
patients is not without risk. It seemed to us that polar
ligation is of no benefit because of the abundant blood
supply which still reaches the thyroid gland after one
or even both upper thyroid poles have been ligated. If
thyroidectomy is performed in two stages, the patients
are informed before they leave the hospital for a two
or three weeks stay in the country that they are to
return for a second operation. They stay on compound
solution of iodine during the interval between the two
stages. They are readmitted to the hospital directly
from the convalescent home. It is inadvisable to have
them return to their homes before they reenter the hos-
pital. In the vast majority of cases such a stay at home
would mean emotional shock and hard work (cooking,
looking after the children and the like). We have had
very little difficulty in enforcing the two stage oper-
ation. Only a few patients absolutely refused the second
stage. None of this small group presented a satisfactory
result when reexamined in our follow-up clinic, demon-
strating the importance of a complete operation in order
to effect a cure.

NONSURGICAL CASES

During the period of this study we observed forty-
seven patients with definite exophthalmic goiter who,
for one reason or another, did not come to operation.
Of these patients, nine died while in the medical service,
and a brief analysis of these deaths will be given. We
offered operation to eighteen others who refused and
left the hospital at their own request. There were eight
patients who presented such a mild form of the disease
that we did not consider surgery' to be indicated. All
these made complete recoveries under medical treat-
ment. Three patients became psychotic with suicidal

Jour. A. M. A.
Ocr. 21, 19j?

tendencies while in the hospital and had to be trans-
ferred to a psychiatric institution. The remaining nine
cases, after study by the medical group, were considered
unsuitable for surgery and were treated medically. In
one case there was a difference of opinion between the
medical consultants — one favored surgery and the other
opposed it. In this instance the surgeon refused to
operate. We refused to operate on another patient aged
69 whom we considered too poor a risk. She was given
compound solution of iodine and roentgen therapy and
was quite well, with a basal metabolic rate of minus
16 per cent, four years later.

Of the nine deaths among patients who were still in
the medical service, six occurred within three weeks ci
admission. All these patients were desperately ill on
admission to the hospital, and most of them were of the
older age group who had serious cardiovascular com-
plications. One patient died of an acute coronary artery
thrombosis complicating diabetic ketosis. The remain-
ing two patients died in typical thyroid storms following
respiratory infections.

POSTOPERATIVE COURSE

Naturally in a series of more than 500 operations
some postoperative accidents are apt to occur. A
very small number of postoperative hemorrhages were
seen. When such hemorrhage occurred, the patients
were immediately taken back to the operating room
where we had an opportunity to inspect the operatise
field carefully and stop the hemorrhage.

W e did not observe any case of tetany of more th®
the lightest grade or of more than passing duration.
As the symptoms never lasted more than from thirty s>x
to forty-six hours, we assumed that they wore o' 1115 ®
by a temporary injury to the parathyroids due
application of the clamp during the removal o
thyroid gland rather than to ablation of a part o
or more parathyroids.

MORTALITY ,

There were three deaths among 460 patients opem ®
on for the first time for their thyroid disease. _
these deaths cannot be considered as an operative
tality. The patient had a subtotal thyroidectomy P
formed in two stages. The second stage was done
an interval of four weeks, during which the pa ie
kept in this hospital. She had reacted we 3 ,] e

second stage of the operation and had a coin , ^
night. The following day, while a special nurse
room for a few minutes, the patient jumped o , s
window and was killed immediately, tne p ^
husband told us later that she had playe ' er

thought of suicide for many months. He , t | ]C
taken her seriously and so had never men i

subject to us. • p-rouP’

There was no mortality among the non ° x nte( l
in spite of the fact that some of these ca se P - ters
serious technical problems (large intratnon p 0 r
and retrotracheal and retro-esophageal goi ' c ] iea
instance, in one case of retrotracheal goiter n ; n g

was divided on its posterior aspect. I he a n

was immediately sutured and the pa )en
uneventful recovery. , . .. _ nrev iously

If we consider the operative deaths m tneP al „
unoperated exophthalmic goiter group, we : nc ] u ded.

ity of 0.5 per cent, if the case of suicide is non ts
There were two deaths among the twenty sP ^
iperated on for recurrent exophthalmic goi rS

patients had had exophthalmic goiter for ma 7

Volume 113
Number 17

DEXTROSE TOLERANCE TEST— MATTHEWS ET AL.

1531

and were extremely poor operative risks. In one case
the operation (hemithyroidectomy) was performed
under local anesthesia, as general anesthesia was defi-
nitely contraindicated because of the precarious general
condition of the patient. In the other case a primary
operation had been performed about twenty years previ-
ously at another hospital. In this case the heart was
of the bovine type and the roentgenograms demonstrated
the extreme risk of any operation in view of the serious
cardiac changes. Yet the medical service felt that an
attempt at relief by surgery should be made.

Among these twenty-six secondary cases operation
had been performed in other hospitals in thirteen. Ten
patients had had their first operation in this hospital
many years before, and three had both their primary
operation and their operation for recurrence during the
period of this study.

FOLLOW-UP OBSERVATIONS

The close cooperation between the medical and
surgical staffs in the management of goiter cases was
continued in the follow-up observation of these patients.
Members of both groups met twice a month in the
thyroid follow-up clinic, where about thirty patients
were seen at each session. The follow-up clinic worked
in close cooperation with members of the thyroid clinic
of the outpatient department (Dr. Benjamin Eliasoph
and his staff, including a social service worker). The
patients were seen by appointment. If necessary they
were sent for further study to the thyroid clinic and
referred back to the follow-up clinic with a detailed
report and careful check up. Thus we were able to fol-
low up 24S of our 360 patients and to classify them
into three groups, according to the final results : group
1 (good), 225 cases; group 2 (fair), nineteen cases;
group 3 (poor), four cases. The subsequent course of
the remaining 112 patients could not be ascertained
because contact with them had been lost.

Any grouping is subject to individual and personal
impression. This factor, however, was minimized as
the category to which a patient was assigned was
decided by a number of physicians and not solely by
the operating surgeon.

• We have often been asked about our position toward
x-ray treatment of exophthalmic goiter. We are opposed
to this form of treatment in primary exophthalmic
goiter. We have rarely seen a definite cure following
x-ray or radium therapy. When improvements are
seen following roentgen therapy, one is uncertain
whether to ascribe this to a remission in the disease
rather than to a specific effect of the x-ray treatment.
Furthermore, any subsequent operative procedure is
probably rendered more difficult, owing to a ten-
dency to excessive bleeding and marked periglandular
adhesions. However, in a few relapsing cases, especially
when the symptoms are caused by a small mass of recur-
rent or persistent thyroid tissue, we have seen some very
good results from x-ray therapy.

SUMMARY

1. Of the 460 patients with thyroid disease not oper-
ated on previously, who were treated surgically from
April 1, 1932, to April 1, 1937, 360 cases belonged to
the toxic group and 100 cases were nontoxic.

2. The mortality (three cases) occurred in the toxic
group.

3. The mortality (including one suicide) was 0.8
per cent among the primary cases of exophthalmic
goiter.

4. Operative deaths numbered two (0.5 per cent)
among the primary cases.

5. There were two operative deaths among twenty-
six cases of recurrent exophthalmic goiter.

6. Twenty per cent of the patients were operated on
in two stages.

1155 Park Avenue — 124 East Sixty-First Street.

THE ' ONE HOUR-TWO DOSE DEXTROSE
TOLERANCE TEST (EXTON-ROSE
PROCEDURE)

DIAGNOSTIC SIGNIFICANCE

MORGAN W. MATTHEWS, M.D.

Fellow in Medicine, the Mayo Foundation

THOMAS B. MAGATH, M.D.

AND

JOSEPH BERKSON, M.D.

With the Assistance of Robert P. Gage

ROCHESTER, MINN.

The present study is a part of a survey 1 of dextrose
tolerance tests of various types used in the Mayo Clinic
between Nov. 1, 1935, and June 30, 1938, inclusive.
The present report is confined to the analysis of results
obtained with the one hour-two dose test introduced
in 1931 by Exton and Rose. 2 A criterion for inter-
preting this test is presented which in our experience
has given fewer doubtful laboratory diagnoses than
could be obtained by other criteria applied in this test,
or by any criteria applicable in other oral tests for
dextrose tolerance.

Following the discovery of chemical procedures by
which the presence or absence of sugar in the urine
can be accurately determined, it was noted that glyco-
suria cannot be constantly demonstrated in patients with
mild diabetes. In them glycosuria was found most
frequently to follow the ingestion of certain foodstuffs,
notably those that contain a high percentage of carbo-
hydrate. Tests utilizing the principle of this obser-
vation were then introduced, with the hope that normal
and diabetic individuals could be differentiated from one
another by this meang. An individual in whom diabetes
was suspected was given an amount of carbohydrate
ranging from 50 to 200 Grn. The urine was then
examined at varying intervals for the presence of sugar.
The discovery of glycosuria was thought sufficient to
warrant a diagnosis of diabetes. This method, however,
soon fell into popular disrepute because the ability of
both normal and diabetic individuals to handle carbo-
hydrate was subject to such wide variation that the test
was unreliable. The objections to the method have
been well summarized by Allen 3 and by Hamman and
Hirschman. 4

From the Division of. Clinical Pathology, Section on Parasitology
(Dr. Magath), the Division . of Biometry and Medical Statistics
(Dr. Berkson), and the Division of Biometry and Medical Statistics
(Mr. Gage), the Mayo Clinic.

1. Matthews, M. W.: A Study of the One Dose Three Hour (Stand-
ard) and the Two Dose One Hour (Exton-Rose) Glucose Tolerance Tests,
unpublished thesis. Graduate School, University of Minnesota (the Mayo
Foundation), February 1939.

2. Exton, W. G., and Rose, A. R.: Diabetes as a Life Insurance
Selechon Problem, Proc. A. Life Insur. M. Dir. America. 18 : 252-286,

3. Allen, F. M.: Studies Concerning Glycosuria and Diabetes, Boston.
W. M. Leonard, 1913, pp. 22-23.

4. Hamman, Louis, and Hirschman, I. I.: Alimentary Hyperglycemia
and Glucosuna as a Test of Sugar Tolerance, Tr. A. Am. Physicians 31:
330-364, 1916; Studies on Blood Sugar: 1. Alimentary Hyperglycemia
and Glycosuria as a Test for Sugar Tolerance, Arch. Int. Med, 20:761-
808 (Nov.) 1917.

1532

DEXTROSE TOLERANCE TEST— MATTHEWS ET AL.

Jour. A. M. A
Oct. 21, 15»

The work of MacGregor, of Rollo and Ambrosini,
of Bang and of Jacobson has been cited by Bailey. 5 *
In 1856 the dependence of glycosuria on an increase of
the concentration of sugar in the blood above the normal
level was recognized by MacGregor and by Rollo and
Ambrosini. The methods of analysis advocated by
these workers were so complicated and inaccurate that
dependence could not be placed on their observations.
Bang in 1913 introduced the first satisfactory and clini-
cally applicable method for the accurate determination
of the blood sugar level. Jacobson in the same year
noted that the ingestion of carbohydrate is followed by
a rapid and often marked hyperglycemia. Fat and
protein were found to produce no particular variation
in the blood sugar level. These observations suggested
to Hopkins, 0 to Janney and Isaacson 7 and to Hamman
and Hirschman that the administration of carbohydrate
followed by frequent determinations of the blood sugar
might be used to determine the ability of an individual
to handle carbohydrate. The use of such carbohydrates

0 Yz hr. 1 hn

Time after sugar

Chart 1. — Average blood sugar value (in milligrams per hundred cubic
centimeters of blood) of members of this study.

as bread, crackers and oatmeal gruel as the test sub-
stance gave disappointing results. Apparently these
products were broken down into their component food
elements so slowly that their subsequent absorption
from the intestinal tract imposed a metabolic strain on
only those patients in whom a serious derangement
of carbohydrate metabolism was present. Mild or even
moderately severe cases of diabetes were frequently
considered to have a normal metabolism for carbo-
hydrate when this method was used.

Hamman and Hirschman in 1917 and Janney and
Isaacson in the following 3-ear independently introduced
dextrose as the test substance for determining the indi-
vidual’s ability to tolerate carbohydrate. The methods
advocated by these two groups of observers, differed
only in the amount of dextrose that was administered.
The former proposed the use of a standard amount of

5 Bailey, C. V.: Studies on Alimentary Hyperglycemia and Gly-

cosuria, Arch. Int. Med. 23: 455-4S3 (April) 3919. q *

6. Hopkins, A. H-: Studies in the Concentration of Blood Sugar m

Health and Disease as Determined by Bangs Micro-Method, Am. J.

M ' <V janne-J N? w!, in? Isaacson, V. I.: f nfl ^ e "£| d ° f 1 4% r |.'foo’

KrVfiS Tderance* JFroW&i®

(April 20) 191S.

dextrose, namely 100 Gin., while the latter advocated
the use of dextrose in proportion to the number oi
pounds of body weight. The amount that was found
to be most satisfactory was 1.75 Gm. of dextrose per
kilogram of body weight. These two methods consti-
tute . essentially. what, is now. known as the standard
dextrose tolerance test. That this test has not proved
a completely satisfactory- procedure is demonstrated
by tire number of modifications that have at one time
or another been proposed.- Jt- is not. our. purpose in
this paper to enter into a discussion of all these.varions
modifications. However, a comparatively recent modifi-
cation of the test by Exton and Rose has gained wide-
spread popularity, and it is with this modification that
we here are primarily concerned.

The Exton-Rose procedure is based on what is known
as Allen’s 8 * paradoxic law of dextrose utilization.
Brief!}' stated, the law is : • The more sugar that is given
to a normal individual, the more that is utilized. Limits
of tolerance in nondiabetic individuals 0 are all apparent,
not real. There is no real limit to the ability of a nor-
mal person to utilize dextrose. In contrast, the inability
of the person suffering from diabetes to handle dextrose
is real. Large doses of sugar in these individuals are
not utilized and assimilation may be made worse instead
of better by' overdosage. Exton and Rose, on the basis
of this law, formulated the one hour-two dose dextrose
tolerance test, or, as it is perhaps better known, the
Exton-Rose procedure. , ,

The technic of the test is as follows : One hundre
Gm. of dextrose is dissolved in 650 cc. of water, ma -mg
approximately a 15 per cent solution. This solution!
flavored with lemon juice and is divided into two equa
parts, each containing 50 Gm. of dextrose. The nur-
ture is served cold. Following an overnight fast
bladder is emptied as completely as possible, and 1
the following steps are taken: (1) samples 01 0

and urine are collected and the first dose of dex r
is given, from one to two minutes being allow®
its ingestion; (2) thirty minutes after the ingestion
the dextrose a second sample of blood is collecte
the second close of dextrose is given, from one °
minutes being allowed for its ingestion, and (•->) j
minutes after the ingestion of the second 05 ,

dextrose a third sample of blood and a second sa
of urine are collected. , ,i ie

There is much physiologic research that s . lI PP° , 0 „
contention that the Exton-Rose procedure is a
sound physiologic principles. Hamman and
man, 10 MacLean and de Wesselow, JJ A
Foster, 13 Lennox 14 and Hale- White and L , c) ,
found that, if successive doses of d extrose arc J y_^

Boston.

irt«;

of

8. Allen, F. M. : Studies Concerning Glycosuria and Diabe

W. M. Leonard, 1913, p. 1050. . . , , „ Given

9. This applies only to dextrose administered by in ■ ^ ra je o

venously, tolerance for dextrose is very definitely unu , \Vood)'3j '

administration, as was demonstrated by Blumentnai (d # method, w
Sansum and Wilder) and later, with more preci te i y Timed I ntr 2*

Woodyatt, Sansum and Wilder (Prolonged and A * 111 j

venous Injections of Sugar, J. A. M. A. 65 : 2067^2070 t uc , th ^
Wilder, R. M., and Sansum, W. D.: glucose Tolerance

Disease, Arch. Int. Med. 19: 311-334 [Feb.] 191/)- Blo°<L? u? V

10. Hamman, Louis, and Hirschman, L I.: .~i u Tn{T( , 5 fjon of Glu^' ’
IV. Effects on the Blood -Sugar of the Repeated Inge^io

Bull. Johns Hopkins Hcsp. 30 : 306-303 (Oct.) 1919. E S tir7tf {,on

11. MacLean, H., and de Wessclow, O. L. * •* .q2\. . .<

Sugar Tolerance, Quart. J. Med. 14: 103-119 (J , Sugar «* .: 1*

12. Hansen, Karen M.: Investigations on the ^ SeafI diw*»

-Conditions of Oscillations, Rise and Distribution,

1923, supp. 4, pp. 1-224. , . Metabolism: M' c f

13. Foster, G. L.-. Studies on Carbohydrate Jl« (be ingest'?"

Interpretation of the Blood Sugar Phenomena F ,

Glucose, J. Biol. Chem. 55 : 303-314 (Feb.) 924 in ,M n ^ c f

14. Lennox. W. G.: . Repeated Blow [ Sugar Stintolat'” ,

Subjects, J. Clin. Investigation 4: 331J52 (Aug.) j(ate Wood -

the Sugar-Regulating Mechanism as Shown by _ ■ r3 -rr

Curves. J. Biol. Chem. 73: 237-249 (May) 1527. nestmc Trier’

15. Hale-White, R., and Payne, , W. W-- “ A) 1926. ■

Curve in Health, Quart. J. Med. 19:393-410 ( P

Volume 113
Number 17

DEXTROSE TOLERANCE TEST— MATTHEWS ET AL.

1533

to man or animal on the same clay, the second blood
sugar curve reaches a peak at a lower level than the
first curve, the third curve lower than the second, and
so on. In the United States the phenomenon has come
to be known as the Hamman-Hirschman effect; in
Germany as the Staub ln -Traugott 17 phenomenon.
Thalhimer, Raine. Perry and Buttles 18 observed a
rise in the blood sugar during the first hour in which
10 per cent solution of dextrose was given intravenously.
Although the injection was continued at the same rate,
the blood sugar level during the second hour declined
progressively. Following the injection, hypoglycemic
levels were often reached and in some cases symptoms
of a mild hypoglycemic reaction were experienced.

The common explanation of the phenomena cited
in these experiments is that carbohydrate stimulates
the pancreas to produce more insulin and by repeated
stimulation so much insulin is produced that the exces-
sive amount causes hypoglycemia. Soskin and his
co-workers 10 have attacked this conclusion and, on the
basis of a series of experiments on dogs, have main-
tained that the pancreas is not essential for such a
reaction. On the other hand Ricketts, 20 also on experi-
mental grounds, has challenged Soskin’s interpretations.
Without denying that the liver may play an independent
part in the regulation of the blood sugar, the experi-
ments of Ricketts indicate, he concluded, that the proper
functioning of the liver under normal circumstances
depends on the availability of an extra supply of insulin
by the pancreas at the time of ingestion of carbohydrate.

The principal advantages of the Exton-Rose test over
the standard test of tolerance for dextrose are as
follows; 1. The shorter duration of the test tends to
diminish the influence of certain external factors, such
as hunger, anxiety, emotion, fatigue and impatience, on
the character of the tolerance curve. Exton and Rose
concluded that no more information as regards carbo-
hydrate utilization could be obtained if the test was
extended over a longer period than one hour. 2. Fewer
venipunctures and fewer chemical determinations are
necessary than under the standard test.

ANALYSIS OF RESULTS OBTAINED WITH THE
EXTON-ROSE TEST OF TOLERANCE FOR
DEXTROSE

In the present study a statistical analysis has been
made of the results of the Exton-Rose procedure in a
group of 117 individuals that were considered to have
a normal tolerance for carbohydrate, a series of 304
individuals with diabetes that had been clinically'- graded
according to the severity of the disease, and a series of
seventy persons for whom the clinical diagnosis was
renal glycosuria. In all three of these arbitrary classifi-
cations we have eliminated all cases with an associated
condition, other than the disease diabetes, that might
possibly influence the effect of ingested dextrose on
the level of the blood sugar.

The diagnosis in some of these cases may not have
been correct. On the contrary, being based on clinical

16. Staub, H.: Bahnung ini intermediaren Zuckerstoffwechsel, Biochem.
Ztschr. 118: 93-102, 1921.

. y Traugott, Karl: Ueber das Verhalten des Blutzuckerspiegels bei
'lederholter und verschiedener Art enteraler Zuckerzufuhr und dessen
wedeutung fur die Leberfunktion, Klin. Wchnschr. 1 : 892-894 (April 29)

d 1 ® ' Tlj ^ Ilinier » William; Raine, Forrester; Perry, Margaret C., and
cutties, Jane: Effect of Injections of Dextrose and of Insulin and
on ^ 00c * Sugar: Preliminary Report, J. A. M. A. 87:391-
^ (Aug. 7) 1926.

th* \ Sos k* ,n » Samuel; Allweiss, M. D., and Cohn, D. J.: Influence of
pr, ■ a , ncreas and the Liver on the Dextrose Tolerance Curve, Am. J.
?n ,0 p* f 09: 1S 5-165 (July) 1934.

n • ketts ’ H. T.: Carbohydrate Tolerance After Protamine Insulin:
1 on the Physiology of Insulin Secretion, J. Clin. Investigation

A 4 * /9a-80l (Nov.) 193S.

judgment, it was necessarily subject to error. Some
sort of classification was necessary, however, and as
each diagnosis was based on a thorough study of all
aspects of each case by clinicians with special experience
in diabetes 21 it was considered the best basis available.
An important part of this study consisted in a com-
parison of the blood sugar level during the various
phases of the reaction with the clinical diagnosis previ-
ously recorded. It will occur to one that there is an
element of circularity involved, for it may be said
that the clinical diagnosis was based on the blood sugar
observations. The objection is not as serious as it
might appear to be. In the first place the clinical diag-
noses were by no means based on blood sugar determi-
nations alone but were made on clinical observations
in conjunction ■ with all laboratory examinations.
Secondly, our conclusions, as will appear, are in favor
of criteria other than those that were used to interpret
the results of the Exton-Rose tests at the time the diag-
nosis was made, for these criteria are in fact a result
of this study.

All patients with diabetes in the Mayo Clinic receive
a clinical grading depending on the severity of the
disease. An individual is said to have latent diabetes or

Table 1. — Averages and Range of Variation of Blood Sugar
Values (in Milligrams per Hundred Cubic Centimeters
of Blood) of Members of This Study

Fasting Blood

Sugar Reading Vi Hr. Reading 1 Hr. Reading

Num-, A , * , , * ,

her of Aver- Aver- Aver-

Clinical Diagnosis Cases age Range age Range ago Range

Normal persons 117 81.6 03-110 125.9 79-170 114.8 51-179

Rena] glycosuria 70 85.4 70-103 131.2 9G-16S 120.5 03-107

Diabetes

Latent 37 91.5 73-139 159.4 116-210 200.5 101-273

Grade 1 210 111.5 OS-231 107.4 111-319 255.4 107-423

Grade 2 30 102.0 84-268 255.2 173-370 327-0 154-4S4

Grade 3 22 220.4 93-403 330.8 127-530 399.7 182-020

Grade 4 5 2S1.C 12S-572 407.0 246-G9S 504.4 341-770

All forms o{ diabetes 301 127.0 6S-572 211.3 Hl-098 270.1 151-770

diabetes grade 1 if the urine can be maintained free
from sugar on a qualitatively restricted diet. It is very
doubtful if any one could distinguish clinically, or by
any other method that we now have, between latent
diabetes and diabetes grade 1. The term latent dia-
betes is reserved for the mildest form of the disease
seen in practice. In most of these cases a dextrose
tolerance test is necessary to establish the presence of
the disease. Grade 2 diabetes exists if a weighed diet
providing adequate calories and containing not more
than 200 Gm. of carbohydrate is necessary to control
the glycosuria. Grade 3 diabetes is said to be present
if, in addition to such a weighed diet, 30 units or less
of insulin each day is necessary to maintain the urine
free from sugar. Grade 4 diabetes is diabetes that
requires such a weighed diet and an amount of insulin
greater than 30 units each day for its control.

Statistical analyses of the means and range of the
blood sugar determinations during the various phases
of the Exton-Rose procedure are summarized in table 1
and are presented graphically in chart 1.

The fasting blood sugar in those individuals whose
carbohydrate metabolism was considered normal ranged
from 63 mg. to 110 mg. per hundred cubic centimeters
of blood. Only five persons had a fasting blood sugar
that exceeded 100 mg. and in but one of these did the
fasting blood sugar reach a height of 110 mg., which
was the maximal concentration in the series. In con-
trast the fasting b lood sugar readings for the persons

n 21 ^^ # apiosis in every instance was made by Dr. E. J. Kepler,
Dr. E. II. Rynearson or Dr. R. II. Wilder.

1534

DEXTROSE TOLERANCE TEST— MATTHEWS ET AL.

Jour. A. M. A.
Oci. 21, 1929

with latent or grade 1 diabetes ranged from 68 mg. to
234 mg. per hundred cubic centimeters of blood. Only
21 per cent of the members of this group had fasting
blood sugar determinations that exceeded 120 mg.
There was a 70 per cent overlap of the fasting blood
sugar readings of the diabetic group into the range
of the normal series (chart 2).

Chart 2. — Distribution of fasting blood sugar readings in 117 normal
individuals and 247 persons with latent or grade 1 diabetes.

The average blood sugar level at any time point
of the test is progressively elevated as one ascends
the scale from normality and mild diabetes to the
severer forms of the disease. In normal individuals and
persons with renal glycosuria the rise in the blood sugar
one-half hour after dextrose has been given is noted
to be moderate when compared with the average rise
that occurs in diabetes during the same period. The
characteristic rise-fall reaction of the concentration of
sugar in the blood of normal individuals and persons
with renal glycosuria at the half hour and one hour
points respectively is evident. The only significant dis-
tinction between normal individuals and persons with
renal glycosuria as far as the tolerance test is concerned
is the excretion of sugar in the urine by members of the
latter group. In the various grades of diabetes the
rise-fall reaction is absent, the average blood sugar
value at one hour being higher than the average blood
sugar value at the half hour reading. The importance
of this observation will be referred to later.

Table 2. — Age Distribution: Average Blood Sugar Values
During the Various Phases of the Reaction in Normal
Individuals and Persons with Latent and
Grade 1 Diabetes

Latent and

Normal Grade 1 Diabetes

Num- Average B. S. Headings Num- Average B. S. Bendings

ber of , * .ber of, * .

Age, Tears Cases P.B.S. % Hr. IHr. Cases F.B.S. 14 Hr. 1 Hr.

0-29 31 82.5 121.8 103.8 14 99.G 1G3.7 231.G

30-49 57 84.9 127.1 11S.G 120 10S.1 189.7 241.3

B0-79 26 8G.9 12S.5 121.4 113 116.6 196.7 255.1

Total 117 84.6 125.9 114.8 247 111.5 191.7 247.2

Youngest 2% years 2 years

Oldest 6S years 75 years

Many investigators have reported a progressive
elevation of the tolerance curve with advancing age.
An analysis of our data supports this conclusion.
Table 2 shows for the normal and grade 1 diabetic
groups the effect of advancing age on the blood sugar
values at the various phases of the reaction. It is seen
that for all determinations, the fasting, half-hour and
hour readings, the concentrations of sugar in the blood
progressively increase with age.

The- next step in our analysis was to apply the
criteria that have been proposed by Exton and Rose and

also those of Gould, Altshuler and Mellen :2 to the
group of 11 7 normal individuals and 247 persons with
latent or grade 1 diabetes. The criteria of Exton and
Rose are:

A. Normal tolerance curve:

1. A fasting blood sugar within the normal limits of the
particular blood sugar method employed.

2. A rise in the blood sugar which does not exceed 75 mg.
in the thirty minute sample.

3. The blood sugar in the sixty minute sample is less, the
same, or does not exceed the thirty minute sample by more
than 5 mg.

4. All urine samples are negative to the Benedict test.

B. Diabetic tolerance curve:

1. A more or less steep curve of not less than 10 mg. of Hood
sugar following the second dose of dextrose.

2. The relation of the blood and urine sugar values to the
severity of the disease.

C. Renal glycosuria tolerance curve:

1. Blood sugars which follow the normal tolerance curve or
in any event never reach the diabetic level.

2. Sugar in both urine specimens.

D. Alimentary glycosuria tolerance curve:

1. Blood sugars that follow the normal curve even when the
level is higher than normal.

2. A sugar-free urine after fasting, with sugar in the final
urine specimen.

Table 3. — Comparison of Criteria When Applied to W
Clinically Normal Individuals and 247 Persons

with Latent or Grade 1 Diabetes

Latent and

Normal Individuals
nestle Cr"'~

Applied

Exton-Bose Gould ct AL Exton-Bose GouldetAK

gnosis According
to Criteria

ibetes

tjdingnostir.

'otal

Num-

Aw

Per

Num-

Per

\r-

Num-

Per

ber

Cent

ber

Cent

ber

Cent

72.7

64.1

1

0.4

, 22

18.8

236

95.5

. 10

8.5

42

33.9

10

4.1

—

- —

—

117

100

117

100

247

100

0.4

191 7!3

55 SS

217 1W

According to our interpretations of these cn e ;
the fasting blood sugar is within normal h mlts .
the one hour reading does not exceed t ie ia ^
value by 10 mg. or more, even though the ' ^

blood sugar determination is as high as • •'

case cannot be considered as diabetic. I os5 j.

that such a reaction is definitely abnormal an . ar .
bility of diabetes should be seriously consul era ■ F ^
cntly but one requisite is necessary acc ? r A- -betes,
criteria of Exton and Rose for a diagnosis
rnd that is that the hour blood sugar de or

should exceed the half hour reac!in | the fasting
nore. If this condition is not fulfilled and ;dered
ilood sugar exceeds 120 mg., the case can t0 | eran ce
leither diabetic nor normal, and there j n the

;urve must be nondiagnostic. When the firs f

ilood sugar one hour after the ingesti g the

lose of dextrose lies between Si ind 1U ^diagnostic-
ia lf hour reading, again it must be called n p {hat

\ curve that has a half hour blood sug e , while

s more than 75 mg. higher than the fasting ^ ]imits ,
he other values of the curve are WJthm n tar) -

ccording to the criteria must be caJieo
hyperglycemia.

22. Gould, S. E.; Altshuler. S. S., a” d D ¥ a ra“i s K of
Xvo-Dose Glucose Tolerance Test ,n the D.aguos.s

J. M. Sc. 193:611-617 (May) 193,.

Volume 113
Number 17

DEXTROSE TOLERANCE TEST— MATTHEWS ET AL.

1535

The criteria of Gould, Altshuler and Mellen are :

A. Normal tolerance curve:

1. The fasting: blood sugar is less than 120 mg.

2. The half hour level is less than SO mg. above the fasting
value.

3. The level of the blood sugar at one hour is less than 30 mg.
above the half hour value.

B. Diabetic tolerance curve: The presence of only two of
the following three conditions indicates diabetes :

1. A fasting blood sugar of 120 mg. or over.

2. A half hour level of SO mg. or more above the fasting
value.

3. A one hour level of 30 mg. or more above the half hour
level.

The difficulties that these criteria encounter are at
once evident. Two out of the three criteria noted
must be present in order to diagnose diabetes. Even
if the fasting blood sugar level were grossly abnormal,
say 400 mg. per hundred cubic centimeters of blood,

Table 4. — Estimation of Effectiveness of Criteria in Designating
Cases in Agreement suit It Clinical Diagnosis

Correctly Diagnosed by Criteria

X

Exton-Hosc Gould ct AI.

Series Number Number Per Cent Number Per Cent

Normal 117 S5 72.7 75 GL1

Diabetes 247 23G 93.5 191 77.3

Total 3C4 321 SS.2 2G0 73.1

Tables 3 and 4 summarize the results of designating
the normal and diabetic series according to the criteria
of Exton and Rose and of Gould and his co-workers.
It is seen from table 3 that, considering the 117 indi-
viduals clinically diagnosed as nondiabetic, 73 per cent
were diagnosed normal by the Exton-Rose criteria and
64 per cent by the criteria of Gould and his co-workers.

Table 6. — Distribution of the One Hour Blood Sugar Readings
in 117 Normal Individuals and 247 Persons
with Latent or Grade 1 Diabetes

Blood Sugar Reading,

117 Normal
Individuals

247 Persons with
Latent or
Grade 1 Diabetes

Mg. per 100 Cc. of Blood

Number Per Cent

Number Per Cent

■10-59

1

0.9

G0-79

7

G.O

£0-99

32

27.3

1 CO-119

29

24.8

320-139

•2*2

18.8

14 0-1 59

20

17.1

100-179

0

5.1

19

7.7

ISO-199

25

10.1

200-219

43

17.4

220-239

33

14.2

240-259

37

35.0

2 GO-279

25

10.1

2S0-299

24

9.7

300-399

33

14.2

*400 plus

4

1.6

Total

Average

Range

. 117

100

114.8

34-179

247

100

247.2

161-423

Table 5. — Effectiveness of Blood Sugar Levels as Criteria for
Designating Cases in Agreement -with Clinical Diagnosis

Correctly Diagnosed by
Criteria of Blood Sugar Bevel

t — *

Critical Values ot

117

247

364

Blood Sugar

Normal

Plnbetic

Total Cases

(Mg. per 100 Ce. Blood)

f— —

> v

f

A v

, %

Blood Sugar

t -

— v Num-

Per

Num-

Per

Num- Per

Reading

Normal

Diabetic

ber

Cent

ber

Cent

ber Cent

Pasting blood

Less than

90 or

74

03

218

88

292 80

sugar

90

more

% hour blood

Less than

342 or

SS

75

237

96

325 89

sugar

142

more

1 hour blood

Less than

15S or

111

95

247

10 0

35S 9S

sugar

158

more

if the half hour reading was less than 50 mg. above this
figure and the hour reading was less than 30 mg. above
the half hour determination the case could be called
neither normal nor diabetic. Such a tolerance curve
must therefore be nondiagnostic. The same reasoning
applies when the half hour blood sugar reading exceeds
the fasting level by more than 50 mg., while the two
other values are within the normal limits that are
specified by the criteria. Similarly, if the blood sugar
at the one hour determination is 30 mg. or more
above the half hour value, while the other readings are
within the limits of normal as defined by the criteria of
these investigators, the curve is again nondiagnostic.
Gould and his collaborators do not consider the diag-
nosis of renal glycosuria and alimentary hyperglycemia.
When we apply their criteria we shall consider renal
glycosuria as a normal tolerance curve with glycosuria.
An alimentary hyperglycemia type of curve fulfils only
one of the three criteria, two of which are necessary
for the diagnosis of diabetes, and cannot be considered
as normal because it exceeds the 50 mg. rule of the half
hour reading ; it must therefore he called nondiagnostic.
With such a variety of confusing combinations we
should expect such criteria to yield a large percentage
of nondiagnostic tolerance curves.

Of the 247 individuals in the diabetic series, 96 per cent
were designated diabetic by the Exton-Rose criteria and
77 per cent by the criteria of Gould and his co-workers.
In table 4 we see that, considering the entire series of
364 individuals, the application of the Exton-Rose
criteria yielded diagnoses in agreement with clinical
diagnosis in 88 per cent of the cases, while that of the
criteria of Gould and his co-workers yielded 73 per
cent in agreement with the clinical diagnosis.

It appeared to us on the basis of general obser-
vations of the level of the blood sugar at the fasting,
half hour and hour points that a better differentiation
between normal subjects and persons with diabetes
might be made by considering the level of the blood
sugar itself rather than the change of the value from
one time to the next. Since each observation is neces-
sarily subject to variation and error, the difference

Chart^ 3.—;Distribution of the one hour blood sugar readings in 117
normal individuals and 247 persons with latent or grade 1 diabetes.

between two observations, say, at the half hour and
hour points, is, a priori, subject to more variability
than the values themselves, though this is not neces-
sarily true. At any rate we undertook to make an
objective examination on the basis of the absolute values
of the blood sugar determinations at each phase of the
tests (table 1, chart 1). We decided to use as a
criterion to demarcate normal individuals from persons
with latent diabetes a value of the blood sugar half

1536

DEXTROSE TOLERANCE TEST— MATTHEWS ET AL.

Jour. A. 51. A.
Oct. 21, !)])

way between the mean values for the particular point
in the test. Thus, utilizing the fasting blood sugar as
a criterion, the mean value for the normal group, was
84.6 mg. per hundred cubic centimeters and the mean
value for the latent diabetic group was 94.5 mg.;
averaging these two groups, the figure of 90 mg. is
obtained. .Accordingly we reasoned that an individual
who had a fasting blood sugar in excess of 90 mg.
would.. be more likely to be- diabetic. ' Conversely, a
fasting blood. sugar below 90 mg. would .be more indica-
tive of a normal tolerance for carbohydrate. Similarly,
a half hour blood sugar value of 142 mg. and an hour
reading' of 158 mg. were selected as critical levels. The
results of applying these criteria to the 117 normal indi-
viduals and the 247 persons with latent or grade 1
diabetes are shown" in table 5.

In table 5 it is seen that, using the fasting blood sugar
alone, 63 per cent, of the normal persons and 88 per
cent of the 'persons with diabetes would have been
designated ' in agreement with the clinical diagnosis,
giving for the entire series of 364 cases 80 per cent
designated in agreement with the clinical observations
by the criterion of the fasting blood sugar level alone,
if the half hour blood sugar reading is employed -for
the entire series, it is seen that 89 per cent were desig-
nated' in. agreement with the clinical diagnosis. If the
hour, reading of the blood sugar is used, 95 per cent
of the" normal persons were designated in agreement
with the clinical findings and all the patients with dia-
betes were so designated, making, for the entire series,
a designation of 98 per cent in agreement with .the
clinical diagnosis. This very close agreement, using
the simple criterion of the level of the blood sugar at
the hour reading, is due to the fact that according to the
observations in our series the distribution of the hour
reading is widely divergent in the normal and diabetic
groups. This is shown by table 6 and chart 3.

It may be emphasized again that the criterion of the
value of the blood sugar at the hour reading could not
have been the one employed in making the clinical diag-
nosis in these cases, since this criterion was developed
in the course of this study after all the clinical diagnoses
had been designated in the histories.

COMMENT

The finding that the value of the blood sugar at a
particular time point (one hour) of the curve obtained
in a one hour-two dose test of dextrose tolerance has
diagnostic significance of importance is in harmony with
the observations of Hansen, 23 who emphasized that the
normal organism has the capacity to accelerate the
removal of sugar front the blood at times when values
for blood sugar would otherwise rise abnormally. A
result of such regulation is the establishment of a defi-
nite upper limit or blood sugar ceiling, called by Hansen
the “optimum concentration.” This upper limit, when
dextrose is introduced into the blood stream at a rate
no greater than is possible by absorption from the
bowel, is normally never exceeded. Furthermore this
upper limit, as Hansen has shown, is nearly the same
value as that of the renal threshold for dextrose, which
explains why glycosuria is avoided no matter how much
sugar is ingested by normal persons. In such persons
the highest values attained by the blood sugar after the
ingestion of as much as 400 Gin. of dextrose were found
by Hansen to lie between 160 and ISO mg. per hundred
cubic centimeters. .

,, ■ Karen M., cited by Faber. Knud: Benign Glycosuria Due

to "Disturbances in the 'Blood Sugar Regulatmg Mechan.sm, J. C!,n.

Investigation 3: 203-227 (Dec.) 39_6.

Other .causes of _ hyperglycemia being absent, a. dis-
turbance of the ability of the organism to prevent ele-
vation of the blood sugar above what Hansen called the
“optimum concentration” ought to represent, a criterion
of diabetes mellitus. This is exactly what is revealed
by the blood sugar reading at one hour in a test like that
of Exton and Rose. The amount of dextrose adminis-
tered by mouth in such a test must be large enough to
effect a maximum rate of absorption from the bowel at
the time (one hour) blood is taken for analysis, but the
amount provided in the Exton-Rose test is ample.
According to. Hansen as great an elevation may be
obtained with 50 Gnr. as with 200 or 400 Gm.

It is possible that the one hour reading of the blood
sugar would be equally' significant diagnostically if all
the dextrose (lOOGrn.) was ingested at the zero hour
instead of in the two doses, each of 50 . Gm. at half
hour intervals, as called for in the Exton-Bose pro-
cedure. Dividing the dose is helpful, however, because
it avoids an unpleasantly, large dose at one time, It
also is not improbable that the second dose, given thirty
minutes after tire first, increases the divergence of the
one hour blood sugar values because of a Havnman-
Hirschman (Staub-Traugott)' effect in cases without
diabetes. This may explain the greater diagnostic sig-
nificance of the value of the blood sugar at one hour m
the Exton-Rose test. over that at thirty minutes. . •

In view of these considerations" we are not suggest-
ing any- change in -the. procedure. of the. tolerance test

of Exton and Rose and have limited our comments to
the interpretation of the values for blood sugar, obtaine
with the test as originally described. Our results 0
suggest, however, that the test may be simplified -Win-
out loss of reliability by' the omission of two of c
three samplings of blood. originally called for, name)
the one. before the dextrose is given and the one a
thirty minutes. • . „

J CONCLUSIONS - -. . . - ,

1. Advancing age produces a progressive e * el ' af ®!
of the blood sugar level at every phase of the 0
sugar time curve obtained with the dextrose toleran
test of Exton and Rose. The degree of this, however,
is insufficient to invalidate conclusions 2 and 3.

2. A fasting blood sugar that exceeds 120 wg : P ,

hundred cubic centimeters of blood .is diagnos 1
diabetes. This value, however, was exceeded >)' .

21 per- cent of' the persons with diabetes m this

of cases in -which .diabetes, was minimal. In c0
no person in whom the carbohydrate tolerance wa , j
sidered normal had a fasting blood' sugar that ex

110 mg. rfective

3. According to our experience, the most e
criterion, with the Exton-Rose procedure, , ma |
entiating persons suffering from diabetes an jyg
persons is the hour value of the blood sugar. as
mg. per hundred cubic centimeters of blood is a ( j
the critical level so that individuals showing a .
sugar reading below this level at the hour are ^
nated nondiabetic and individuals with rea ‘"T . et j Ci
above this value are designated presumptive} jc( p
a high percentage of correct diagnoses can ne e M ^
As far as the observations in this series are c ° j 54
all individuals with values at the hour '9 s ?, 1 . w 'th
mg. were found to be normal, and all mdivi ' ^
values at the hour of 180 mg. or more were '■

be diabetic. Hence these two groupings are mo
nite. Individuals with values at the hour ) - c }j of i

and 179 mg. inclusive constituted only | a sm ‘ con .
of our cases (six, or .ml per cent, of 117 p

Volume 113
Number 17

ANATOMY OF INTESTINE— CHAMBERLIN

1537

sidered to be nondiabetic and nineteen, or 7.7 per cent,
of 247 patients considered to have latent or mildest
diabetes). The number of cases with a doubtful lab-
oratory diagnosis was smaller by this criterion than by
any other criterion applied to the results of the Exton-
Rose test. It also was smaller than that obtained by
any criteria applied to the interpretation of other oral
tests for dextrose tolerance with which we have had
experience. 2 ' 1

THE ROENTGEN ANATOMY OF THE
SMALL INTESTINE

GEORGE \V. CHAMBERLIN, M.D.

PHILADELPHIA

Anatomically, the small intestine is a convoluted tube
which begins in the upper part of the abdomen just
distal to the pylorus and ends at the ileocecal valve.
Roentgenologically, it is a highly active and dynamic
organ with certain characteristic anatomic and physio-
logic features. Normal roentgen morphology is, for the
most part, dependent on' muscular tone, physiologic
motion, mucosal pattern or a combination of these three
factors.

Fig. 1. — The lumen of the small intestine diminishes from above
downward. This shows the roentgenologic appearance of the duodenum,
jejunum and ileum.

The length of the small intestine is variable. At
autopsy it may measure from 5 to 7 meters. Intubation
by measured length of tubing has indicated a length of

24. The analytic technic used in the examinations for concentration of
lilood sugar was that of Folin and Wu, and all specimens of blood were
obtained from the vein. For other methods of analysis or for blood taken
for analysis from arteries or capillaries, the values for blood sugar
accepted here as criteria for diagnoses would be modified. It also must
be emphasized that the diagnostic significance of any values for blood
sugar will be modified by all the various conditions, other than the
n reS I nce or a .^ sence of the disease diabetes, that are known to modify
blood sugar time curves. Such conditions include previous fasting, pre-
ceding diets low in carbohydrate and complications such as infection and

hyperthyroidism.

c £ Tom the Department of Radiology of the Hospital of the University
ot Pennsylvania.

Read before the joint meeting of the Section on Gastro-Ent ecology and
■t roctology and the Section on Radiology at the Ninetieth Annual Session
°* American Medical Association, St. Louis, May 19, 1939.

from 2.5 to 3 meters from the pylorus to the cecum.
Such figures, however, may not be accurate because the
intestine may telescope itself along the course of the
tube and thus produce abnormal shortening. It is
generally assumed that the upper three fifths of the

Fig. 2. — The normal mucosal pattern in the jejunum is herring bone
or reticular.

mesenteric small intestine is jejunum and the lower
two fifths is composed of ileum. On the basis of
embryologic and roentgenologic data. Cole 1 has
described six primary coils of small intestine. The
first coil is the duodenum, while the remaining five
groups comprise the ileojejunum, or mesenteric small
intestine. In my experience, many variations in the
appearance of these coils have occurred.

In 1936 Pendergrass and his associates 2 stressed the
importance of a standard type of meal for the study of
the small intestine. The meal that I have used is made
of 5 ounces of distilled water and 5 ounces of barium
sulfate. Water is distilled to remove the chlorine, which
may produce a disturbance in the roentgen appearance
of the intestinal tract. A standard preparation of barium
sulfate has been found to be quite satisfactory. Recently
I compared this usual preparation with a meal com-
posed of water and more finely divided barium. A
striking difference in the small intestinal pattern and
motility was found when these two meals were studied
in the same patient.

Factors such as the composition, size and consistency
of the meal, speed of gastric emptying, drugs, emotional
disturbances, disease and reflex disturbances from dis-
ease outside the gastrointestinal tract are capable of
producing changes in the roentgen appearance of the
small intestine. In this presentation the discussion will
be limited to the roentgen anatomy as seen in healthy
subjects.

1. Cole, L. G., and others: Radiologic
the Gastro-Intestinal Tract, St. Paul and
Company, 1934, p. 61.

2. Pendergrass, E. P.; Ravdin, I. S.
P. J. : Studies of the Small Intestine:
Pathologic States on Gastric Emptying
Radiology 26: 651-662 (June) 1936.

Exploration of the Mucosa of
Minneapolis, Bruce Publishing

; Johnson, C. G., and Hodcs,
Effect of Foods and Various
and Small Intestinal Pattern,

1538

ANATOMY OF INTESTINE— CHAMBERLIN

Jom. A. JI. A
Oci. 21, 153?

In the normal controls that I have studied, the head
of the meal reaches the cecum in from one and a half
to three hours. The small intestine is completely empty
in from five to six hours. The caliber of the lumen
diminishes from above downward (fig. 1), Roent-

Fig. 3. — Note the longitudinal folds in the duodenal cap and the coarse,
reticular pattern of the remainder of the duodenum. The duodenal stream
is intermittent.

genologically, one can distinguish duodenum, jejunum
and ileum, although the line of demarcation between
them is not well defined. The duodenum, which begins
just distal to the cap at the first circular fold of mucosa,
is short, wide and relatively fixed in position. It forms

trig. 4 . — a bolus of barium sulfate passing rapidly through the proximal
ieiunum. Note the widened loop with the obliterated mucosal pattern.
Proximal to the bolus, the mucous membrane folds all points in the
direction of motion.

an incomplete loop around the head of the pancreas and
may be divided into a superior, a descending, a trans-
verse and an ascending portion. The cap and superior
duodenum are usually retentive, but in the remaining

portions of the duodenum peristaltic rushes and to and
fro motion may be seen. In the duodenum the stream
is of the intermittent type. Beyond the suspensory
ligament of Treitz the speed of forward motion
decreases. The barium stream tends to be continuous
with an occasional peristaltic rush. Through the
jejunum and ileum the progress of the meal is mostly
a gradual creeping forward of the contents, becoming
slower as it approaches the cecum. This progress is
so slow that it is practically impossible to study the
barium stream continuously because of the danger oi
overexposure to the patient. In some instances a com-
plete arrest of the meal may occur in the ileum. If the
patient is then allowed to eat, the contents will proceed
into the colon without further delay.

The mucosal pattern of the small intestine shows
many variations which seem to be specific for a given

Fig. 5— The "snow flake” pattern, taking « te ”h° n p ° 0 rt£"o(
arium in the mucous membrane folds after
ariura mea? fias passed.

et of physical conditions. Sudia^
rom the primary circular folds ot lkerk & { ;, e

he secondary induced folds which may o are

nucous membrane. The primary folds o sma ller
argest in the duodenum and jejunum, x a nd

nd less frequent in the lower jejunum and « '
nay be poorly developed or absen 1,1 ^ they

leum. They are not obliterated by distention ^
lersist in postmortem specimens. Sue *° ;rc *, ar 0 r
nto the lumen of the small mtestin heights

piral form. Adjacent folds may be of diffe ^
nd point in different directions ^ [0

ell 3 the mucous membrane folds adapt tj ^ a , £0
he muscular contractions of the mtesti - oen t-

o the consistency and form of the irking

enographic examinations one 15 ' : , en segment

.attern; therefore t he pattern of _ a jg^enjj^

— . thr Gast^V

3.: Role of Autonomous
Membrane m Digestion, Am. J*

Volume 113
Number 17

ANATOMY OF INTESTINE— CHAMBERLIN

1539

depends on its anatomic character and also on its
physiologic activity at the time of the examination. In
the duodenum the pattern is coarsely reticular but may
sometimes resemble stacked coins (fig. 3). While the
stomach and duodenum are emptying, the jejunum
shows a reticular or herring bone pattern when thinly
coated by barium (fig. 2). During the passage of large
boluses, the pattern may be obliterated except for cir-
cular folds near the periphery (fig. 4). As the meal
progresses distally a “snow flake” pattern occurs owing
to retention of small quantities of barium in the vasa
digestiva (fig. 5). The central lumen is variable. When
small amounts of barium coat the mucous membrane,
the folds can be seen to meet near the center of the
intestine. When larger quantities of barium are present,
one cannot be certain of the presence of a central canal
because of the obliteration of the pattern. If a small

Fig. 6. — Longitudinal folds in the jejunum occurring as a result of
segmental contraction.

quantity of gas is present, the central lumen may be
more readily observed. Longitudinal folds of mucosa,
the “barring” pattern of Forssell, may occur as a result
of segmental contraction in the jejunum (fig. 6). Occa-
sionally, one also sees a localized fuzzy appearance
which I have attributed to a rapid movement at the time
of examination.

In the proximal ileum the pattern is somewhat
similar to that in the distal jejunum. Farther along in
the ileum the pattern gradually changes. Frequently a
continuous or segmented column of barium without a
visible profile pattern is present. In other instances the
pattern may resemble a stack of coins (fig. 7). Some-
times one observes a sharp change in density of the
barium in the ileum as a result of increased secretion
or dilution of the meal. Near the terminal ileum,
longitudinal folds can sometimes be identified.

3he frequency with which normal variations and con-
genital anomalies of the small intestine occur depends
largely on the thoroughness of the examination and the
examiner’s ability to detect them.

Failure of rotation may result in finding the small
intestine in the right half of the abdomen and the colon
to the left side of the midline. This condition, also
called mesenterium commune, is easily recognized by
roentgen examination.

Fig. 7. — Mucous membrane pattern in the ileum. This appearance has
been called the “stacked coin” pattern.

. ■*- uivHireuia oi me s:

they are all placed along the mesenteric border.

oiuuu iiiicatxne.

Intra-abdominal hernia can be diagnosed by roentgen
study of the small intestine. In this condition the coils
are grouped closely and they may occupy the right, left
or midabdominal position. In the patients studied by

1540

ANATOMY OF INTESTINE— CHAMBERLIN

Joi’j. A. M. A
Oct. 21, ]}i)

Alexander 1 the distal duodenum and duodenojejunal
junction were located in an abnormal position.

Enterogenous cysts and aberrant pancreatic tissue are
rare anomalies which may produce anatomic deformity
of the duodenum. When small, these deformities are

Fig. 9. — Congenital veil producing distortion of the second portion of
the duodenum. This patient also had gallstones, but there were no
adhesions between the gallbladder and the duodenum. The arrow points
to the duodenal deformity.

seen as an obliteration of the normal mucosal pattern,
with or without a central filling defect simulating a
polyp.

Congenital diverticula of the small intestine occur
most frequently in the duodenum. Usually placed along
the inner curvature, they vary in size from a few mil-
limeters to several inches in diameter (fig. 8).

Congenital membranes and veils attached to the
duodenum may produce roentgenologic appearances

Fig. 10. — Congenital anomaly of the jejunum resulting in a narrow
segment. Note the dilatation and retention of the barium proximal to
the lesion. Arrows point to the area of involved intestine.

which in some instances cannot be differentiated from
pericholecystic adhesions or duodenal ulcers (fig. 9).

In 1906 Ochsner 0 called attention to a more or less
marked thickening of the intestinal wall from 2 to 4 cm.
below the entrance of the common duct. Microscopic

4 Alexander, F. K.: Roentgen Diagnosis of Intra-Abdomina! Hernia.

Am. T. Roentgenol. 3S: 92-101 (July) 193/. ^ ,

5 Ochsner. A. J. : Constriction of the Duodenum Below the Entrance

of the Common Duct and Its Relation to Disease, Ann. Surg. 43:80-8/,
1906. •

sections taken from various portions of the intestinal
wall demonstrated that this thickness was due to an
increase in the number of circular muscle fibers present.
The arrangement was somewhat like that seen at the
pylorus, although the fibers were spread out in a more
diffuse fashion. Ochsner was of the opinion that inflam-
matory processes in the duodenum or biliary tract might
result in delayed passage of the contents because of
spasm of these muscular fibers. I have not been able
to corroborate his anatomic observations by roentgen
examination of healthy persons.

Congenital defects which result in a narrowed small
intestinal lumen or complete atresia are most commonly
found in children. In most of the cases, these defects
are incompatible with life. The routine use of study of
the small intestine has enabled me to diagnose in one
instance a narrowed jejunum iii a white man. Oper-
ation on him revealed that approximately 5 inches of
the jejunum was reduced to half its normal outside
circumference. The lumen of this portion of the intes-
tine was about the size of a lead pencil (fig- 10).

leckel’s diverticulum may sometimes be “ j„
roentgen examination of the sma , ser ious
e instances this anomaly has pro ana tofflj c
airment of function as well as a c Meckel's

amity of the small intestine. I ha ' e was com-
rticulum as large as one s thumb v J- abdom inal
sly missed by roentgen study an « Iunl was

-ations. In another instance ‘ ! ie of the small

irge that it was mistaken for a segm in the

stine. Whenever delayed mom occur for
n, one should examine the intestine car

anomaly. . cent years, ni»>

eal stasis, a term seldom used m i rcc j fs c0!! -
It from a Lane’s tank. One ma ? « thak infcd
m if a partial obstruction is ass anatomy

somewhat fixed m j nal J^Xsions which tin*

rmity is thought to he due to ad i|(ac fos?a__

mesentery of the lower ileum — —

,rdnn. A. C: Radiography in
! 9 - 37 , 1911.

Volume 113
Number 17

INTESTINAL LESIONS— WEBER

1541

(fig. 11). Clinically, some of these patients have been
suspected of having duodenal ulcer, but their symptoms
have been relieved by releasing the fixation of the
terminal ileum.

The value of a roentgen study of the small intestine
is increased by the use of a standard type of meal and
technic of examination. With such a basis a specific
roentgen appearance may be established for normal
subjects. Such studies may well result in a clearer
conception of the roentgen anatomy in disease states.

ROENTGENOLOGIC MANIFESTATIONS OF
NON-NEOPLASTIC LESIONS OF THE
SMALL INTESTINE

HARRY M. WEBER, M.D.

ROCHESTER, MINN.

My purpose in this paper is to discuss the roentgeno-
logic manifestations of the more commonly encountered
non-neoplastic diseases of the small intestine. There
is not a great variety of such processes. Peptic ulcer
of the duodenum and of the jejunum occurring after
gastro-enterostomy is omitted, because these parts are
so intimately associated with the stomach that they are
more properly considered in connection with lesions
of that organ. Acute inflammatory processes of the
small intestine are not included because patients afflicted
with them rarely are, and probably never should be,
submitted to roentgenologic examination. Syphilitic
and actinomycotic lesions of the small intestine have
been reported in the literature, but such lesions are so
exceedingly rare that for practical purposes they may
well be omitted from a discussion of this kind. The
literature also contains reports of cases in which animal
parasites, notably Ascaris lumbricoides, have been dem-
onstrated in the small intestine at roentgenologic exam-
ination ; such instances are also comparatively rare, and
the condition is mentioned here only by way of recog-
nizing it. The non-neoplastic lesions of the small intes-
tine more commonly encountered may be listed as
follows, and this discussion will be confined to these :

1. Chronic enteritis.

Tuberculous enteritis.

Nontuberculous enteritis.

2. Diverticula.

Meckel’s diverticulum.

3. Deficiency states.

4. Co-involvement of the small intestine by extrinsic non-
neoplastic lesions.

THE ROENTGENOLOGIC EXAMINATION OF THE
SMALL INTESTINE

I shall not attempt to describe the conduct of the
roentgenologic examination of the small intestine in
detail. However, the roentgenologic appearance of even
the normal small intestine may vary widely, depending
on the technic employed in the examination ; therefore
it seems proper to describe at least those features of
the examination considered to be important.

The patient presents himself for examination in the
morning after an overnight period of fasting. The first
step is the roentgenoscopic survey of the abdominal
field. If there is no evidence of intestinal obstruction
the exam ination may proceed. The patient is asked to

From the Section on Roentgenology, the Mayo Clinic.

Kead before the joint meetinp of the Section on Gastro-Enterology ana
rt/Tu °P* a *?d ttoe Section on Radiology at the Ninetieth Annual Session

the American Medical Association, St. Louis, May 19, 1939.

drink 8 ounces (240 cc.) of a suspension made of equal
parts by volume of barium sulfate and water. The
roentgenoscopic examination of the stomach and duode-
num is made in the usual way. Then the examiner
attempts to express as much as possible of the opaque
suspension from the stomach into the duodenum and
jejunum. This is the first of a series of attempts the
examiner makes to prevent a wide dispersion of the
opaque material through long reaches of the small intes-
tine. Ideally the suspension will be confined to the
smallest possible number of intestinal loops and will be
carried down the intestinal tract as a coherent compact
mass. Usually only a certain quantity can be expressed
from the stomach at a single roentgenoscopic session
lasting from five to ten minutes, but enough will have
left the stomach to permit satisfactory examination of
the entire duodenum and upper coils of jejunum. The
patient is then permitted to rest for a brief interval.
To accelerate the spontaneous discharge of the rest of
the opaque suspension from the stomach the patient is
instructed to lie relaxed on his right side, for it seems
that the stomach empties itself best in this posture.
After from ten to fifteen minutes a lower series of
intestinal coils are filled with the opaque suspension
and the patient is again submitted to roentgenoscopic
examination. Periods of rest followed by roentgeno-
scopic observations are repeated at intervals of fifteen
minutes until the stomach has delivered all but an insig-
nificant quantity of the suspension of the opaque medium
into the intestine. At about this time a lull in the more
vigorous intestinal movements sets in, and unless the
intestine is stimulated to activity again the opaque
material tends to become widely dispersed without dis-
tending the coils in the desired way referred to. A
simple palatable breakfast, preferably chosen by the
patient according to his taste and custom, is a pleasant
and practical way to stimulate the intestinal motility
at this phase of the examination. Immediately after
breakfast, periodic roentgenoscopic examinations are
resumed until such time as the opaque material has
made its way to the lowermost portion of the ileum and
cecum. The time required for the contrast material
to pass from the stomach to the cecum varies consider-
ably in apparently normal persons. Forty-five minutes
of elapsed time is not considered to be abnormally fast ;
four or five hours, not abnormally slow.

Roentgenographic examinations, with or without the
use of the Potter-Bucky diaphragm, are made at the
examiner’s discretion, to clarify doubtful or suggestive
areas of abnormality and to supply a permanent record
of the roentgenologic manifestations. It is worthy of
emphasis, however, that the roentgenoscopic examina-
tion is the cardinal roentgenologic maneuver, and, in
my opinion, no number of roentgenograms could satis-
factorily supplant it.

To me the most satisfactory way of examining the
lowermost portion of the ileum is by filling it in retro-
grade direction through the ileocecal orifice at the con-
clusion of the examination of the colon, bj' using a
contrast enema. Examination is made before and after
the patient is permitted to empty the opaque fluid from
the colon. Under these circumstances the ileal coils
are elevated out of the bony pelvis, are filled with fresh,
undehydrated contrast fluid, and are well visualized
and readily manipulated. Retrograde filling of the
lowermost portion of the ileum can be effected in most
cases if the examiner will make a special effort to do so.
It is well to consider the roentgenologic examination
of the lowermost portion of the ileum as part of the

1542

INTESTINAL LESIONS— WEBER

Joint. A. XI. A,
Oci. 21, 1939

examination of the colon in much the same way as
the examination of the duodenum is considered to be
part of the examination of the stomach.

CHRONIC ENTERITIS

Pathologically, chronic enteritis, using this term in
its broadest possible sense, would include chronic intes-
tinal lesions of tuberculosis, syphilis, bacillary dysentery
and lymphopatbia venereum as well as lesions caused
by pathogenic fungi and parasites, and lesions for which
a specific etiologic agent has not as yet been determined.
It is probable that these lesions, whatever their cause
may be, will have very similar gross pathologic features
and they will be distinguished from one another only
by their microscopic characteristics. Syphilitic, mycotic,
parasitic and proved specific bacillary and streptococcic
forms of enteritis occur so rarely as to be negligible
in a practical consideration. Tuberculous enteritis and
a nonspecific form of chronic enteritis of undetermined
origin are the most common types of chronic enteritis
encountered in practice.

In the truly voluminous literature that has accumu-
lated on these two forms of chronic enteritis the clinical,
pathologic, roentgenologic and therapeutic phases have
been studied and described so often and so well that
further elaboration seems not only unnecessary but pre-
sumptuous. I xvish only' to emphasize that the two
diseases have many clinical, morphologic and roentgeno-
logic features in common and to submit some sugges-
tions for making at least a presumptive roentgenologic
distinction between them.

Traditionally, intestinal tuberculosis is described as
being either ulcerative or hyperplastic in character.
Practically, a purely ulcerative or purely hyperplastic
tuberculous intestinal lesion is but rarely encountered.
Usually a combination of ulceration and hyperplasia is
observed, and one or the other feature is found to be
predominant in the picture. A true hyperplastic tuber-
culous lesion of the small intestine is notoriously uncom-

Fig. 1. — Left, colon distended with contrast enema; right, after eval r“ a '
tion of contrast enema and redistention with air. Tuberculous ileocolitis.
The patient had cavernous tuberculosis of the right lung.

mon. Masson and Mclndoe 1 reported the one case in
which a lesion of this type was observed at the Mayo
Clinic and, significantly, the lesion was discovered in a
part of the small intestine caught in a right paradu-
odenal hernia. Traditionally, too, tuberculosis of the
intestine is considered to be a combined enterocohc

1 Masson I C and Mclndoe, A. H.: Right Paraduodenal Hernia
,,, Tsnlated Hvnemlastic Tuberculous Obstruction: Comment and Report
rf^se AffeS^Tejunum and Ileum- Operation and Recovery, Surg.,
Gynec. & Obst. 50:29-39 (Jan.) 1930.

disease, that is, tuberculous lesions are observed to be
distributed throughout the colon and in the small intes-
tine as well, and especially in the ileocecal region. This
distribution of tuberculous lesions is but the rule to
which there are many exceptions. Proliferation, necro-
sis, cicatrization, ulceration and perforation, with devel-
opment of extra-enteral abscesses and fistulas, are

Fig. 2 — Left and right, phases in the examination of the small intestine.
Tuberculous ileitis. At necropsy no other focus of tuberculosis
found.

universally recognized features in the pathogenesis of
tuberculous intestinal lesions.

In 1932 Crohn, Ginzburg and Oppenheimer * reported
a series of cases of benign, subacute or chronic, necro-
tizing and cicatrizing inflammation of the small intes-
tine. Neither these observers nor any of the nian)
who have conducted investigations on the cause ot :ie
disease since that time have given a satisfactory answer
as to its cause. The pathologic features of the diseas
have been described in detail, and the similarity ot
gross pathologic characteristics of this disease to t ios
of intestinal tuberculosis is striking in all description •
As in tuberculous enteritis, the pathologic P roces ?
subacute or chronic ; proliferation, necrosis, ulcera ■
cicatrization, perforation and the formation o P
enteral and extra-enteral abscesses and .fistulas •
characteristic features. Macroscopically, it 15 ® ‘
difficult, and usually impossible, to distinguish 1 1
tuberculous from the tuberculous form, and cases , u
been reported, that of Schapiro 3 being a notew __
example, in which the ultimate correct diagnosis,
in doubt even after expert and thorough mic P
examination. If distinction between the w ° -j.
is difficult, even when the diseased tissue is nu ■ .
able for macroscopic examination, it is liar j < ^
ing that a roentgenologic differentiation shou ‘ ation s
difficult, as indeed it is. The following j„

have been found to be of value, at leas t00

which the original pathologic process has devc 1-

badly obscured by very extensive ulceration an
opment of abscesses and fistulas. , . or gan,

Like the colon, the small intestine « a tubular^ ^
and since pathologic processes deform the roent .

the same way as they do the other, d t0 t hc

genologic criteria of diagnosis can be PP intest j n c.
small intestine as are applied to the : k g ^ as \
There are several forms ofehrome “ de f orn i the
have nointed out elsewhere, all of thenj- __ ;

" I r n •

2. Crchn. B. B.;.Cinzsl, u ^

Ileitis: A Pathologic and Clinical Entit>, J-

3C, ‘ 15) 1932 ‘- -■ Hypcrtvo I d,i U cjm,«^r ,,, "‘::i:, f

Am. b

Roc? 1 '

hapiro, I. S.: H^crlrcpmc jej (Sept> ) 1934.

- -

ncountcred Chronic Ulcerative Diseases o

mol. no: -188-496 (Oct.) 1933.

Volume 113
Number 17

INTESTINAL LESIONS— WEBER

1543

colon in the same fundamental ways. The roentgeno-
logic distinction between the different etiologic types
of chronic colitis is made chiefly on the distribution of
the pathologic process in the colon, but roentgenologic
evidence of disease in other organs and the results of
other clinical tests must frequently be drawn on to reach
the final diagnosis. Besides these, the experienced
observer can frequently recognize what, for want of
l a better term, I have called a certain “look” by which,
| intuitively almost, he perceives the underlying cause
j for the changes he sees. The roentgenologic manifes-
! tations of the different forms of chronic colitis are
much more familiar than those of similar processes in
the small intestine because of their very much greater
incidence, but tbe same roentgenologic diagnostic cri-
! teria are applied to lesions of both parts of the intestine.

As has been mentioned, the tuberculous and non-
tuberculous forms of chronic enteritis have so much in
common morphologically that the two are not readily
distinguished from each other even at gross pathologic
examination and, therefore, not at roentgenologic exam-
ination. But, as in the colon, close comparison of the
roentgenologic appearances often shows a different
roentgenologic “look” of the two diseases. 5 This is
largely related to the contours the affected segment
assumes when filled with the contrast material. The
contours of the tuberculous intestine have typically a
rougher, more corrugated, appearance corresponding
to a more irregular, disconnected insemination of the
ulcerohyperplastic process (figs. 1 and 2). In its
roentgenologic manifestations the nontuberculous form
of chronic enteritis imitates the classic, familiar picture
of chronic ulcerative colitis very closely. The contours
are characteristically smooth and the narrowing is uni-
form, corresponding to the typical diffuse, even devel-
opment of the underlying pathologic process (figs. 3
and 4).

Other aids in the differentiation are chiefly those con-
cerned with the exclusion of tuberculosis. Investigation
of extra-enteral foci of tuberculosis, especially in the

rig. 3.-— Left, colon after evacuation of the the contrast enema; right,
alter _ redistention with air. Nontuberculous ileocolitis. Microscopic
examination of the resected specimen failed to show evidence of tuber-
culosis.

lungs, should always be made when evidence of chronic
enteritis is at hand. If a focus of active pulmonary
tuberculosis is found to be coexisting with any non-
neoplastic lesion of the small intestine below the
duodenum, the intestinal lesion should be considered
tuberculous until proved otherwise. Conversely, in the

1 ■ M.: Discussion, Proc. Staff Meet., Mayo Clin, lit
-t-w ov - '930; Regional Enteritis; Roentgenologic Manifesto-
t'ons. ibid. 13 : 545-550 (Aug. 31) 1938.

absence of such a focus the intestinal lesion is likley
to be nontuberculous. Isolated intestinal tuberculosis
occurs just often enough, however, that this conclusion
is not to be drawn definitively. Instances in which non-
tuberculous enteritis is associated with pulmonary
tuberculosis of questionable activity have also been
observed.

Fig. 4. — Left, ileum and upper part of colon filled with opaque suspen-
sion administered by mouth; right, after evacuation of opaque enema.
Nontuberculous ileitis. At necropsy, no evidence of tuberculosis was
found either in the intestine or elsewhere in the body.

Other diagnostic clues may be offered by the discov-
ery of calcified mesenteric lymph nodes, the application
of intradermal tuberculin tests and the search for Myco-
bacterium tuberculosis in the stools. It is granted, of
course, that a definitive diagnosis will certainly not be
reached in many instances, and the roentgenologic
examiner will often find it necessary to confine his diag-
nosis to a description of the general morphologic char-
acter of the process and its distribution in the intestinal
tract. His clinical and surgical colleagues will be able
to carry on if this is done with a reasonable degree of
accuracy.

DEFICIENCY STATES

Peculiar changes in the roentgenologic appearance of
the small intestine are often observed in certain states
of dietary deficiency, especially when steatorrhea, with
or without diarrhea, is one of the principal clinical fea-
tures. These roentgenologic changes have been seen in
such conditions as nontropical sprue, pellagra, celiac
disease in children, pancreatic insufficiency, chronic
alcoholism and some other conditions of long continued
primary or secondary nutritional deficiency. At present
I am not prepared to state that the roentgenologic
appearance of the small intestine is identical in all of
the different types of deficiency disease enumerated.
But this much can be said : Whenever these changes
are encountered in the roentgenologic examination of
the small intestine, they have many features in common,
and a distinction between the various types of deficiency
disease on the basis of roentgenologic appearances alone
is not as yet attempted.

Pillai and Murtlii, 0 Snell, Camp and Watkins, 7
Mackie and Pound, 8 Golden 9 and others have described
the roentgenologic changes seen in these conditions.
One of the surprising features is the marked depression

iuuum, a. iv: naaioiogic Mgns in Uises ot
i * S £ udy , Cases ’ Indian J. Med. 12:116-138 (June)

1931; abstr. Trop. Dis. Bull. 29:8 (Jan.) 1932.

7. Snell, A. M.; Camp J. D., and Watkins, C. H.: Nontropical

!r?77U84°TMa r ch P 20) 5935. ea, ° r 3) ’ Pr0t SUff Meet " Mayo Clin '

Tnrt Tl T 't, and Po “nd. R. E.: Changes in the Gastrointestinal

T rflA,„ 5 C,enCy States, with Special Reference to the Small Intestine;

«3^1S t (Feb°23) a i935 C m,C: ' Sludy of Fort - v Cascs . J- A. M. A. 104:
genoi. G 36 : e 892 R 9°0r (Dec?) Am ' I" R °™>-

1544

IN TEST INAL LESIONS— WEBER

Jot's. A. M. A
Oct. 21, 19<«

of motility throughout the intestinal tract, and this is the
more striking if the patient has been complaining of
diarrhea. Peristaltic activity is definitely subdued, the
contrast suspension making its difficult, slow way down
the tract much as if it were being poured through a half-
lifeless tube. Peculiar segmentation of the intestinal
loops is commonly found. Contracted segments are
observed to alternate irregularly with dilated ones. In
another phase, a loop that was dilated is found to he
contracted. The contours of well distended segments
may be abnormally smooth at one period of roentgeno-
scopic observation, abnormally shaggy at another. The
internal relief of involved loops may he markedly sup-
pressed or markedly exaggerated. Fantastic agglomer-
ations of the opaque suspension take place. In the
normal small intestine the opaque suspension assumes
a smooth homogeneous continuity ; here part of it is
collected in a pool in an isolated dilated segment, another
part is clumped in an apparently unrelated amorphous
mass, and the rest of it assumes the appearance of a
flocculent precipitate throughout a long stretch of some
other part of the small intestine. The changes arc the
more marked the more well defined is the clinical pic-

Fig. 5. — o, phases in tile examination of the small intestine; left, ' - c
earlier phase shows no roentgenographic evidence of the diverticulum,
although it was identified at rocntgenoscoptc examination; right, the arrow
points to the diverticulum; b, left, the abdomen fifteen hours attcr
administration of 2 ounces (60 cc.) of castor oil and twenty-four hours
after patient took the contrast meal (a); the arro\v points to the residue
of the contrast suspension in the diverticulum; right, after evacuation
of contrast enema.

ture, and the involved segments have a decided tendency
to return to normal as the patient gives evidence of
clinical improvement.

At the present time one can do little more than
speculate about the morphologic and physiologic sig-
nificance of these roentgenologic changes. In only a few
cases Avere actual morphologic studies made available.

Starr and Gardner 10 noted atrophy, dilatation and pas-
sive congestion of the entire intestinal tract; Whipple 11
described extensive deposits of neutral fat and fatty
acids in the intestinal mucosa, with passive congestion
and cloudy swelling of the viscera; in one of three cases
reported by Blumgart 12 ileal ulceration, distention of
the cecum and atrophy of its mucosa were noted. That

Fig. 6. — Meckel’s diverticulum was diagnosed at roentgenologic exam-
ination. The patient had a marked secondary anemia and evidence ot
intestinal bleeding but refused to submit to operation. Left and ngnl,
phases in the examination of the small intestine.

the intestinal secretions are grossly abnormal is evident
from physical and chemical examination of the stools
and intestinal secretions. ,

On the basis of my own observations I am inclined
to discredit the importance of inflammatory changes,
such as edema, ulceration and infiltration of the intes-
tine, in the production of this roentgenologic syndrome.
It seems to me that the roentgenologic changes arc more
plausibly' explained by' holding the degenerative changes
accountable for the abnormal motility and for some o
the bizarre intestinal patterns observed, while 1
abnormal secretions are made responsible for the o i
peculiar roentgenologic manifestations.

DIVERTICULA OF THE SMALL INTESTINE

Duodenum . — Diverticula are found in the duoden® 1
ore frequently than in any other part of the in es
:cept the sigmoid colon. The most common si
igin is near the ampulla of Vater. They n ,a )
igle or multiple, very small or very large. l)1 ' c
len large they are usually symptomless. 1 ‘

stances they become large enough to produce )
ms of partial or intermittent obstruction meem • ^
d in this event radical therapeutic measures D
cessary' for relief. It is conceivable too tha ‘ er>
iy result from prolonged retention of ingestc * ^
d symptoms may develop from such a situa ■
ignosis is strictly roentgenologic when ^ ]ia J ac , cr .
e ration or necropsy. Even when small, t cl ^
ic extraluminal outpouching is readily reco f’ ,| lC
e contrast meal is observed as it P a ^ e ‘ ], the

urse of the duodenum after it has passed S
lorus. Sometimes diverticula are distended »
with fluid or with both. . arc

Jejunum . — The diverticula found m t :hc J J ^ am i

•ger, as a rule, than those m the duodenu.m ^
iy are more frequently multiple than s g__

itnrr, Paul, and Gardner, Lois: A Bioc|,ennealS,ujr ^
s with a Condition Simulating Sprue, Am. )■ - (P |

H, A I^erto Undescrilie-. W

"ric'^ptatrTlssues^BulE «<*“"* ^

llumgart. 11 . L,: Three Fatal ^ Cases of Arch. ^

tion and Anemia, and in T»o Aculo i.

12:113-128 (July) 1923.

Volume 113
Number 17

INTESTINAL LESIONS— WEBER

1545

jejunum, as in the duodenum, the diverticula are usually
symptomless, although instances have been reported in
which the diverticula were held responsible for symp-
toms such as borborygmi and intermittent cramps after
the ingestion of food. The diagnosis of jejunal diver-
ticula "is likewise a roentgenologic problem. Since the
outpouchings are usually large, they are recognized
with comparative ease as the contrast meal makes its
way through the jejunal coils. Frequently the diver-
ticula fail to evacuate the contrast substance rapidly,
and they are recognizable even after the jejunal lumen
in the immediate vicinity has contracted and all but
the smallest residue of the opaque substance has been
expelled from the mucosal folds.

Ileum . — Diverticula are but rarely found in the ileum,
and those not designated as Meckel’s diverticula rarely
are associated with clinical symptoms. The roentgeno-
logic appearance of ileal diverticula is the same as that
of diverticula in the duodenum and jejunum.

MECKEL’S DIVERTICULUM

This developmental anomaly occurs in about 2 per
cent of the population, males predominating in a ratio
of 2: 1. It is always found somewhere in the first 5 feet
(150 cm.) of ileum above the ileocecal valve. Almost
any variation in size, shape and position may be encoun-
tered. Thus Dixon and Famiglietti 13 and Goldstein
and Cragg 14 described a gigantic Meckel’s diverticulum,
66 cm. in length, which was found in a girl aged 5 years.
Often the diverticulum is simply a small, budlike projec-
tion from the ileal lumen.

Fig. 7. — Meckel’s diverticulum and hyperplastic ileitis. The arrows
point to the diverticulum; left, in the roentgenogram made after evacua-
tion of the contrast enema; right, in the specimen removed by resection.

Pemberton and Stalker, 13 reviewing twenty consecu-
tive cases in which Meckel’s diverticulum was encoun-
tered at operation, classified the cases into three groups :
(1) those in which there were no symptoms, (2) those

13. Dixon, C. F„ and Famiglietti, E. V.: Gigantic Meckel s Diver-
ticulum with Ulceration Producing Massive Hemorrhage: Report ot
Case, Proc. Staff Meet., Mayo Clin. 12:345-547 (Sept. 1) 1937.

14. Goldstein, Moe, and Cragg, R. W.: An Elongated Meckel s Diver-
(tculum in a Child, Am. J. Dis. Child. 55: 128-134 (Jan.) 1938.

15. Pemberton, J. dej„ and Stalker, L. K. : Meckel’s Diverticulum: A
e\Te\v of Twenty Cases with Report of Two Cases, Surgery 3: 563-56/

(April) 1938.

in which there were symptoms of intestinal obstruction
and (3) those in which there were symptoms of intes-
tinal bleeding. Only eight of the twenty patients had
symptoms believed to be due to the diverticulum; in
the remaining twelve cases the diverticulum was discov-
ered at the time laparotomy was performed for some
other abdominal lesion.

Fig. 8. — Meckel’s diverticulum; left, lower part of the ileum filled with
contrast suspension administered by mouth; right, diagrammatic repre-
sentation of the condition found at operation: A, Meckel’s diverticulum;
B, neck of diverticulum; C, narrowed ileum.

The clinical diagnosis of Meckel’s diverticulum,
even when the diverticulum is diseased, is notoriously
difficult. However, the condition can frequently be
suspected and a presumptive diagnosis made on the
basis of exclusion of other possibilities. The roent-
genologic examination assists in the diagnosis of
Meckel’s diverticulum in two ways: (1) by the actual
demonstration of the diverticulum somewhere in the
lowermost 150 cm. of the ileum; (2) failing this, by
assisting in the exclusion of other intestinal lesions as
causes of symptoms.

Very few successful attempts at demonstrating
Meckel’s diverticulum by roentgenologic methods have
been recorded. Case 10 was the first to demonstrate
this anomaly, and many years elapsed before another
instance was recorded in the roentgenologic literature.
Then others, among them Pfahler, 17 Allemann 18 and
Prevot 10 reported cases. Up to the present time
Meckel’s diverticula have been demonstrated roent-
genologically on but six occasions at the Mayo Clinic.
Since these diverticula vary so widely in their gross
morphologic characteristics, a typical roentgenologic
appearance is not to be described. The roentgenologic
appearance may, however, be expected to reflect the
morphologic contour of the particular diverticulum. A
review of the cases seen at the Mayo Clinic and those
reported in the literature shows that Meckel’s diver-
ticulum will usually be found in those coils of the lower
part of the ileum that are situated near and somewhat
to the right of the midline and at or near the level of
the umbilicus. One of the six cases seen at the clinic
was reported by Skinner and Walters, 20 and the pre-
operative roentgenologic diagnosis of Meckel’s diver-
ticulum (fig. 5 a and b) was confirmed at operation.
In three cases in which the diagnosis was made, the

IS. Case, J. T.: Jejuno-Ileal Diverticula, Acta radiol. 6: 230-240.
1926.

17. Pfahler, G. E.: The Roentgenologic Diagnosis of Meckel's Diver-
ticulum, Surg., Gynec. & Obst. 59: 929-934 (Dec.) 1934.

18. Allemann, R.: Zur Diagnose und Therapie des chronisch-inter-
mittierenden subtotalen Ileus, Schweiz, mcd. Wchnschr. 64: 331-333
(April 14) 1934.

c * ^ ec kelsches Divertikel ira Rontgenbild, Rontgenpraxis
s : oV7i I9.it>.

Skinner, I. C., and Walters, Waltman: Leiomyosarcoma of
Meckel s Diverticulum, with Roentgenologic Demonstration of the Diver*
ticulum: Report of a Case, Proc. Staff Meet., Mayo Clin. 14:102-107

1546

SMALL INTESTINE— KIEFER

Joui. A. M. A.
Oci. 21, 1923

patients were not submitted to operation and lienee
the diagnosis has not been confirmed (fig. 6). One
patient had extensive hyperplastic ileitis, which was
recognized roentgenologically. The diverticulum was
discovered in the resected portion of the intestine and
a review of the roentgenograms after operation revealed
the site of the diverticulum and its contours accurately
(fig. 7). In the fifth case a preoperative diagnosis of
perforating obstructing neoplasm of the ileum was made
(fig. 8). At the primary operation the real nature of
the lesion was not determined with certainty, but it
seemed to be a narrow, annular tumor of the ileum
associated with marked inflammation. Ileocolostomy
was performed. At the second operation, which was
performed twenty-five days later, it was found the
inflammatory process had subsided, and the real nature
of the lesion became apparent. It was a Meckel’s
diverticulum 3.5 cm. in diameter at its base and 7.5 cm.
long ; the anterior portion had become ulcerated. There
was also considerable inflammation of the ileum on each
side of the diverticulum. A review of the roentgeno-
grams in the light of these surgical observations revealed
that the true morphology was readily apparent but mis-
interpreted preoperatively.

As roentgenologic experience with the diagnosis
of Meckel’s diverticula accumulates, it seems reason-
able to expect that the condition will be recognized
more frequently at roentgenologic examination. Such
Meckel’s diverticula, however, as are small and com-
municate with the ileal lumen by a very wide neck will
be recognized only with the greatest difficulty, and
many of them will inevitably escape roentgenologic
detection. Careful and painstaking examination of that
part of the ileum in which this anomaly occurs will, I
think, result in many more accurate diagnoses of this
condition than have been recorded in the past.

EXTRINSIC PROCESSES

The small intestine seems to be co-involved by
pathologic processes extrinsic to it with relatively
greater frequency than is the large intestine. Usually
such processes are neoplasms which deform the small
intestine segmentalty either by direct extension and
invasion or by producing trophic ulceration which
extends into the lumen. Neoplasms of the pancreas
seem especially prone to do this, but tumors of the
mesentery ancl of the female pelvic organs may act
similarly. Of the extra-enteral non-neopiastic processes
which extend to and involve the small intestine, per-
forating diverticulitis of the sigmoid colon and salpingo-
oophoritis seem to be encountered most frequently. The
roentgenologic evidence of the extrinsic nature of the
process is obtainable at the roentgenoscopic examina-
tion, if at all ; palpation will possibly reveal the extrinsic
mass or a more diffuse tenderness or muscular rigidity
than would be expected if the disease were confined to
the intestine. If actual perforation into the intestinal
lumen has not taken place, considerable deformity of
the affected segment may be observed, yet as the
mucosal surface is carefully examined it will be noted
that the mucosal pattern, although altered considerably
by functional changes and by edema and submucous
infiltration, will be left unbroken throughout the
deformed segment. Conditions of this kind, however,
may be very confusing and will often demand fullest
cooperation of all special diagnostic services if the
correct diagnosis is to be made preoperatively. For-
tunately, situations of this kind are not commonly
encountered.

CLINICAL ASPECTS OF CHRONIC
DISORDERS OF THE SMALL
INTESTINE

EVERETT D. KIEFER, M.D.

BOSTON

This study has been restricted to the role of the small
intestine in the etiology of chronic abdominal disorders
and to the considerations that must be given it in the
diagnosis of chronic digestive complaints.

Clinical signs and symptoms of disorders of the small
intestine arise as a result of interference with the
physiologic functions of digestion, absorption and
motility.

SYMPTOMATOLOGY OF DISEASE OF SMALL INTESTINE

There are few symptoms which are highly diagnostic
of disease of the small intestine. Obstructive lesions
may cause vague prodromal symptoms such as a sense

Fig. 1 (case )). — Appearance of the abdomen “A^adhesic"*'

of intermittent intestinal obstruction caused by postop The

Barium series during symptom-free intervals were neg* j,,*ununi.
gas bubble in the left upper quadrant is in a dilated loop oi jej

af fulness or cramplike pain after meals, but the '
completely fluid nature of the content of the sma
:ine makes for an “all or none” type of obstruct on
rhere is no obstruction until suddenly there is c
obstruction with an acute onset of symptoms ^
dther persistent or intermittent, depending
nechanical status of the point involved. v mp-

Hypermotility of the small intestine produces Ad-
onis that are less dramatic and more subt e
icter. Abdominal distress immediately alter
latulence and diarrhea are suggestive of . f oU l,

grossly inadequate absorption results m S’ an( j
atty stools, failing nutrition, calcium imbaUnc

ivitaminosis. „f tl,e small

Anemia is not uncommon in disorders .j on of
ntestine and is the result of inadequate _ — — •

From the Department of Gastro-Enter^a, C35tro -Enterotoer
Read before the joint meeting of the Sec Annual - e

octology and the Section on Radiology at the Xme
the American Medical Association, St. Louis, -May

Volume 113
Number 17

SMALL INTESTINE— KIEFER

1547

iron or othet blood forming substance or more com-
monly the result of chronic blood loss. Gross hemor-
rhage also occurs and the passage of a large amount of
red blood by rectum points to a possible lesion in the
jejunum or ileum.

Fig. 2 (case 2). — Partial obstruction and marked dilatation of the
jejunum caused by adhesions and a malfunctioning, gastro-enteroslomy
from torsion of the jejunal loop, five hours after the ingestion of barium
sulfate.

PHYSICAL SIGNS

The general physical signs of disease of the small
intestine are malnutrition, anemia and signs of vitamin
deficiency. Inspection of the abdomen may disclose an

,*S. 3 (case 2). — A, appearance of patient Jan. 14, 1938, showing the
malnutrition and the mental apathy which were present. Weight, 104
pounds (47 Kg.). B, appearance May 19 showing the striking change in
. appearance after surgical relief of the obstruction and the associated
improvement in his nutrition. Weight, 144 pounds (65 Kg.).

irregular pattern of dilated small intestine with or with-
out visible peristalsis. If the abdominal wall is thin,
>t is usually possible to distinguish distended loops
of small intestine from the stomach or the colon by
the characteristic pattern and the type of peristaltic
activity.

The other important abdominal finding may be a
mass. Benign and malignant neoplasms of the jejunum
or ileum vary in size, feel rounded and are usually
movable and somewhat tender. An intussuscepted mass
is firm but soft and gives the impression of being
elongated or sausage shaped. Infectious granulomas
may also be elongated but are harder and more ropelike.

ROENTGENOLOGIC SIGNS

By far the most important single laboratory pro-
cedure is the x-ray examination of the gastrointestinal
tract, yet a remarkably large percentage of lesions of
the small intestine are missed in the ordinary routine
study. Although the study of motility of the small intes-
tine, outline and mucosal pattern with serial films is
well known and the interpretation well appreciated by
specialists in roentgenology, these methods are not
generally applied in gastrointestinal diagnosis, and the
small intestine remains the relative blind spot in x-ray

Fig. 4 (case 3). — 'Rigid annular constriction with a sharp line of
demarcation between rigid bowel wall and distended intestine, three hours
after the ingestion of barium sulfate. Diagnosis, annular carcinoma of
the jejunum.

diagnosis of the digestive tract. There follows the
axiom that lesions of the small intestine are not found
unless tliejf are looked for.

There are practical objections, especially the cost of
films, to the routine employment of numerous serial
films in every case, and a compromise may be effected
in the form of a film taken between two and three hours
after the barium meal. Since, in the average case, the
head of the meal reaches the cecum at this time, a con-
siderable portion of the jejunum and ileum is well out-
lined and the film has much more diagnostic value than
the ordinary six hour film. The examiner should be
familiar with the clinical history and alert for symptoms
pointing to the small intestine so that additional films
can be ordered in suspicious cases. The rather wide
variations in the normal mucosal patterns and outlines
of the small intestine introduce difficulties in interpreta-
tion, but long experience in viewing normal patterns
sensitizes the examiner to the occasional abnormal
appearing loop.

1548

SMALL INTESTINE— KIEFER

Joub. A. M. A.
Oct. 21 , 1955

Intubation of the small intestine combined with x-ray
studies with air and opaque mediums recently described
by Miller, Abbott and Johnston 1 promises to add
further diagnostic aid.

CHRONIC OBSTRUCTION DUE TO ADHESIONS
One of the commonest forms of chronic organic dis-
orders of the small intestine is the intermittent obstruc-
tion caused by postoperative adhesions.

In case 1 there was a history of a panhysterectomy
and appendectomy performed fourteen years before

Fig. 6 (case 6). — Abnormal x-ray appearance of the jejunum charac-
terized by exaggerated markings and sharply serrated borders. The ileum
is smooth and dilated with spastic areas. Diagnosis, chronic nonulcerative
enteritis.

admission. About nine years later the patient began
to have attacks of severe, cramplike pain in the lower
part of the abdomen, occurring at intervals of from one

I Abbott. W. O., and Johnston. C. G. : Intubation Studies of the
Human Small Intestine: X. A Xonsurgical Method of Treating, Local-
izing and Diagnosing the Nature of Obstructive Lesions, Surg., Gynec. &
Ohst. 66: 691-697 (Arrit) 193S.

to twelve weeks, lasting several hours and sometimes
accompanied by vomiting. Between attacks she had an
important gastrointestinal symptoms. Characteristic of
this condition, not only: her physical examination but
the gastrointestinal x-ray films were entirely negative
during these intervals. Fortunately, while the patient
was under observation she experienced a typical attack,
which made it possible to make an x-ray examination
of the abdomen during an attack (a diagnostic oppor-
tunity which should never be overlooked) (fig. 1).
This disclosed a dilated, gas-filled loop of small intes-
tine indicating obstruction, which was confirmed at
laparotomy.

In association with chronic partial obstruction there
is not only a disturbance of motility but sometimes a
marked disorder of nutrition due to fear of eating

Fig. 7.— The normal small intestine may show consideraHe^naho j
in position, caliber, outline and mucosal pattern. in|S * ^ sn)3 ll

the common variations in the outline and mucosal p*
intestine.

because of the resulting pain, frequent vomiting a
diarrhea. Mild states of malnutrition and
deficiency are common, and occasionally an '
avitaminosis develops comparable to severe P e | ‘ ( j
In case 2 a gastro-enterostomy had been p •
for pyloric obstruction thirty-five years be o * ( j ]f

sion. Until five years before the patient cat t0
clinic he had been well, but at that time i , . nl j.
reduce his food intake gradually because o < c j,j e f
nal pain that followed meals of ordinary size. an ,j
complaints on admission were neuritis m > . 0 f

diarrhea. The physical manifestations " er e( ]cnw-
severe pellagra including emaciation, mam , . a ,
polyneuritis, glossitis, dermatitis. P r ° ct ' . ‘ - n therapy

ihanges. Parenteral fluids and energetic v quantity
improved his condition, but an increase 11 v stu <ljc.'
:>f food resulted in obstructive vomiting. - ‘ j j 0 op

(fig. 2) showed obstruction of the proxima J J ^ t | u c
it the gastro-enterostomy, which P rov ^ - ca | relief
o adhesions and torsion of the loop, bt g

Volume 1U
Number 17

SMALL INTESTINE— KIEFER

1549

resulted in the patient’s return to health. Figure 3
reveals the striking improvement in the patient’s appear-
ance. The nutritional disturbances had become so
marked that in the clinical picture they overshadowed
the gastrointestinal disorder responsible for the con-

fldion. TUM0KS of tiiic small intestine

Benign and malignant tumors of the small intestine
may cause obstruction which is progressive but may be
steady or intermittent. An annular carcinoma of the
small intestine characteristically tends to give rise to
slowly progressive obstruction with increasing pain and
vomiting. The loss of weight in this type of case is
usually marked and rapid. The stools contain occult
blood and there is anemia as a rule. Figure 4 demon-
strates a typical annular, constricting filling defect of a
carcinoma in the jejunum with dilatation and stasis
above it. Surgical resection in this case was followed
by recovery, and the patient is alive seven years after
the operation.

New growths of the small intestine which are not
annular in structure but are mural or polypoid in type
are the most frequent cause of intussusception in the
adult and are prone to cause intermittent attacks of
obstruction similar to the attacks associated with post-
operative adhesions. The attacks tend to become pro-
gressively more frequent and more severe. As in the
cases of chronic adhesions, the x-ray examination may
be disappointing except when carried out either during
or immediately after an acute attack.

l’ig. 8 (case 7). — Distortion of tlie outline and mucosal pattern of the
duodenum beginning in the second portion with extension of the process
the jejunum producing changes in the outline and mucosa. The
process extends well down into the jejunum, but the lower part of the
jejunum is almost normal in the mucosal pattern, indicating that the
Hutammation was limited to the duodenum and upper part of the jejunum,
diagnosis, ulcerative enteritis.

DIVERTICULA OF TIIE SMALL INTESTINE

Meckel’s diverticulum is another important cause of
intussusception in young adults. The mechanism is
probably identical, since in most cases there is in rela-
tion to the diverticulum either an inflammatory mass
or a small benign tumor.

Occasionally it is possible to demonstrate an intussus-
ception of the ileum bv x-rav examination, as illustrated

by the following case : A man aged 34 had intermittent
spells of cramplike, midabdominal pain for over a year.
Films of the small intestine showed not only disturbed
motility but the presence of gas and barium, which out-
lined the filling defect caused by the tumor of intus-
suscepted bowel (fig. 5).

Fig. 9 (case 8). — Changes in the outline and pattern of the mucosa of
the upper part of the jejunum one hour after the ingestion of barium
sulfate. The lower part of the jejunum and the upper part of the ileum
show contraction and rigidity over an extensive area. Dilatation and
sacculation of the lower part of the ileum are present. Diagnosis, chronic
ulcerative and cicatricial enteritis.

Also in cases of bleeding from the lower portion of
the intestine, particularly in children and young adults.
Meckel’s diverticulum should be considered, since the
occurrence of aberrant gastric mucosa within the sac-
giving rise to peptic ulceration, hemorrhage and per-
foration is a well known clinical entity.

CHRONIC INFLAMMATORY DISEASE

Our knowledge of chronic inflammatory disease of
the small intestine other than tuberculosis dates mainly
from the report of Crohn 2 in 1932.

SUBACUTE OR CHRONIC NONULCERATIVE ENTERITIS

A subacute or chronic nonulcerative inflammation of
the small intestine is frequently seen and is illustrated
by a school boy aged 15 who had complained of malaise,
anorexia, mild abdominal distress, mild diarrhea, a
slight elevation of temperature and moderate leuko-
cytosis for three months. The colon was normal by
x-ray and by sigmoidoscopic examination, but definite
changes in the mucosal pattern of the small intestine
were demonstrated (fig. 6). There was no blood in
the stools. Following treatment the symptoms disap-
peared and subsequent x-ray films showed a return to
normal of the pattern of the small intestine.

CHRONIC ULCERATIVE ENTERITIS
The following case of chronic ulcerative enteritis is
an example of a more severe and more chronic form
of active inflammatory disease of the small intestine
showing evidence of ulceration of the mucosa but with-

2. Crohn, B. B.; Ginzburg, Leon, and 0|>renheimer, G. D.r Regional
Ileitis, J. A. M. A. 99: 1323-1329 (Oct. 15) 1932. 1

1550

Jons. A. M. A
Oct. 21, Hi:

SMALL INTESTINE— KIEFER

out extensive hyperplastic reaction : A married woman
aged 31 had complained of chronic abdominal pain for
eighteen months. On examination she was found to
have fever, a moderately severe anemia, mild leuko-
cytosis and occult blood in the stools. Gastrointestinal

r

Fig. 10 (case 9). — Changes in the mucosal pattern of the jejunum and
markedly irregular coils of ileum with numerous crater-like depressions
in the outline one hour after the ingestion of barium sulfate. Diagnosis,
chronic regional ulcerative and cicatricial ileitis.

x-ray examinations showed changes in the mucosal pat-
tern, irregularities in outline and in caliber and some
loss of flexibility in certain areas of the upper portion
of the small intestine. The rest of the tract was normal
(fig. 8).

hyperplastic stage

The hyperplastic stage is more chronic and may show
surprisingly extensive involvement of the small bowel.
The case illustrated in figure 9 shows x-ray changes
throughout the small intestine which are highly remi-
niscent of the changes found in the colon in extensive
ulcerative colitis.

From a roentgenologic point of view, chronic ulcer-
ative enteritis of either the small or the large bowel
produces obliteration of normal outlines, loss of flexibil-
ity, shortening of loops, stenosis and contraction of the
lumen and occasional fistula formation.

TUBERCULOUS ENTERITIS

Tuberculous enterocolitis produces changes in the
ileum and proximal colon which, from a roentgenologic
standpoint, are indistinguishable from nonspecific enter-
itis. Brown and Sampson 3 pointed out that localized
hyperirritability of the intestine was indicative of early
ulcerative lesions in the mucosa. As the process
advances, changes in the mucosal pattern, irregularities
of outline and lumen and finally rigidity and narrowing
are demonstrable by x-ray examination. Since it is
generally accepted that ileocecal tuberculosis practically
never occurs except secondarily to active, open pul-
monary disease, the differential diagnosis is not a com-
mon proble m.

3. Brown, Lawrason. and Sampson, H. L.: Intestinal Tuberculosis,
Philadelphia, Lea & Febiger, 1926.

INTESTINAL CHANGES IN DEFICIENCY STATES

While malnutrition and deficiency states are common
results of organic disease of the small intestine, it is also
true that avitaminosis may lead to secondary changes
in the intestinal tract which are sufficiently definite to
be demonstrated by x-ray study. Irregular distortion;
of the normal mucosal pattern, localized dilatation of
the lumen and a tendency for the barium sulfate to
form pockets in isolated loops are noted. These changes
are thought to be produced by edema of the mucosa,
disturbances in the motor activity and loss of tone in
the intestinal muscle.

Figure 12 shows an example of small intestinal atony
found in a young woman with chronic malnutrition.

FUNCTIONAL DISORDERS OF SMALL INTESTINE

Purely functional disorders of the small intestine are
difficult to establish on a sound clinical and laboratory
basis. Nevertheless, experience with functional indiges-
tion leads to the belief that in some cases disturbances
of the small intestine play a prominent role. This dis-
order is usually manifested by signs and symptoms of
hypermotility.

In some cases of hypermotility of the small intestine
the barium sulfate meal may reach the cecum in less
than one hour, and the entire meal may pass into the
colon in three or four hours. A sense of extreme fulness
in the upper part of the abdomen immediately after a
meal is rather characteristic of distress of the small
intestine. An unusual amount of borborygmi and a
sensation of motion and gnawing within the upper par
of the abdomen noticed immediately after a meal is a so

Fig. 11. — Contracted irregular lumen with loss , 0 :i, 0 ?Sl rfS’ 1 ®'
sinus formation. Diagnosis, tuberculous granuloma o

indicative of hypermotility. Rapid emptying °^.j ve
small intestine may cause diarrhea and

latulence. . ,■ na | dis-

Factors that are important in causing inn 0 f

irders of the small intestine are an i_rn ta ,n f r -X cS or
liet, habitual catharsis, alcohol, food idiosyn .
tllergic phenomena, endocrine disorders, f? cnc . 0 ;

tnd nervous or emotional factors. The excess

Volume 113
Number 17

DISCUSSION ON THE SMALL INTESTINE

1551

cathartic’s is commonly associated clinically with dis-
orders of the large bowel, but it is also true that
cathartics have a pronounced effect on the small intes-
tine. Patients with true food idiosyncrasies usually have
a pronounced effect within a few minutes after ingesting
the specific foods, and their symptoms often indicate a
marked irritation of the small intestine.

SUMMARY

Chronic intermittent obstruction, most commonly
caused by adhesions, is characterized by acute attacks
of abdominal pain interspersed with asymptomatic

Fig. 12 (case 9). — Rapid filling of the small intestine and the dilated
atonic appearance present throughout the jejunum and ileum one and a
half hours after the ingestion of barium sulfate. Diagnosis, atony of
intestine; malnutrition.

periods with negative physical and x-ray manifestations.
Positive diagnosis is often made possible by roentgeno-
grams taken during an attack.

In some cases nutritional disturbances may be the
outstanding feature.

Annular tumors produce gradually increasing
obstruction.

Mural and polypoid tumors cause intermittent attacks
of intussusception which increase in severity and
frequency.

Except for Meckel’s diverticulum, diverticula are
usually asymptomatic.

Tuberculous enteritis usually secondary to pulmonary
tuberculosis rarely involves the ileum alone.

Chronic nonspecific enteritis may occur as a febrile
condition with irritation of the small bowel, as an
ulcerative enteritis with fever and anemia or as a
granulomatous condition with thickening, obstruction
and fistulas.

Functional disturbances are manifested by signs and
symptoms of hypermotility.

X-ray diagnosis depends on signs of disturbed motil-
>ty and changes in the outline, caliber, flexibility and
mucosal patterns as illustrated by films taken at suitable
intervals after a barium sulfate meal.

60S Commonwealth Avenue.

ABSTRACT OF DISCUSSION

ON PAPERS OF DRS. CHAMBERLIN, WEBER AND KIEFER

Dr. Sara M. Jordan, Boston: The first striking thing
which comes to attention is the need for more complete x-ray
examination of the small intestine. We probably cannot, in
all cases, do wbat Dr. Chamberlin and Dr. Weber so ade-
quately outlined, but we can follow their example and use the
fluoroscope at frequent intervals and take frequent films and
use either their technic or a standard technic in each labora-
tory, so that we have something on which to base our judg-
ment of the condition of the small bowel, and this especially
in those cases in which there is any reasonable suspicion of
disease in the small intestine. We can also adopt what Dr.
Kiefer has shown to be a satisfactory' routine method of
making some estimate of the motility of the small intestine ,
by a film taken in two or three hours, in addition to one taken
after the jejunum and ileum have been almost completely'
emptied. That simple addition to the routine procedure will
help us in the acquisition of more knowledge of the small
intestine. We do not have endoscopy for the small intestine,
but we shall use, I am sure, the Osler-Abbott intubation.
Peritoneoscopy, which Dr. Benedict has described, will also
help in visualizing parts of the exterior of the small intestine.
We are constantly going to have more and more help, but we
shall still depend mostly on increased facilities and increased
skill in the visualization of the small intestine through roent-
genology. The second point which has been important in this
group of papers is that we need constantly more and more
security in our diagnosis of functional disease of the digestive
tract. In the past when we have eliminated disease of the
stomach, biliary tract and colon and have found no gross
obstruction in the small intestine, we have said that the patient
who complains of abdominal symptoms is probably neurotic.
It is an age-old difficulty of internal medicine to separate the
sheep from the goats, the neurotic from those with real organic
disease. This new knowledge that we are finding of the small
intestine will help do that. We shall be able to determine in
addition to the functional disease of the colon arid of the
stomach, of which we have talked so much, definite indica-
tions of functional disease of the small intestine and probably
in more cases we shall be able to find real organic disease.
I should like to stress the fact which was emphasized by
Dr. Weber, namely that repeated examinations are important.

Dr. Ross Golden, New York: For years we complacently
did our examinations of the stomach, the duodenum and the
colon and didn't bother to look at the loops of small intestine
which happened to be filled at the time of examination. At
Presbyterian Hospital in New York we began to do a special
examination of the small intestine ten years ago. The clini-
cians soon became convinced of its value and it has become
a standard, frequently requested procedure. Our technic dif-
fers from that of Dr. Weber in that we use a smaller quantity
of barium sulfate; namely, 2 ounces (60 Gm.) with the neces-
sary water to enable a patient to take it. The smaller quantity
is advisable because there is less danger of one loop obscuring
another and, furthermore, we withhold food for at least five
hours unless the barium reaches the cecum in a shorter time.
There are three important indications for a special, small
intestine which might be mentioned: (1) diarrhea, (2) bleed-
ing and (3) persistent abdominal pain remaining unexplained
after adequate examinations of the stomach and duodenum or
of the large intestine have been done. This deficiency state
is of unusual interest. The manifestations on the x-ray exam-
inations are not specific. There are a number of different
conditions which may produce those changes. Vitamin defi-
ciency is probably the most important. The Abbott tube has
been used at Presbyterian Hospital in from sixty to seventy
cases. As a result the mortality in intestinal obstruction has
been reduced to 7 per cent. We believe that the development
of this tube is of major importance. Not only does it change
the surgical operation from an emergency to an elective pro-
cedure but also it enables diagnoses to be made which would
be extremely difficult any other way. I have never seen the

1552

Jouk. A. M. A
Oct. 21, 1939

DISCUSSION ON THE SMALL INTESTINE

giving of barium sulfate produce any deleterious effects in the
presence of disease of the small intestine. I should like to
second what Dr. Kiefer said about the importance of exam-
ining the small intestine during an attack. Not infrequently
I request the clinician to let us do the examination during an
attack. I should like, furthermore, to emphasize Dr. Weber’s
remarks about the use of spot films with or without compres-
sion, particularly with compression. We have been able to
show things in that way which would be very difficult to
demonstrate by other methods, particularly in the terminal
ileum. One interesting fact which came out in a study of the
autopsy protocols of primary malignant disease of the intestine
in our department of pathology was the frequency with which
metastases in other parts of the gastrointestinal tract occur
with carcinoma of the small intestine.

Dr. W. Edward Chamberlain, Philadelphia: I too have
found it necessary to examine the patient during the attack in
order not to miss the diagnosis. In one case it took a third
laparotomy to discover the lesion, which would have been
missed the third time had it not been for the fact that the
patient entered an attack while on the way to the operating
room. There is one observation which I feel I should record
here under the heading of motility changes of the intestinal
tract. There is a type of human being who is subject to
exaggerated constipation without abdominal distention and with
relatively few symptoms until catharsis is indulged in. The
bowel movements are markedly inspissated. That type of indi-
vidual has invariably exhibited a strange hypermotility of the
upper intestinal tract; in fact, in a number of cases repeatedly
examined I have found that the head of the barium column
is in the descending colon in approximately one hour from the
time it passes the mouth. That is a definite hypermotility of
the stomach, the small intestine and the colon, yet it occurs
in individuals who will go perhaps seven or eight days, after
the one hour of hypermotility, before they will discharge some
of that barium from the rectum. I want to emphasize what
Dr. Golden has said about the tremendous value of the Miller-
Abbott tube in intestinal obstruction. We too have found our
patients made comfortable. We are able to feed them and give
them water and prepare them for operation in a perfectly
spectacular way. We owe a great debt to those who created
the Miller-Abbott tube and taught us how to examine the
small intestine with x-rays.

Dr. T. L. Althausen, San Francisco : There are two
points I should like to make in connection with the subject
presented here this afternoon. One is to mention a method to
prevent the excessive spread of barium through the small intes-
tine during fluoroscopic examination, which is in use by the
radiologists of the University of California Hospital and has
not been mentioned today. It consists of passing a tube into
the duodenum and injecting the desired amount of barium mix-
ture through the tube. With this method the usual successive
passages of barium through the pylorus are absent, resulting
in more satisfactory examination of the small intestine. Even
marked hypermotility of the intestine does not necessarily
impair intestinal absorption. We unexpectedly found this in
studying intestinal absorption by a test the description of which
will appear shortly in the American Journal of Digestive Dis-
eases. With this test, four of five patients in whom the head
of the barium column at the six hour examination of a gastro-
intestinal series was seen at the splenic flexure of the colon
or distal to it proved to have normal intestinal absorption.

Dr. John T. Murphy, Toledo, Ohio: A number of the
authors and discussers have used the term “spot” film and, as
the men at this meeting are not all radiologists, I feel that it
would be well to inject a word of caution about this procedure.
When “spot” films are made at the fluoroscope, it is necessary
to “step” up the current so that the film may get an adequate
exposure in a short time. This produces a marked increase in
both the direct and the secondary radiation. Repeated too
frequently, this exposure may cause harmful effects on the
personnel in the fluoroscopic room.

Dr. George W. Chamberlin, Philadelphia : In the cases in
which I have used a water barium meal I have found normal
motility to be an hour and a half to three hours from the

stomach to the cecum, and the small intestine is completely
empty m from five to seven hours. There are some patients
who show variations in the normal motility. In some instances
m which the motility is unusually rapid, we have considered
the possibility of allergy. Dr. Jordan mentioned the functional
disturbances of the small intestine. This is the field that 1
have been particularly interested in and one of the reason;
why I have urged every one to recognize a normal appearance
of the roentgen pattern in the small intestine. There is evi-
dence that such conditions as hypothyroidism and hyperthy-
roidism, adenomas of the pituitary, disturbances in the chemistry
of the blood and other conditions outside the abdomen may
produce an abnormal roentgen appearance of the small intes-
tine. I should like to disillusion those of you who are gastro-
enterologists concerning what Dr. Kiefer said about the cost
of the examination, particularly about the cost of the film. In
our department we feel that the film is the least expensive part
of the roentgen examination. In other words, adequate fluoro-
scopic and radiographic examination of the small intestine i'
possible if the radiologist will take the time to do a complete
examination.

Dr. Harry M. Weber, Rochester, Minn.: Meeting as tie
are with the Section on Gastro-Enterology and Proctol®'
with whom our professional associations are very intimate, I
think that they should have the assurance of the members ol
the Section on Radiology that we are continuing to lend our
best efforts to what Dr. Jordan has aptly called “separating
the sheep from the goats.” In other words, we consider it
our first duty to separate that group of patients who hau
organic disease as the basis of their symptoms from a much
larger group whose symptoms are to be explained in another
way. It has been said that in the past this has not been do*
very efficiently in cases of disease of the small intestine. Dis
cussions of this type, together with more diligent applicate”
of roentgenologic methods to the small intestine, will do m*
to make the management of diseases of this division 0 ,e
alimentary tract more satisfactory. Dr. Chamberlin emp a
sized that it means a lot of hard work-hard work, of cour 1
for the roentgenologic examiner, which means first of a n'»
diligent and more frequent use of the roentgenoscopic ™ e 1
in this field. None of us today consider the examnia ion
the stomach or the colon adequately done without men „
scopic examination. Why then should the small mtes *1
most difficult of all divisions of the alimentary tract to exa
roentgenologically, be exempted from this the most use ti
illuminating of all roentgenologic maneuvers?

Dr. David Adlersberg, New York: We all
fact that we are beginning to think in terms of t esm ^ ..
tine. In regard to the interesting work of Dr. ’ (r0 _
also my feeling that many of the complaints a snB ||
enterostomy and resection are due to disturbances .. grJ
intestine. Some of these cases resemble mik eases . a ] s o
and sprue. As to the remarks of Dr. Chamber in, ^ t(]e

interested in cases in which there are hyqierm ^ j n

small intestine and colonic hypomotility, and iav pen y.
some of these cases the latter may be considered
tory mechanism for the former.

Inherited Structural Defects.— Most a PP* r ?"* )

mman “abnormalities,” by their very na ure < ‘ circus

ffect external appearance or sensory fum : • triples

ideshows you can see some of the more sta ‘ 8 heads

black” gene caprice— midgets, dwarfs with > But for

nd bodies, Negro albinos, “India-rubber m > > ^ struc turM

nd Domes, wegro * - rltrf _ re or -

rch one of these there are dozens of other su ^ ; t B of
Meets found in the everyday walks of » uraI abnof

2 said that most persons have some inherited ^ Bn1)St sl

lality — if we include, as “abnormal, con further, _ a«|

jt not necessarily harmful or defective. w ),jch singb

king into consideration “hidden reces* % onc 0 i vs*
-oduce no effect, it is pretty certain that . O __ ScllC i n feIA
trrying some one or another of these g Stokes

mram : You and Heredity, New ^ork, Irene
ompany, 1939.

Volume 113
Number 17

BIRTH CONTROL— KOSMAK

1553

THE RESPONSIBILITY OF THE MEDI-
' CAL PROFESSION IN THE MOVE-
MENT FOR ‘BIRTH CONTROL'

GEORGE W. KOSMAK, M.D.

NEW YORK

The avoidance of conception as a result of normal
sexual intercourse has been made in recent years the
subject of extensive scientific study as well as of
propaganda movements directed largely by lay and, in
part, by professional groups. The desirability of birth
control in a limited medical sense has been extended
into the realms of sociology, economics and eugenics,
and as a result a considerable confusion of thought and
purpose has been developed. The doctor, however, has
been made to feel that his participation in the world-
wide discussion is a minor one ; he is accused of failing
to keep in step with modern requirements and to be
unwilling to support a movement of such paramount
importance. Undoubtedly the medical profession has
been hesitant to take an active part in a propaganda
with which many of its members are out of sympathy,
largely because of the hysteria and exaggeration which
have accompanied its dissemination. However, it must
he evident that the profession cannot refuse to recognize
the firm conviction on the part of the public that pro-
creation can, and perhaps should, be regulated.

As physicians, we should constitute an active and
influential force by which this effort can be guided in
the proper direction. How shall this be accomplished?
Is it for the medical profession to propose means and
methods or shall it all be left to chance? It should be
possible to view the problem from its various angles
and to formulate certain standards of thought and
practice through which at least a partial solution of a
difficult question may be reached. In other words, and
speaking broadly, there is a sane as well as what may
be termed an insane approach to a question which is
agitating a great many people. Moreover it becomes
necessary to define as nearly as we can the responsibil-
ity of the medical profession and what its part must be
in the application of knowledge thus far available. This
may not prove a simple task, but it is one which cannot
well be evaded or shirked. Mere blind opposition will
accomplish nothing and will only react to its detriment.
It is essential- therefore that in our discussion we con-
sider the problem from its varying aspects : historical,
social, economic, legal and medical. Full consideration
of all these is necessary to a proper understanding of
this complex situation. For the control of conception
is not a simple matter if we reflect on its wider implica-
tions, some of which are already becoming evident,
among them the effect on our population balance. It
is essential therefore that not only the medical profes-
sion but the public at large be thoroughly informed on
the subject and that reason take the place of hysteria
and unreason.

EARLY EFFORTS

Man has attempted to control his procreative powers
probably since the dawn of history, and the actual
limitation of the family by direct means was sought
as soon as civilization as such became manifest. It is
interesting to read of the crude methods employed by
primitive races and the survival of some of these up to
the present by people supposedly of a higher degree of

, 1( ««1 before the Section on Obstetrics and Gvnecolojry at the Ninetieth
loro"'' 1 . faessi °n of the American Medical Association, St. Louis, May 18,

intelligence. A knowledge of the physiology of impreg-
nation was and still is an unknown quantity to most,
but it is of interest to note in many instances that the
methods for avoiding it were fairly ingenious and suc-
cessful and, if not, there was always at band a resort
to abortion or infanticide. Strangely enough, with all
these efforts to avoid conception there went almost
hand in hand a desire to relieve infertility in women
by procedures quite as thoughtful as the reverse. The
responsibility for undesired pregnancy was not invari-
ably placed on the woman’s shoulders, and we find that
mutilating operations were practiced on men for the
same purpose by various primitive people who were
evidently aware of the function of the seminal fluid.

As civilization advanced, crude methods and mechan-
ical devices became gradually displaced by more rational
procedures but, from a careful reading of the history
of contraception, it is evident that the desire for preven-
tion is not a new thing ; it is merely the search for and
distribution of effective and harmless means of achiev-
ing this which characterizes the later day movement.
However, during the nineteenth century we find a note-
worthy departure. From a purely personal basis, con-
traception in the larger sense became involved with
social and economic problems. Woman’s emancipation,
so called, has served to stimulate her self expression.
She demands what she terms protection against unde-
sired or too frequent child bearing, and this attitude has
extended to all social levels ; the underprivileged classes
are no longer to be discriminated against.

BIRTH CONTROL IN ENGLAND

Himes 1 accords to Francis Place, an Englishman
who lived from 1771 to 1854, the same position in
social education on contraception that Malthus holds
in the history of overpopulation theories. Malthus had
approached the problem of birth control from an
entirely different standpoint, for he believed that
unchecked population growth in a country would in
time overreach its available food supply. He recom-
mended moral restraint and essentially condemned birth
control as we know it today. Moral restraint did not
imply restriction in intercourse within the married
relationship but rather postponement of marriage until
the contracting parties were able to support possible
offspring. It is readily seen why the more radical ideas
of Place and his successors developed a larger follow-
ing. Place made a strenuous campaign in England in
1822 and the subsequent years, circulating handbills
freely among the working classes, describing the use of
a vaginal sponge or coitus interrupts as effectual con-
traceptive methods. Place and his followers, although
including medical conditions, made a strong plea for
their devices as factors in preventing poverty and rais-
ing the standard of living of the masses. Place also
argued that birth control would favor earlier marriages
and . that postponement led to vice- and prostitution.
Place was not a physician and he was not supported
by the medical profession hut he frequently sought the
advice of its members. He did introduce the organiza-
tional element into the control of contraception; which
has developed into the prominent propaganda movement
that w'e know today. ‘ ’

After the clamor for social reform died . down in
England, following the general readjustment after the
Napoleonic period, interest in birth control likewise
diminished but found a new field of activity in America,
where the publication of sever al books by Richard Owen

Himes. ?s. E.: Medical History of 'Contraception, Baltimore.
Williams and Wilkins Company, 1936. '

1554

BIRTH CONTROL— KOSMAK

and Dr. Charles Knowlton, among others, served to
revive the agitation. The latter recommended chiefly
astringent douches after coitus, and his book “The
Fi nits of Philosophy’ was widely sold in this country
and in England.

During the last quarter of the nineteenth century,
prosecution of several writers and publishers in England
characterized the campaign for democratization of birth
control knowledge by publicity. The Free Thought
Movement of that period, under the dominance of Annie
Besant, Bradlaugh and others, became involved in court
procedures and in 1878, as the result of two jury trials,
a sentence combining prison and fines was imposed on
a Mr. Truelove, a book publisher of London. The pub-
lic of England became intensely stirred, but the results
of various appeals were unsuccessful, although the trials
did aid finally in making legal the general free dis-
tribution of contraceptive knowledge. There seems to
be little doubt, moreover, that the diffusion of birth con-
trol knowledge has reduced the English birth rate by
half since 1S76.

Mrs. Annie Besant brought out in 1884 a booklet
entitled “Law of Population,” which found general favor
as shown by the fact that more than 175,000 copies
were sold, the last edition appearing in 1897. Addi-
tional contraceptive devices, including the soluble sup-
pository and the rubber cervical cap, were proposed.
Another pamphlet, written however by a doctor, also
appeared during this time and by 1927 its circulation
had passed the half million mark. Its author, H. A.
Allbutt, a Leeds physician and fellow of the Royal
College of Physicians of Edinburgh, was accused in
1887 before the General Medical Council of having pub-
lished an indecent book and his name was ordered taken
from the Medical Register, mainly, it seems, because
the author’s conduct was considered unprofessional in
permitting advertisements of contraceptives to be
included. Appeals were unsuccessful as far as Allbutt
was concerned, but his pamphlet continued to circulate
widely.

Various individuals and organizations too numerous
to mention have identified themselves with the birth
control movement in England. Characteristic of more
recent sentiment is the stress laid on birth control as
a health and eugenics measure rather than as one solely
dictated by economic status.

Jot's. A. 31, A.
Oct. 21, 19J»

of coitus, a sort of male continence. This colony con-
stituted an interesting eugenic experiment but, its
essential principle being unphysiologic and contrary to
what Himes terms “the sexual pattern of the male
developed over a long physiological period,” it did not
long survive. Moreover, internal dissensions and the
force of public opinion assisted the disintegration.

Others took up the birth control propaganda in this
country and many books had wide circulation notwith-
standing the many prosecutions brought about through
the Comstock laws. These legal restrictions centered in
certain postal regulations and curbed for a considerable
period the dissemination of birth control information
and devices. Of course all sorts of evasions were prac-
ticed, but in the course of time legitimate medical
indications became more clearly recognized. Teachers
of prominence in medical schools talked about and
approved of contraceptive measures yet for many years
did little to advance the scientific side of the subject.
In the early part of this century the name and per-
sonality of Margaret Sanger became prominent through
her dramatic efforts in circulating literature and open-
ing clinics for contraceptive advice. She came into
conflict with the law, and her persecution by the police
served merely to draw greater attention to her selt-
assumed martyrdom. Her attitude toward tire subject
may be regarded perhaps as exaggerated and often
hysterical, but her influence was undoubted and she
succeeded by her strength of will and determination
in interesting and enlisting many well meaning and
wealthy women for the support of the American Birth
Control League and allied organizations. Mrs. Sanger
claimed that from the first she attempted to operate
through the medical profession but the unwillingness
of its members to assist her forced her to indepen den

action. COMMERCIAL EXPLOITATION

It has been claimed (Himes, 1 p. 326) that tbefajj^
of the medical profession to accept its response i * e
is the principal cause for the extensive commercia an
antisocial participation in the contraceptive movetue •
There can be no question of the enormous and “ig )
profitable traffic in preventives — good and bad—s
widely everywhere at the present time without appa
restraint. One must carefully divorce the legi t
from the illegitimate demands in arriving at a cone
about what should be done to restrain sales an s

PROPAGANDA IN THE UNITED STATES
The birth control movement in the United States
during the nineteenth century was associated rather
closely with that in England. A number of physicians
wrote similar books of advice and direction for married
couples, but there developed likewise a good deal of
quackery and also an association of the movement with
certain erratic individuals who were active in a variety
of religious and quasireligious cults and organizations.
Liberal political thought, as expressed by socialists,
communists and even anarchists, included birth control
propaganda, and legal restrictions against the distribu-
tion of information and devices were incorporated in
the laws dealing with obscenity and indecency in the
federal Postal Code and in various state laws. An inter-
esting social experiment of this time. was the Oneida
community of New York State, which existed for a
period of years during the latter part of the nineteenth
century This was a voluntary communistic colony
which was founded and led by John Humphrey Noyes
and combined its peculiar religious doctrines of Per-
fectionism with a complex system of marriage m which
control of conception was exercised by a peculiar type

standardization of products. . , . t.

There is one aspect of the problem to wiici
ficient attention has been given by the P r0 “; J
namely its responsibility in the teaching and P <
of birth control measures when these are in
The history of the movement shows however tnar, i
ticularly in recent years, physicians have gjv^ 1 f i 10C js
to the matter of judging the efficacy of various e
of contraception and have instituted scien i
to evaluate them. Medical indications have also ^
more closely defined. But it must be acknmv 8 . ;e
the stimulus has come largely from lay gr P u | ei
sense of direction and application has L doct0 T,
been satisfactorily guided. For much of th is
both in an individual and in a collective capacit , .

assume the blame. It should not have
to establish extramural clinics for tins purpos , ^
ever advice and treatment were necessary co
been done in the established hospital chneand doc^
offices. Moreover, the assumed illegality o tt
ceptive advice has, m my belief, bad t he

psychologic effect, and the confusion that exis s
minds of physicians likewise requires clarification

Volume 113
■ Number 17

BIRTH CONTROL— KOSMAK

1555

It is questionable whether the imposition of statutes,
.either state or federal, can control a movement of this

• kind, in which concerted agitation, largely by interested
lay groups, has too often distorted and magnified indi-
cations. Medical men have given their names in aid of
efforts to do away with restrictive laws, so that a
physician’s right to prescribe as he saw fit would not be
invaded. There can be no question about the paradox-
ical and absurd situation created by the retention of
outmoded statutes, both federal and state, which have
interfered with legitimate practice and contributed little
to control the indiscriminate dissemination of contracep-
tive advice and products. The commercial exploitation
that has resulted can be regarded only as disgraceful. In
a recent magazine article the number of dollars involved

• is quoted in millions. An extensive and thriving busi-
ness has been developed by a large number of manufac-
turers and distributors whose field of activity is by no

means directed to those people legitimately entitled to

■ employ their devices. The resultant advertising cam-
paign has become nauseating and under the more accept-
able and supposedly refined appellation of “feminine
hygiene” an important and serious matter has become

■ flouted for purposes of financial gain. We can thank
the unrestrained popular propaganda for this, as we
can for the lack of sexual restraint which has become
so evident. There is a hope but, it must be admitted,
a rather faint one, that through proper education and
the possible help of the medical profession we may
arrive at a more sane attitude toward this question.

THE COMMITTEE ON CONTRACEPTION

The American Medical Association long resisted
efforts to give its official sanction to the study of con-
traception but finally, at a meeting of the House of
Delegates held in Atlantic City in 1935, provided for a
study committee, which has rendered two reports. 2 This
.action by organized medicine should be given careful
consideration, and I want to review briefly the reports
of the special committee which thoroughly discussed
and studied the various claims that have been made
concerning the need for contraceptive practices, as well
as the accepted medical indications and the possible
dangers associated with the widely disseminated propa-
ganda. The committee approached the subject from
various points of view, beginning with that dealing with
.overpopulation. This problem is very complicated and
.resolves itself today into a question of selected growth
.rather than a haphazard increase. If this means, a
wider acceptance of the need of contraceptive practice
applied in particular to the unfit, using this term in a
wide sense, the committee was hesitant to enter into
an endorsement of such a movement because it felt
that, as far as the United States or similar countries
is concerned, we have as yet little to guide us in formu-
lating a national policy on the subject. The committee
also believed that it must limit its consideration of the
'question as it refers to the relationship of physician
and patient. The committee called attention to the
inadequacy or ineffectiveness of many contraceptive
procedures and to the actual dangers of others. While
clarification of laws is needed, there was no evidence
that existing laws interfered with a physician who felt
called on to give information to patients. The commit-
tee expressed its opposition to independent and unli-
censed birth" control clinics and suggested the need of
instruction to medical students in the entire subject
of fertility.

2. Report on the Use of Roentgen Rays for Contraception, Council’s
Committee’ on Contraception, j. A M. A. Ill: 1267 (Xov. 5) 1938.

As for eugenic considerations, the committee con-
cluded that there is little scientific basis to justify wider
birth limitation except in the case of acknowledged
transmissible congenital diseases. Moreover, there
seems to be no evidence that a wider dissemination of
contraceptive information would establish a better social
and economic equilibrium in society. While family
limitation among lower income groups might prove
advantageous, the lack of adequate and effective
methods makes this difficult, especially where the exer-
cise of ordinary restraint is inapplicable.

Medical considerations naturally could be more
appropriately discussed by a group of physicians and
more definite conclusions could be presented. The
committee recognized that voluntary limitation of con-
ception may be necessary to safeguard the health of
some women, as in the presence of active tuberculosis,
nephritis, heart disease, certain psychopathic conditions,
arteriosclerosis, chorea, pernicious anemia, a recent
serious illness or operation and a number of other con-
ditions, especially' in women physically' incapable.

A recommendation that a responsible group be
authorized to develop standards for judging contracep-
tive materials was not endorsed until the y'ear following
the introduction of the first report, when it was referred
to the appropriate councils of the Association. It was
also reaffirmed that contraceptive information should
be limited to physicians in their private practice and
to regularly licensed clinics under medical supervision.
This formal recognition of the subject by organized
medicine constitutes an important step, but thus far
no impression can be recorded on the status of the ques-
tion as a whole. It will take years to curb and regulate
a movement which has had such wide and appealing
publicity.

RESULTS

I have attempted to review briefly the history of the
birth control movement and its development in this
country. While efforts to develop contraceptive prac-
tices are by no means new, the effects on our social
structure have become more evident during recent
decades, particularly the influence on birth rates and
population balance. This influence cannot be disre-
garded, for we must face the fact that the birth rate
of this country is diminishing and that the older age
groups soon may dominate the younger. The former
are outside of the productive and reproductive periods
and it will take more time to determine the effect of
such biologic interference on the economic and social
status of a nation.

Much has been said about the influence of contra-
ceptive practices and their free discussion on morals
and a changing attitude toward parenthood and child
bearing. This is a broad subject and its interest to
the profession may' be secondary, for undoubtedly the
physician no longer occupies the position of adviser
and family counselor which he did in the past. Never-
theless I feel that he has an important role to play,
for it would have been well if he had chosen or had
been chosen to carry out the practical application of
a contraceptive program in a sane and reasonable man-
ner. Organized medicine, speaking through its official
body, has attempted to define this position but with
what success remains to be seen. However, the indi-
vidual physician may feel that he must be guided by
conscience or religious precepts and it would be unwise
in such instances to resort to persuasion in any effort
to bring about a change of views. A considerable por-
tion of the active practitioners of medicine acknowledge

1556

BIRTH CONTROL— KOSMAK

and believe that contraception is justified and plays a
pai t in their professional duties. It would appear rea-
sonable, therefore, to review the practical phases of
contraceptive therapeutics, if I may so designate them.
Before doing so it may be well to discuss briefly the
religious aspects of the question.

the “safe period”

Many religious bodies have condemned severally
interference by artificial means with the process of
insemination, particularly the Catholic church, and yet
we find apparently a change of sentiment in recent
years, since fairly definite knowledge is available about
the so-called safe period. While one must approach the
subject with caution, it is evident that no condemnation
by church authorities attaches to the practice of this
method of contraception by married people. Prominent
Catholic clergymen and physicians have endorsed and
written about the availability of the “safe period.” This
view assumes, of course, that the time of ovulation can
be determined absolutely in all cases. Unprejudiced
medical opinion is somewhat less certain. While ovula-
tion in most cases occurs during the middle of the inter-
menstrual month, a variety of physical and emotional
factors may advance or postpone menstruation and thus
throw calculations out of balance. This uncertainty is
of particular moment in cases in which pregnancy is
contraindicated for definite medical reasons.

The so-called Ogino-Knaus theory has stimulated a
vast amount of clinical and biologic investigation.
Undoubtedly there are women in whom a “safe period”
exists, but in actual practice the procedure demands
a degree of restraint and cooperation which cannot be
relied on to do what is so glibly claimed for it. How
can such a method of self control be imposed on that
large group of people who most need a foolproof method
of either child spacing or contraception ? Mathematical
calculations based on menstrual dates are scarcely relia-
ble or opportune in moments of sexual excitement. It
places too much of a strain on human nature.

THE DOCTOR’S QUANDARY

The doctor, assailed by conflicting opinions, natu-
rally is in a quandary when consulted by patients in
the legitimate practice of his profession. He is well
aware of the consequences of pregnancy when this is
contraindicated medically or in certain instances socially.
Whatever his principles, he may find it necessary to
sacrifice these to expediency. He may in consequence
be damned if he does and equally damned if he does
not. There must be a middle ground on which the
physician may stand which is legitimate and yet not
contrary to the just demands of his patients. There-
fore, what advice and suggestion can we accept as
practitioners for the practical application of contra-
ceptive knowledge now available?

Numerous technical manuals on contraception have
been published for the use of physicians which offer
a multitude of methods. It is well in each instance to
stud}' the individual patient and adopt the most suitable
procedure to the case. Passing by what may be termed
physiologic methods such as continence and coitus inter-
rupts (withdrawal), the commonly employed methods
may be divided into chemical and mechanical.

methods in use

The principal chemical methods include the medi-
cated douche and a variety of jellies, suppositories and
foam powders. The douche is effective mechanically
to a certain degree and may be rendered spermicidal
by the addition of soap. suds, a variety of astringents

JOUK. A. M. X
Oct. 21, 19J9

(vinegar, alum and the like) or chemicals (mercury
bichloride or saponated solution of cresol). The uncer-
tainty of the former and the dangers of poisoning by
the latter render this procedure undesirable in most
instances. Jellies and pastes contain a variety of chem-
icals suspended in a water soluble vehicle to be injected
by an appropriate device into the vaginal vault. Sup-
positories are solids melting at body heat, usually of
gelatin or cocoa butter, incorporated with boric acid,
chinosol, quinine or a similar drug. Foam tablets are
stable in the absence of moisture and are made up of
sodium bicarbonate and a solid acid such as tartaric or
boric. They depend for their activity on producing a
mechanical barrier at the cervical os, as well as on the
spermicidal effect of the carbonic acid gas generated and
the incorporated spermaticide. A variety of powders for
vaginal insufflation have also been employed.

These procedures depend largely for their effective-
ness on the occlusion of the cervical opening, and the
jelly is perhaps the most suitable. On the whole, how-
ever, they do not prove as highly effective as the actual
occlusive pessary or the condom. Vaginal barriers can
be made out of soft absorbent materials such as wool
tampons or sponges, saturated perhaps with vinegar
or some chemical solution or made from rubber in the
form of a cervical cap or a diaphragm. The latter,
supplemented with a jelly, is generally regarded as the
most effective device and is widely used in contraceptive
clinics, where it serves as the basis for the mystery
which it is claimed is freely accessible to the rich and
denied to the poor. The occlusive pessary must be
carefully fitted to be effective, and the necessary
manipulations may prove offensive to some women,
but evidently most of them have overcome any possible
scruples. .

The foregoing methods are limited to the woman an
applied before each exposure. Prolonged protection
has been sought in the form of a variety of intra-uterine
devices as well as subjecting the ovaries or testes o
irradiation. The injection of sperm to produce sperma
toxins has also been made the subject of exten e
experiments. Intra-uterine stems and rings are men
tioned merely to be condemned. Their dangers a
so evident that they should never be employed, n
withstanding the claims made for them. T he he
irradiation of the ovaries to produce either tempo >
or permanent sterility is too limited for genera
cussion and we have too little satisfactory or ®
knowledge about spermatoxin to warrant its consi
tion in general practice.

METHOD USED BY THE MALE

The condom is perhaps the better known an m
common contraceptive device for use by t!ie , m ?- f ' r jb u -
an enormous expansion of its manufacture and ^ ^ frv

tion has taken place in recent years in th -
Of its use and safety there can be but little q
However, popular contraceptive propaganda
directed largely to the woman, who is made th r l
sible partner. I wonder whether the various ag
groups would have been so successful in their *1 j
for sympathy if the responsibility for taking c
tive measures bad been lodged primarily in by

Complete sterilization of either man o v j ia t

ligating the seminal tubes or the oviducts j s a

out of the province of this discussion, , u ld

growing sentiment that vasectomy m particular
not be limited to the mentally defective. briefly

The relative value of the various met . j iann -

outlined is based on their efficacy and comp

Volume 113
Number 17

BIRTH CONTROL— KOSMAK

1557

lessness. It is in this field that authoritative and
unprejudiced information is needed, and we may hope
that an official body, preferably medical, may in time
promulgate the desired knowledge. Extended studies
have been made by the special birth control organiza-
tions and others, but little has been made available to
physicians through official publications. The choice of
method depends on the particular indication and the
particular patient and also on whether contraception
shall be temporary or permanent. Certain medical indi-
cations are distinct and perhaps permanent, certain
social indications may verge closely on the medical and
perhaps be only temporary. I have already referred
to the group of transmissible diseases. Fortunately they
are not numerous and in many instances the pathologic
condition itself may constitute a barrier to pregnancy.
When organic disease is present, including disorders
of the heart, lungs, kidneys or blood forming organs,
a physician need not hesitate ; but there is another group
of cases in which merely a state of overfertility may
come into the question.

Fertility among individuals varies greatly and is
dependent on a number of factors. Frequent child
bearing, aside from its social and economic aspects, may
have a decidedly depleting and perhaps harmful effect
on a woman’s general health and well-being. No one
would deny the desirability of properly spaced preg-
nancies or even a reasonable number of children in order
to avoid the drain on a woman’s physical resources,
which have had added to them so many other demands
in more recent years. We cannot measure today a
mother’s ability to bear children by the standards of
the past or by the much heralded occasional large fami-
lies so dramatically shown on the screen or the Sunday
supplements of our daily papers. The economic value
of large families to factory workers and farmers is
doubtful in this present day and age, and changing
social and housing conditions call for a changed point
of view. Unfortunately we have gone back a little too
far in the popular estimate of the size of the family
which, as far as the number of children is concerned,
has gradually drifted to a point where a population
balance is no longer being maintained. The physician,
however, is often drawn into the picture, and his advice
is sought by harassed parents who may not have found
their way to a convenient birth control clinic where no
embarrassing questions are asked. What shall he do ?
If truly acquainted with the facts, he should not hesitate
to take the steps necessary for the welfare of that par-
ticular patient, provided he knows what to do and how
to do it. Continence seems to be out of the question
as a remedial agent in most cases; he cannot control
nature’s urge and he would get little encouragement
or cooperation if he attempted to do so.

It is difficult to make a rule for the proper spacing
of children, but an interim period of not less than two
years should prove a desirable physiologic reply to this
question. This brings up the consideration of the
problem of postponing the first pregnancy in a young
married couple. The universal dissemination of the
birth control propaganda has fixed quite firmly in the
minds of many people that such postponement until a
convenient or suitable time is a perfectly legitimate and
proper desire for a variety of good, or at least appar-
ently good, reasons. What with our already late mar-
riages, this has increased the average age at which the
first labor takes place with a consequent increase in
possible abnormalities, including a demonstrable higher
incidence of toxemia and operative intervention with

its attendant morbidity and mortality. Undoubtedly a
great many instances of sterility are covered up by the
use of contraceptives which might have been discovered
and treated at an earlier period. Moreover, the psycho-
logic effect of avoiding pregnancy in the earlier years
of married life is, in my belief, inherently unfortunate
because it makes of this perfectly normal function an
undesired complication, in many instances to be accepted
finally if it cannot be avoided. It is true there may
be extenuating circumstances in individual cases, but
accepting contraception as a first stage in marriage is
contrary to sense and to reason. It takes from possible
parenthood that aspect of dignity and desirability which
contributes much to connubial happiness.

MATERNAL MORTALITY

There is one further aspect to this problem to which
I want to call attention. We have heard much in recent
years about the high mortality associated with child
bearing in the United States — that six women die out
of every thousand who give birth to a living child.
Ignorance, neglect and lack of proper and adequate care
have been ascribed as causes, and constant efforts are
being made by the medical profession and interested lay
groups to reduce the preventable deaths, which are
calculated as about one third or more of the total num-
ber. Is it possible that a knowledge of these facts
has made women fearful of pregnancy and thus stimu-
lated a demand for contraceptive measures ? And in this
connection we must likewise think of the many abor-
tions with their high toll of death. If one half of the
women who died from preventable causes and a like
number of babies who were stillborn or who were lost
as the result of abortions could have been saved, we
might have less need to worry about our declining
population. We are told that a wider resort to contra-
ceptives would avoid these needless deaths of mothers
and that legalized abortions, if contraceptives failed, are
indicated in undesired pregnancies. It seems to me
that this constitutes an illogical manner of thinking. .We
should be grateful for the fertile women and preserve
their function, not inhibit or destroy it. Pregnancy
must be made safer, it must not be regarded as either
an unfortunate accident or a disease, and the increased
resort to contraceptives is not the answer to the prob-
lems of maternity. The procreative instinct must not be
stilled; our young women should be encouraged to
develop and not to hamper it.

PHILOSOPHIC BASIS

The wider use of contraceptives is not apparently
bringing about that unalloyed state of bliss which cer-
tain groups and individuals have promised. Doctors
have been looked on as obstructionists to progress in
this matter. But we are not obstructionists, we are
merely doubters. There has been much sentimental
appeal and much loose thinking on this subject and,
notwithstanding all that has been said, we are still far
from a satisfactory solution of the question of whether
conception can be completely or satisfactorily controlled
by artificial means. In the meantime the physician must
play his part and assume his responsibilities. Whether
he concludes to limit his participation to the strictly
medical indications for contraceptive advice or whether
lie is ready to acknowledge the desirability of spacing
children or limiting their number when this is needed,
he should inform himself of the necessary procedures
and their proper application and look on this knowledge
as a part of his therapeutic armamentarium. If be
declines to do so because of inherent principles or

155S

BIRTH CONTROL— KOSMAK .

Jour. A. M. A.
Ocr. 21. I9J9

religious beliefs, that is a matter for his own conscience
and for which he should not be condemned.

I feel that too much attention has been centered on
the mechanics of birth control and too little on the
underlying philosophy which should govern its applica-
tion. It would be preferable to have the physician con-
sider the points of view of the eugenist, the biologist,
the economist and the student of population rather than
the so frequently hysterical “contraceptive propagan-
dist.” It can hardly be expected that the practicing
physician will familiarize himself sufficiently with all
the varied factors in the problem, but he should be
prepared to evaluate and carry out whatever procedures
are necessary as an essential part of bis practice. He
is a participant in other fields which have a bearing on
public health, why not in one of an import equal to
that dealing with the prevention of communicable and
other diseases? In the handling of a patient afflicted
with tuberculosis, syphilis, diphtheria, pneumonia and
other illness, he not only administers the remedy but
in doing so he must observe the relation of this patient
to the community. A similar point of view may be
applied to contraceptive measures. There are definite
indications for their employment in the presence of
disease which have been satisfactorily formulated, but
how and when and where to employ them is not at the
present time a matter of general medical knowledge,
and there is a prevalent hesitancy throughout the pro-
fession to make use of whatever knowledge we do pos-
sess. It would appear incumbent for medical schools
to give such instruction, including not merely a demon-
stration of means and methods but to implant in the
student’s mind the wider implications of these practices
which should be a part of a physician’s armamentarium.

It is frequently claimed that economic and social con-
ditions are the underlying reasons for family limitation.
However, if this were true we would not find the
procedure so widely practiced among those who may
be designated as belonging to the middle and highei
income groups. No, we must look elsewhere for such
reasons and among the latter must be included the
influence of what I myself regard as a vicious propa-
ganda movement, developed and continued^ by false
sentiment and inadequate reasoning. Physicians as a
group have failed to evaluate this fact or to have
exerted their influence in its regulation. ' This is a
problem committed to their early attention, so that a
solution may be possible with benefit to those most
concerned, namely the parents of the future.

23 East Ninety-Third Street.

ABSTRACT OF DISCUSSION
Dr Charles E. Galloway, Evanston, 111.: I agree with
Dr Kosmak that the medical profession has an important
responsibility in the matter of birth control I should like to
mention two important factors: the first is that women do not
find their chief sexual expression in sexual intercourse but

epr.S.» »d U* £&£

truth * namely that according to our present Knovneage

ZreTno satisfactory method of birth control. Manywomen
inrl most men are being led to think that a woman s sexual life
should imitate that of a man, and our psychologists seem to be
ti e chief source of this erroneous notion. Every erotic book
is filled with this same idea. Women discuss the matter free y
these days and come to their physician with the query Why
is intercourse .not the |*»e^ ™ ^t^ot Ewe

K h ‘ ltLe a r ny and 0 mS Sly

is reproduction and she t .''‘ :f she does reproduce a reasonable

SfJlSTS- io-.y of .... — *> ™»..

physicians today do not have need for their advice and it would
be to their advantage if they were so occupied with the responsi-
bilities of a growing family that they would not have time to
become so introspective. The second great responsibility ol our
profession is to disseminate the truth that we really do not hate
any satisfactory means of preventing pregnancy. Too many of
our profession are conducting birth control clinics and in other
ways going before the people, telling them that, if a certain
procedure is followed or a certain gadget used, intercourse will
not result in conception. There is no gadget or procedure that
does not fail a good percentage of the time and there is no time
in the month when conception cannot take place. In my private
practice I see an average of one patient who is pregnant against
iicr will about every two weeks. She invariably conies with
the story that she went to a birth control clinic or a doctor and
was fitted with a diaphragm and told that by using it properly
she would not conceive. I have also delivered at least ten
so-called “rhythm” babies. I have seen the published statements
of some of my colleagues maintaining that hundreds of dia-
phragms had been fitted without a failure, and you know that
sucli a statement is not the truth. Therefore, our two chief
responsibilities are, first, the dissemination of knowledge relative
to the proper place of reproduction as regards the happiness anu.
well being of women and, second, that the present methods o
birth control are far from satisfactory.

Dr. Joseph L. Baer, Chicago : I am convinced that those
who seek information about family limitation and family spacing
for whatever reason are entitled to get that information rom
their physician. The Council’s Committee on Contraceptives o
the American Medical Association hopes that clinical rese ^
of adequate quality will enable it to make recommen a io
within the next year. The public interest is directly conce ”
with the endless stream of newborn who by known m
criteria are reasonably certain to become public burden k , ,
legislatures which have sanctioned sterilization are
and are serving the public interest. I believe that tie 1
of the American Medical Association should be direct
furthering this method of control of an unfit popu a 1 •
equally convinced that the present wave of deli era ^
limitation, based on the desire of the parents to a ' • ^

many children as they can rear and educate as they ' e
them to be reared and educated, will give way in ■ ■

to the normal desire and most parents to have m j s

than this present handicap seems to permit. ^‘ n “ ” tive
great anxiety lest the widespread dissemination of c ra P ;e
information will undermine the morals of our y • g
and promiscuity are far more current today 13 , ... ■yi,j 5 is
generation ago. This is observable in all walks 0 [ ! „ us , be
a problem of the home. Ethical values an t j, at the

instilled in children by their parents. It is my ^ homC .
current wave of lax morals will eventually su s essential

life regains its stability and its recognition o t0 what

value of all the virtues. I should like to call at en M feW
I think was a most significant movement in tr Univcri ity
Last fall the Student Religious Association of t B of

of Michigan had a course of six lectures n ccmrse being
a combined faculty and student! «K m ” ltt ’ characterized
entitled “Marriage Relations. The lecture ^, jsh to get

as follows by the committee: In this series s ^ presen t

away from sociological and philosophical I pit at t (!il .

the facts as they are in a frank and accur n ’ j followed

course as practical as possible. In my 0 f scN id

this outline: 1. The attitudes toward t0 a demand
problems are changing, from ignorance and ta (

for accurate and sane information. • cons titute a chub
cases of marital maladjustment and divorce an!

lenge. 3. It is necessary to replace many f^ ction and
superstitions surrounding the physiology be t , 10tl g!it-

sexual practice by scientific facts 4. * Iarr '^ {orraation obtained
fully considered by college students, and the .. d m3r rid

by specialists who have carefully and horough^^d. . ^
relations must be interpreted and fr ®"^ nd e rsta nding ;
beauty of romance is not spoiled tr « of emotional a" 4

intelligent appreciation of important J. ' s;otime nt aftervf 4 -
sexual problems will help prcient dissociate

Dr. Fred J. Taussig, St. ^uis : -s diffict. ^ ^ ^

the purely medical aspects of birth

Volume 113
Number 17

POLIOMYELITIS— STEBBINS ET AL.

1559

economic environment. Yet as far as it is possible and prac-
tical it is our duty as physicians to do this. Let those who
are concerned with problems of population growth, with eco-
nomic want, with improper education and other social phases
of an uncontrolled birth rate organize, discuss and take action
on these matters. How far physicians may desire to cooperate
in this movement is not our concern. We are concerned, how-
ever, in the medical phases of birth control, in the cases in
which the proper spacing of children, the condition of the heart,
kidneys and lungs of the mother present a contraindication to
pregnancy for shorter or longer periods of time. Let us as
physicians recognize that this is a matter that concerns every
one of us regardless of creed. Some may advise one method,
others may advise a different procedure, hut we all recognize
the cases in which a pregnancy presents a peril to the preserva-
tion of the family, and that in married life prolonged con-
tinence is not practical. Let us all get together and attack this
problem scientifically. There must be other methods besides
the so-called safe period that would be acceptable to those who
do not approve of mechanical or chemical procedures. Inten-
sive research as to better methods must be carried on by all
groups. Some may approve one, some another method, but the
advisability of preventing conception for shorter or longer
periods to preserve the mother’s health is an accepted fact.

Dr. John Zell Gaston, Houston, Texas: The points that
have been brought up here today bring out clearly the need for
scientific information on contraception. There are three ques-
tions of vital interest, namely: 1. Is birth control effective?

2. What is the relationship between birth control and abortions?

3. Is birth control dangerous? At the Maternal Health Center
of Houston in the past three years we have seen 2,635 cases,
and in that length of time we have not found a single one in
which scientific evidence can say that birth control has been
harmful. Is birth control effective? We heard one of our
discussers say that birth control was not effective and that
reports were made of thousands of cases of failure. Here are
our results. Of 2,500 women, we have had thirty-seven failures
to date, or an efficiency of 98.5 per cent. What is the relation
between abortion and contraception? The answer is a negative
one, like the relationship of black to white, but we were curious
to find out the frequency of abortions before contraception was
used; hence a careful history was taken and we have the data
to offer on a study of 2,069 case histories. We divided our
cases into white, colored and Mexican groups. Of 1,002 white
patients, 357 admitted one or more abortions before coming to
the clinic. There was a total of 615 abortions in the 1,002
white patients, and one woman admitted fifteen abortions having
been done on herself. In other words, 35 per cent of the white
women had had abortions before applying to our clinic for birth
control. The Negro patients show practically the same ratio:
Of 730 Negroes, 211 admitted a total of 354 abortions. Mexican
patients have almost exactly the same ratio ; namely, of 337
Mexicans, 114 admitted on admission a total of 185 abortions.
Birth control clinics do not condone abortions, and any state-
ment to the contrary is not true. On the other hand, we teach
that abortions are dangerous. The need for this teaching is
brought out clearly by this study. If the figures we obtained
are at all representative, the frequency of abortion the country
over will reach a staggering figure. Of 2,069 white, Mexican
and colored married women in the low income group, 682
admitted a total of 1,154 abortions before seeking advice on
contraception. Therefore we need some scientific observations
on this point to separate the dogma from the fact.

Dr. George W. ICosmak, New York: There is just one item
to which I should like to refer ; namely, the placing of the
extramural clinics on a more satisfactory foundation. As far
as I know there is no formal licensing of birth control clinics
and in this country these operate more or less without the pale
of the law. If this question is such an important one, I believe
that the profession should recognize it to the extent of provid-
ing regularly licensed clinics in hospitals. There is no need, in
mv estimation, for separating clinics devoted to this particular
part of the practice of medicine from those of any other, and it
seems to me that one of the early steps in the movement to
standardize this entire procedure is to provide for more hospital
clinics so that they can be kept under control and definitely
managed under medical auspices.

AN EPIDEMIC OF POLIOMYELITIS

IN WHICH BULBAR PARALYSIS OCCURRED
WITH UNUSUAL FREQUENCY

ERNEST L. STEBBINS, M.D.

EDWARD E. GILLICK, M.D.

NIAGARA FALLS, N. Y.

AND

HOLLIS S. INGRAHAM, M.D.

ALBANY, N. Y.

During the two months period from July 23 to Sept.
20, 1938, twenty cases of poliomyelitis occurred in the
city of Niagara Falls. However, one of the cases
occurred in a resident of an adjoining town who was a
frequent visitor to Niagara Falls and had had a tonsil-
lectomy performed in that city fourteen days before the
onset of poliomyelitis. There was an unusually low
incidence of poliomyelitis in New York State during
1938 and the epidemic character of the series of cases
in Niagara Falls is shown clearly by a comparison of
attack rates in that city with attack rates in the state
as a whole and in adjoining areas (table 1). The most
striking features of this outbreak were the large pro-
portion of cases in which bulbar involvement was

Table 1 . — Prevalence of Reported Poliomyelitis: Nciv York
State, Niagara Falls and Adjoining Areas, 1938

New York state

Niagara Falls city...

Niagara county*

Erie county

Orleans county

Genesee county

Province of Ontario,

Cases Attack Rate
121 0.89

19 23.37

1 1.30

3 0.31

0

1 2.17

103 4.0

* Exclusive of Niagara Falls city.

observed and the high fatality rate. In thirteen of the
twenty cases definite bulbar paralysis was observed and
twelve of these terminated fatally, a fatality rate of 60
per cent.

CLINICAL CHARACTERISTICS

The onset of the illness was in most instances
characterized by mild gastrointestinal disturbance or
evidence of mild infection of the upper respiratory tract,
or both. In several cases there was a lapse of several
days between the first indisposition and the onset of
paralysis. In the majority, however, there was a sud-
den onset with rapidly progressive paralysis. Marked
rigidity of the neck and of the spine was observed in
almost every case. As shown in table 2, spinal fluid
was obtained for examination in eleven of the twenty
cases and moderately increased pressure was observed
in all eleven. Cell counts of the spinal fluid varied from
17 to 450. An increase in globulin was reported in nine
of the eleven specimens of spinal fluid.

Extensive peripheral paralysis was the usual finding,
and only one nonparalytic case was observed, although
diligent search was made for mild or abortive cases. In
ten of the fatal cases peripheral paralysis was followed
by a rapidly progressive bulbar paralysis with respira-
tory failure. In one case there was no evidence of
peripheral paralysis, the first evidence of paralysis being
difficulty in articulation. In another case bulbar and
peripheral paralysis apparently occurred simultaneously.
Table 3 shows the muscle groups involved, the classi-
fication of the cases according to the type of paralysis
observed and the outcome of the case.

1560

POLIOMYELITIS — STEBBINS ET AL.

Jour. A, >1. .y
Oct. 21, 19M

Because of the frequency of the bulbar type of
paralysis, careful inquiry was made as to previous ton-
sillectomy or other operative procedure in the mouth,
pharynx or nasopharynx. As seen in table 3, only four
of the patients had ever undergone a tonsillectomy ; two
of these had had the tonsillectomy four and fourteen
years previously. One had been tonsillectomized four

Table 2.— Poliomyelitis in Niagara Falls, 193S

nationalities. There was a rather definite geographic
grouping of cases in the city. Ten of the cases occurred
within a radius of three city blocks and ail but two
occurred in persons residing within ten blocks of the
Niagara River. This did not, however, constitute a
definite concentration of cases near the waterfront,
because the city is located at a bend in the river and is
distributed along both arms of the angle. The economic
status of the families in which cases occurred was in

Case

Date

Tonsil-

Spinal Fluid

of

Jcctomy

Date

Number

Sex

Age

Onset

Cell Count Glohulin

1

e

S yrs.

7/2 3

None

54 +

2

6

2 yrs.

7/27

None

20 +

3

cf

m yrs.

S/ 7

April 193S

Not done

4

<?

3 yrs.

SI 9

July 20, 10JS

70 4-

o

9

2 yrs.

siu

Mono

Not done

G

<$

3 mos.

S/20

None

Not done

7

9

S mos.

8/2 2

None

SO 4-

S

9

■1 mos.

8/21

None

Not done

9

9

7 yrs.

S/27

None

GO -h

30

s

o yrs.

S/29

19.31

150 4*

33

<$

S yrs.

0/ I

None

Not done

32

C?

14 mos.

9/ o

None

.30 0

13

9

8 yrs.

9/ a

None

Not done

14

9

8 yrs.

!>/ 7

None

Not done

35

J

IS yfs.

9/30

1921

3:50 4-

10

9

5 yrs.

9/32

None

Not done

37

J

21 yrs.

one,

None

iso +

IS

c?

11 mos.

0/17

None*

17 -f

39

cf

23 mos.

0/ 20

None

Not done

20

9

3 yrs.

9/20

None

322 0

months before the onset of poliomyelitis and one had
had a tonsillectomy and adenoidectomy two weeks
before the onset of poliomyelitis. No history of other
operative procedures could'bc elicited.

ETIOLOCA'

A portion of the cord and brain stem obtained at
autopsy from patient 16 was sent to Dr. Charles Arm-
strong at the National Institute of Health, who reported
that an emulsion of the material inoculated into a rhesus
monkey produced paralysis and death on the seventh
day and transfers to a second monkey produced typical
paralysis. Pathologic study of the cord of the second
monkey showed evidence of severe poliomyelitis. Three
additional transfers produced typical poliomyelitis.

A portion of brain and cord removed at autopsy in
case 13, also studied by Dr. Armstrong at the National
Institute of Health, produced paralysis in a monkey and
through three transfers tremors and paralysis were pro-
duced. Pathologic study of the tissues resulted in a
diagnosis of poliomyelitis, although this strain was
apparently less virulent for monkeys than the strain
taken from patient 16.

Microscopic examinations in case 13 at the Division
of Laboratories and Research of the New York State
Department of Health confirmed the diagnosis of polio-
myelitis, and inoculation of the material into a monkey
produced typical experimental poliomyelitis; further
passage through a second animal gave similar results.
Histologic appearances in both monkeys were those of
poliomyelitis. Nasal washings from patient 17, obtained
on the sixth day of illness, were sent to Dr. Armstrong,
who reported that this material filtered and inoculated
into a rhesus monkey failed to produce symptoms.

EPIDEAnoLOGIC EXAAIINATIOX.S

Twelve of the cases occurred in males and eight in
females ; the ages varied between 4 months and 21 years.
Twelve of the patients were 5 years of age or younger
and all but three were under 10 years of age. Seven of
the. cases were in children of Italian descent and four
were in children of recent descent from other European

general a little below average, but in none was there !
evidence of great poverty. The children suffering from
the disease almost invariably were especially healthy
and well nourished prior to the illness. No history oi j
direct contact between the patients was obtained, but in
a number of instances friends were found to have been
common to more than one patient. No multiple cases |
occurred in any household nor were there any suspicious
illnesses among contacts of the patients. In only one
instance was there a history of previous poliomyelitis
in the immediate family, and in one there was a history
of poliomyelitis in a first cousin several years previously.

No one milk supply'- was found to have been used by
any disproportionate number of the patients. The usual
water supply in all but one case was the municipal
supply. In less than one third of the cases a history
of recent use of a bathing beach or swimming pool was
obtained and various bathing places were used by these-
No history of recent insect bites was obtained in any
case. Many oi the patients, however, had died by the
time the epidemiologic investigation was made, and the
history obtained from the parents, although apparently
given much thought, is open to question. Mosquitoes
were prevalent at the time of the outbreak and were
apparently more prevalent than is usual at that season.

Table 3 . — Muscle Groups Involved and Clinical Classificoiwii
in Niagara Falls o] Poliomyelitis, 193S .

Muscle Groups Involved

Upper
Ex-
cuse treini-
Xo. ties

Abclora
Lower in a I
Ex’- and
t romi- Trunk
tics Muscles

Evidence
Muscles Facial of , . ,

oi and ITcspi- Clinical
Deglu- OcPlar ratory Ciassi-
tition Muscles Failure flcfltion

3

4
3

7

5
9

10

13

12

13

14
13
1C
17

15
39
20

4-

?

-h

0

?

•h

+

4*

0

+

0

+

0

4-

+

0

+

+

4-

0

4-

+

+■

+

+

0

+

+

0

4-

4*

+

0

4-

~h

-h

+

0

4~

0

?

?

4 %

?

?

6

0

4*

?

0

4-

4*

0

4-

0

4-

4-

4-

4*

0

4*

4-

0

0

0

4-

0

-f

0

0

0

0

-r Bulbospinal
4- Bulbospinal
0 Spinal
? Bulbar
+ Bulbospinal
+ Bulbospinal
0 Spinal

+ Bulbospinal
+ Bulbospinal
0 Nonpnrolytic
** Spinal

Bulbospinal
Bulbospinal
Spinal

-T- Bulbospfaai
-f Bulbospinal
0 Spinal
0 Spinal
-f BuIbofpJ***

+ Bulbospinal

0

+

0

+

Pied

Pled

Hecovetf"'

Pled

pied

pled

KccoriTfO'

pied

Pled ,

Recovered

gffovmdl

Recoverfdt

Died

Recorwn

J)Jod

Pied

pceoveroJ.

jjfcorerfi'

pied

Died

+. indicates definite positive siens: 0, no evidence of pamly 1
i Recovered with residual paralysis.

is unusual prevalence of mosquitoes was _ 0, ’^ n!5
vever, in other areas in the state. Several
en questioned as to prevalence or mse ,

larked that an unusual number of spiaers as eo-
erved. In no instance was there a kno iatet ] a «
ion with horses. Cats and dogs were , - . ]elKC of
5 in several instances, but no defin .W t« ^

Dciation of more than one case with tl ■ vr -

No evidence of rat infestation o

Volume 113
Number 1?

POLIOMYELITIS— MORROW AND LURIA

1561

SUMMARY AND CONCLUSIONS

A definite epidemic prevalence of poliomyelitis
occurred in the city of Niagara Falls during July,
August and September 1938. Clinical and laboratory
observations confirmed the diagnosis of poliomyelitis.

Thirteen of the twenty cases showed evidence of
bulbar paralysis; twelve of these cases terminated
fatally.

In only two of the cases classified as bulbar in type
had a tonsillectomy ever been done, one two weeks
preceding the onset of poliomyelitis and one four years
preceding the onset. No other operative procedure in
the mouth, nose or throat had preceded the poliomyelitis
in these cases.

No evidence of direct or indirect contact between
cases could be elicited, but there was a distinct grouping
of cases in a limited area. No factor in the environment
was found to be common to any large proportion of the
cases other than the water supply.

Clinic nl Notes, Suggestions and
New Instruments

PREGNANCY COMPLICATED BY ACUTE
ANTERIOR POLIOMYELITIS

Joseph R. Morrow, M.D., and Sanford A. Luria, M.D.

Ridgewood, N. J.

Little has been written on pregnancy complicated by acute
anterior poliomyelitis. This is especially true of case reports
that were followed to term and through parturition. One of
the most recent articles on this subject was published in July
1933 by Brahdy and Lenarsky, 1 in which three cases were
reported which were followed post partum. The summary of
eight previous cases was also given. It is likely that a few
other similar cases may not have been reported. Nevertheless,
the incidence of epidemic poliomyelitis during pregnancy is
probably rare.

This case is of particular interest not only because of the
unusual and hazardous complications of gestation but also
because of the many problems which were encountered relative
to the disease process per se. Some of the questions for con-
sideration were (1) viability and effect of this disease on the
fetus, (2) the antiviral power of the fetus toward this disease,
(3) type of delivery necessary, (4) whether surgical interven-
tion would be advisable prior to term and (5) effects of the
muscle atony on the parturient canal and bony pelvis.

In the eleven cases previously reported, delivery of the child
was spontaneous in most instances, although there were two
cesarean sections and one therapeutic abortion. The newborn
infants were not infected by the poliomyelitis virus, although
there was one stillbirth in which no evidence of this disease
was shown but death was due to prematurity.

There are two schools of thought regarding the occurrence
of poliomyelitis in pregnant women. Aycock 2 is of the opinion
that poliomyelitis may occur more frequently in the latter part
of pregnancy than would normally be expected if this condition
had not been predisposed to the disease. On the other hand,
Jungeblut and Engle 3 state that both early pregnancy and
infancy are the high water marks of natural resistance to
poliomyelitis. Their accounts were based on the results of the
examination of blood from several women during various stages
of pregnancy. They found higher antibody titers than are

The authors were aided by Dr. William Tompkins, who cooperated in
this case.

L Brahdy, M. Bernard, and Lenarsky, Maurice: Acute Epidemic
Complicating Pregnancy, J. A. M. A. 101:195 (July 15)

2 . Aycock, W. L.: J. Frev. Med. 4:201 (May) 1930.

3- Jungeblut, C. W-, and Engle, E. T.: Resistance to Poliomyelitis,

J- A. M. A. 99 : 2091 (Dec. 17) 1932.

commonly found in healthy, nongravid persons. McGoogan 4
in 1932 published an article on three cases of pregnancy com-
plicated by poliomyelitis and also the results in five similar
cases which were reported in the literature during a period
of twenty-five years. This is the first case of its kind in this
hospital since its inception twenty-three years ago.

REPORT OF CASE

History. — E. W., a woman aged 28, was admitted to this
institution Aug. 16, 1938, by transfer from one of the near
general hospitals. She had had measles, epidemic parotitis and
varicella; otherwise the past history was not remarkable. The
patient was married ; her husband and one child were living and
well. Her father and mother were both living and well.

One week prior to admission, the patient complained of severe
headache and felt “feverish.” This condition was followed in
a short time by nausea and vomiting. The family physician
was called and made a tentative diagnosis of meningitis, based
on the meningeal manifestations. The patient was immediately
sent to a general hospital, where a spinal tap was performed
and meningococcus serum was introduced intrathecally, as is
customary in many institutions in cases of suspected meningitis.
Twenty-four hours later she noticed an inability to move her
legs and complained of severe pain through both lower and
upper extremities and the lumbosacral region. She also gave
a history of being unable to void urine or defecate. She was
then transferred to Bergen Pines. It was further learned from
the history that she had been gravid for five and one-half
months. Cessation of menses occurred in the month of March,
approximately five months prior to admission.

Physical Examination (by systems at time of admission). —
The patient was found to be well developed and well nourished.
She appeared very lethargic and responded poorly to questions,
although answers were coherent. Her face was flushed, the
skin moist and smooth, and there was no evidence of any erup-
tion over the entire body.

The eyes were normal except that the pupils were dilated
slightly more than normal. There was slight deviation of the
septum to the left. The pharynx was mildly injected. The
tonsils were atrophic and submerged. There were slightly
palpable anterior and posterior cervical glands.

The heart sounds were distinctly audible over the entire
precordium. No adventitious sounds were heard. There was
moderate tachycardia. Respiratory excursions were diminished,
more noticeably on the right side. The breath sounds were
heard clearly throughout the upper two thirds of the chest and
slightly diminished over the bases, especially anteriorly. No
rales were heard.

The abdomen was markedly distended and the uterus could
be palpated, extending from behind the symphysis to three finger-
breadths below the umbilicus. There was a tympanitic note
heard on percussion over the entire abdomen, except for the
lower third, which was dull because of retention of urine in
the bladder. Tenderness was elicited over both costovertebral
regions. The fetal heart sounds were heard with difficulty, and
the rate could not be determined.

The neck was markedly rigid. The pupils were slightly
dilated but reacted to light and in accommodation. The ophthal-
moscopic examination revealed normal fundi. The right palatine
muscles were paralyzed. The pharyngeal reflex was diminished
and phonation impaired. The intercostal group of muscles were
weak bilaterally, as evidenced by the diminished respiratory
excursion, more so on the right. The abdominal reflexes could
not be elicited. Peristaltic or borborygmic sounds could not be
heard in spite of marked distention. There was no muscular
contraction on voluntary effort. There was also paralysis of
the lumbosacral group of muscles.

There was weakness and partial paralysis of the arm, forearm
and shoulder girdle of both upper extremities. There was com-
plete flaccid paralysis of both lower extremities from the trunk
line down. In addition, there was involvement of the autonomic
nervous system as related to the gastrointestinal tract and the
urinary bladder, resulting in an inability to defecate and void.

Kernig’s sign was positive bilaterally. Both patellar and
achilles reflexes were absent. Babinski, Oppenheim, Gordon

•n ntutc nnienor I'oJiomyeli

PreKnancy. Am. J. Onst. & Gyncc. 24:215 (Aug.) 193?
J. Michigan M. Soc. 23:58 (Feb.) 1924. k ’

Complicating
Miller, N. F.:

1562

Joint. A. M. "A.
On. 21, 1939

POLIOMYELITIS— MORROW AND LURIA

and ankle clonus were all negative. Biceps and triceps reflexes
were also negative. The Hoffman sign was negative.

Since the paralysis was ascending, beginning with the lower
extremities and progressing upward, it was very similar to
Landry’s type. A diagnosis of acute anterior poliomyelitis, early
paralytic stage, superimposed on a five and one-lialf months
pregnancy, was made from the results of the foregoing exami-
nation and the confirming spinal fluid report, which will be given
along with other laboratory data.

On admission August 16 the urine was normal. Blood exami-
nation revealed 3,870,000 red blood cells, hemoglobin (Sahli)
80 per cent, 11,250 white blood cells, polymorphonuclears 85 per
cent, lymphocytes 14 per cent, mononuclears 1 per cent.

A throat culture was positive for hemolytic streptococci.

As the result of a spinal tap, opalescent fluid was removed
under slightly increased pressure with 180 cells: polymorpho-
nuclears 48 per cent, lymphocytes 52 per cent, globulin reaction
2 plus, sugar 74 mg. per hundred cubic centimeters. Chloride
determination was not done. The spinal fluid report obtained
prior to the patient’s transfer was similar.

Course . — This was very stormy, owing to the patient’s extreme
toxemia and the extensive paralytic involvement. Her facies,
which was very conspicuous, varied from marked apathy to
extreme apathy.

On the second day following admission the patient had a chill,
the temperature rising to 106 F. At this time she became irra-
tional. Fortunately, this condition was transitory in nature and
the patient regained her mental clarity within twenty-four hours.
The gastrointestinal atony, simulating a paralytic ileus, and the
associated distention, which was very resistive to almost all
remedial agents, contributed greatly to the respiratory embar-
rassment, which had already been hampered by partial paralysis
of the intercostal and diaphragmatic muscles. Bowel evacuation
was obtained only by daily enemas. Frequent catheterization was
necessary owing to rapid filling of her temporarily denervated
bladder. In the following few days there developed a urinary
tract infection which, along with the toxemia, caused a con-
tinuation of the septic type of temperature, which ranged between
101 and 104 F. for a period of sixteen days. Blood studies at
this time revealed a hypochromic anemia, which further compli-
cated the clinical course. This iron deficiency anemia was unlike
the usual anemia associated with pregnancy in that it was very
resistive to therapy. Massive doses of ferric and ferrous salts
in the form of sulfate, carbonate and ammonium citrate were
given at different times with no apparent response. Liver and
vitamin Bi were then given, along with the iron salts, but these
also were of no substantial value. Multiple transfusions were
necessary to help maintain the hemoglobin and red blood cells
at a fairly constant level, in spite of which they remained
slightly subnormal. We attributed this anemia not only to the
pregnancy but also to the toxemia, which may have partially
exhausted the hemopoietic system. Hemoglobin levels ranged
between 50 and 77.

August 28, blood examination revealed 3,190,000 red blood
cells, hemoglobin 61 per cent, 20,900 white blood cells, polymor-
phonuclears 90 per cent, lymphocytes 8 per cent, mononuclears
1 per cent, basophils 1 per cent. The polymorphonuclear cells
showed toxic granules.

Urinalysis at this time revealed the specific gravity to be
1.010, acid reaction, a heavy trace of albumin, pus clumps, and

many white blood cells and bacteria.

The patient’s condition was considered critical for eighteen
days. Following this period she started to show gradual and
progressive improvement. The temperature returned to within
normal range. The abdominal distention, however, continued
to cause her 'discomfort frequently, but less so than previously.
Within the following four weeks it was noticed that there was
some muscle restoration in both upper extremities, the chest
and the trunk. There was a return of bowel and bladder func-
tion to voluntary control. The pyelitis improved but still showed
occasional pus clumps and traces of albumin in fte daily speci-
mens of urine. The blood pressure, which had been 160/90,
finally became 138/85. It was possible that the poliomyelitis
had .'begun to precipitate a preeclamptic state earlier in this

disease.

The remaining course in , the hospital was comparatively
uneventful. During the entire stay of the patient in the hos-
pital the fetal heart sounds could be heard and movements
could be felt both objectively and subjectively. The size of the
gravid uterus reached to one fingerbreadth above the umbilicus
prior to discharge.

Treatment . — Although the value of convalescent serum is still
controversial, there have been some encouraging reports fol-
lowing the administration of large doses of serum intravenously
early in the disease. Our own experience with convalescent
serum has always been of doubtful value. Nevertheless, the
patient was transfused with the blood obtained from an adult
who had recovered from this disease. It was believed that it
would therefore serve a twofold purpose (1) as a therapeutic
for the toxemia and (2) for possible specific antibody effect.
The specificity of this procedure was doubtful.

Vitamin Bi and C parenterally was also given, as this form of
treatment has been suggested more recently by various workers
in this field. Vitamin Bi intraspinally, as suggested by Stem 5
in one of his recent reports, was decided against, as we feared
the possibility of further meningeal irritation and development of
a chemical meningitis, which one of us (S. A. L.) has observed.
The remaining treatment consisted essentially of hypertonic
intravenous infusions in the form of 50 per cent sucrose, spinal
taps as indicated, multiple transfusions, iron and liver therapy,
ultraviolet radiation and other symptomatic and supportive
measures. The orthopedic care was limited to immobilization
of the involved members, followed three months later by very
gentle massage therapy.

Although the patient was discharged with the understanding
that she should be further hospitalized for orthopedic and
obstetric care, she preferred to remain at home under the care
of her family' physician and obstetrician for economic reasons.
The course while at home, as related to us by her family physi-
cian, was also uneventful except for the persistent anemia.

December 20 the patient suddenly experienced labor pains an
was immediately rushed to the hospital. The labor progresse
rapidly and it was felt then that she might precipitate. On
arrival at the hospital she was taken immediately to the delivery
room and delivered a 6 pound (2,720 Gm.) living girl baby
apparently good condition. The delivery itself was rather simp e,
although it required forceps and episiotomy. . . '

Her postpartum course was also uneventful. In sp' te 0 3
apparently lowered resistance, no puerperal infections develope •
She had received three transfusions and her blood P'j-
returned to normal within three weeks. The infant s con 1 1
remains good up to the present writing, showing no evl en
of paralytic involvement.

comment ^

In reviewing the case, one is inclined to believe that t
antiviral titer toward poliomyelitis in gravid women ocs
differ from that of other adults who may contract tins ise3
However, this is not true, apparently, as it has been pom e
that the incidence of poliomyelitis during pregnancy
tively low. The fetus perhaps does not contract t c j ’
as the virus probably does not enter the placental circu j; 0 . ’
However, there has been a case report by Lance o
myelitis in the newborn, but the evidence presented is ' .
elusive and there was no history of an acute in fe c ^ n j s

the course of pregnancy. If death does occur to the e >
probably due to the toxemia which accompanies po io
rather than to the virus per se. _ r ; a .

With regard to the parturition, there is apparent y « . al

tion from other paraplegias due to other causes sue .] esSj
cord tumor or trauma except that, in the latter, labor 5CC ticm
although in cases with respiratory involvement cesar lltcn js
may be indicated before term if the increasing size o j )U ibar

further hampers respiration. Also in those cases sect j on
involvement in which death is imminent a cesare ave -

should be done immediately after the patient s en

■. viable fetus.

* . • m Vitatn'O

5. Stem, E. L.: The Intraspinnl (Subarachnoid) Inject-^ DteeB nv
tor the Relief of Intractable Pam and for Infammtoo 30:

Diseases of the Central Nervous System, Am. )■ ^

^tlncef-Iufautile Paralysis Noted at Birth. Bull. Soc. de
is 31:229 (May) 1933.

Volume 113
Number 17

COLOR VISION TESTS— BERENS AND STEIN

1563

This case differs from most of those that have been reported
because of the extensive involvement which, unfortunately, the
patient encountered because of her relatively high susceptibility
and other complications which developed relating to both preg-
nancy and poliomyelitis. Nevertheless it is encouraging to learn
further that these women can deliver normally and also give
birth to healthy infants.

Blood studies of the child and the mother for neutralization
against the poliomyelitis virus have been determined. The
laboratory results of the tests on the newborn babe show that
she carries poliomyelitis neutralizing antibodies in such amount
that 0.2 cc. neutralized about 25 minimal infective doses of virus
in an exposure of two hours at 37 C. followed by an overnight
temperature of 4 C. 7

The mother’s blood, which was studied six months following
the acute onset of the disease, showed a very high antiviral blood
content, as the control monkeys developed acute anterior polio-
myelitis eleven days after intracerebral inoculation, while those
injected with the serum virus mixture remained healthy. The
laboratory procedure in the latter instance was done merely
to determine whether the patient may have lost any of her
immunity since the onset of the disease.

GROUP COLOR VISION TESTS
Conrad Berens, M.D., and Lester Stein, M.D., New York

The desirability of including routine color vision tests in all
eye examinations is widely recognized. Of particular importance
is the evaluation of the color vision of civil service applicants,
motor vehicle licensees, mariners, railway employees and others
whose occupations require normal color vision. Routine school
examinations should include some form of color vision testing,
but the necessity of examining large classes has frequently led
to the omission of color vision testing. The regular physical
examination for the military services includes rigorous color
vision tests.

When large groups of persons are involved, color vision tests
by the present methods are usually arduous and expensive and
require the services of numerous examiners. Therefore the need
for quick, accurate, acceptable color vision tests of large groups
of persons is evident.

METHOD

The method to be described apparently fulfils the require-
ments for color vision tests for large groups of subjects. A
search of the literature from 1929, when color photography
became more accurate, reveals no mention of this method. It
employs among other tests the standard pseudo-isochromatic
Ishihara or Stilling charts, which are world accepted for testing
color vision. The published color vision charts are copied with
Kodachrome film and then made 'into colored lantern slides.
These colored lantern slides can be made in miniature size by
employing the 35 mm. Kodachrome film. The copies can be
made with any of the usual miniature cameras available in con-
junction with the manufacturer’s recommended copying acces-
sories. In this way 2 by 2 inch miniature lantern slides are
obtained. These are suitable for projection in any of the special
miniature lantern slide projectors. The image projected is just
as large, clearly defined and of good color value as that projected
with the large lantern slide projectors. For those wishing to
use the large lantern slide projectors, however, it is also feasible,
but more expensive, to employ 3)4 by 4)4 inch sheet Kodachrome
film and make large slides for use in the large projectors. The
larger slides afford no advantage over the miniature slides. For
best projection results glass bead screens should be employed.
Many models, both of fixed and of portable types, are available
commercially.

This projected test has been used in testing color blind per-
sons and the results have been compared with a similar test
employing the original test plates. It was found that the results
were identical.

<■ Neutralization tests for poliomyelitis by Dr. John Kolmer, Research
Institute °f Cutaneous Medicine.

4vHiea by a grant from the Ophthalmologtcal Foundation. Inc.

. r/ e f. e M e( t before the Section on Ophthalmology', New York Academy

of Medicine, April 17, 1939 . „ .

v 7 r ?. m , c Department of Research of the Lighthouse Eye Clinic of the
-'cu lork Association for the Blind.

TECHNIC OF EXAMINATION

In actual use the test is performed as follows: The subjects
are seated in a suitable projection room, semidarkened to permit
a good view of the screen, and each is supplied with a printed
schema containing key numbers corresponding to the slides,
which are projected on the screen in order. The subjects are
required to write the figure that they identify on the pseudo-
isochromatic chart projected on the screen next to the key num-
ber on the schema. The written responses may be rapidly totaled
by matching them with the master record, and a quick estimate
of color vision can be made and duly recorded. This permanent
record may be kept for future comparisons to be written in
adjacent columns.

ADVANTAGES

The advantages of the method are the ease with which the
tests are performed on large groups of subjects and the small
expense involved. A few examiners can determine the color
vision of thousands of subjects in much less time than has
hitherto been required.

Permanent self-written records are obtained and repetition of
the test is fairly simple and easily carried out and can be per-
formed as part of an annual examination.

Easy interchangeability of the various color tests is afforded
because one can employ Ishihara or Stilling charts or other
forms of pseudo-isochromatic charts with equal facility by
merely altering the order of the slides.

The malingering tests included in the Ishihara and Stilling
plates, the threshold tests after the Young method, the Edridge-
Green and other lantern tests, the Worth four dot test 1 and
its modifications 2 and the kindergarten chart with colored
figures 3 may be similarly projected.

Visual acuity need not be normal, since it is easy to magnify
the images by projection and thus obviate errors occasioned by
subnormal vision of moderate degree.

Disturbances of color vision which are found in certain dis-
eases, e. g. toxic amblyopia, optic neuritis and retrobulbar
neuritis, may be revealed.

Motor vehicle license control is facilitated greatly by this
method of testing large groups of licensees.

For the testing of illiterate subjects and young children,
charts have been constructed employing the international broken
ring, the illiterate E or the Snellen pronged figure. In addi-
tion, for little children pseudo-isochromatic tests may be drawn
using kindergarten figures such as animals, toys, men, dogs,
boats and similar easily recognized objects placed on a con-
fusion color background. A method of constructing these charts
simply has been devised and is being studied at the Lighthouse
Eye Clinic.

An important corollary of this method is the possibility of
employing projected color slides of various scenes, objects
and charts to educate color blind persons to differentiate various
colors and by association teach them to adapt themselves to
their environment.

In addition, it is feasible to include the test in any of the
projector type visual acuity apparatus now available, for exam-
ple the Ferree-Rand visual acuity projector or the projectoscope,
and thus increase the field of usefulness of these machines and
provide satisfactory office color vision tests.

SUMMARY

In a method for testing large groups of subjects for dis-
turbance of color vision the Kodachrome film is employed to
make colored copies of the Ishihara or Stilling or newly
constructed charts in either miniature (2 by 2 inch) or regular
(3)4 by 4)4 inch) sizes.

Projection of the slides yields good images, readily perceived
in large audience halls and thoroughly satisfactory for the
testing of the color vision of large groups of subjects.

The advantages include ease of testing, small expense and
permanent records, written by the subject himself. Disturbances

I. Worth, Claud: Squint: Its Causes, Pathology and Treatment
London, Bnilliere, Tindall & Cox, 1921, p. 14. ” anQ treatment,

. 2 : F- H-: A Modification of the Four Dot Test. Tr Am

Acad. Ophth., 1937, P- 491. Berens, Conrad: Modification of the Worth
v J- C5 V f m a J- .°phth., to be pub), ’shed; A Test for Binocular

Tr! Am P Ophth. a Soc't P 19;9 ab e the E -’ cam,na,ion ° f Amblyopic Children;

2lf'6?7 Cr (June)°lW8 : . Kindcrear,en Visual Acuity Chart, Am. J. Ophth.

1564

INTESTINAL OBSTRUCTION— HAVENS

Jour. A. II. A.
Orr. 21 , 1925

of color vision, which would suggest further studies for the
diagnosis of certain diseases, may be revealed by these mass
color vision tests. This method of testing greatly facilitates
the examination of drivers of motor vehicles, aviators, railroad
employees and applicants for the army, navy and marine services.
Forms of the pseudo-isochromatic color vision tests, employing
illiterate and kindergarten figures and the international broken
ring, are being developed.

The possibility is suggested of educating color blind persons
to differentiate colors by demonstrating colored scenes and charts.

35 East Seventieth Street.

WOOD TICK SIMULATING PEDUNCULATED TUMOR
Kurt Wiener, M.D., Milwaukee

Ormsby writes that the female of the wood tick (Ixodes)
after sucking blood from the skin swells to the size of a pea
or a small bean and may be mistaken for a small pedunculated
tumor. How true this is may be illustrated by the case reported
here.

An elderly man who has a number of partly pedunculated
and pigmented senile keratomas and fibromas on his chest (fig. 1)
complained that one of them started to burn and itch. At first
•dance the little tumor did not look especially different from the
others. When viewed more closely (fig. 2) the coffee bean size
tumor was found to have eight legs and proved to be a wood
tick (Ixodes) which the patient had picked up in the woods of

Fig. 2 .— Close view of object
'indicated by arrow in figure 1 .

Fi g# 3 — Wood tick with beak-
buried in skin.

Northern Wisconsin' two weeks previously. The tick, appar
ently aware of the high value of good mimicry and well
acquainted with Ormsby’s textbook, had chosen a human, skm
with little tumors where it could partake of its sangumary
meals with much less danger than on a normal skin. A drop ot
turpentine helped to remove it. Figure 3 shows how its beak
is buried in the skin.

425 East Wisconsin Avenue.

INTESTINAL OBSTRUCTION CAUSED BY COLLOIDAL
ALUMINUM HYDROXIDE

W. Paul Havens, M.D., Philadelphia

Colloidal aluminum hydroxide has been widely used for the
treatment of peptic ulcer since Crohn reported its value as an
antacid in 1929. There has been little information available
concerning any untoward effects. Kraenier 1 described frequent
constipation and the occurrence of fecal impaction in two
cases, but the majority of observers have not mentioned such
complications.

The following case illustrates the- danger which exists and
the unfortunate result which may occur when colloidal aluminum
hydroxide is used in the treatment of certain cases of bleeding
duodenal ulcer.

M. F., a Negro woman aged 59, a widow, was admitted to
the hospital complaining of generalized weakness and inter-
mittent pain in the lower part of the abdomen of two weeks
duration.

There was moderate enlargement of the heart, and the blood
pressure was 180 systolic and 110 diastolic. She was treate
for hypertensive cardiovascular disease for three weeks. . 1
the end of this time an episode occurred which suggested a
sudden internal hemorrhage. She became weak and rested
and the mucous membranes appeared pale. The blood pressure
fell to 110 systolic and 60 diastolic, and the pulse rate rose o
138. The hemoglobin content and the red cell count, whin
had been 80 per cent and 3,850,000 respectively, fell to JU p*
cent and 1,000,000. Several unformed stools were tarry. »
was given frequent feedings of gelatin water and grue \u
8 cc. of colloidal aluminum hydroxide every two hours
three and one-half days. A tube was then place m
stomach, and a constant drip of two parts water an on
colloidal aluminum hydroxide was allowed to flow 11 ,

rate of 2,000 cc. in twenty-four hours. To this wa >

160 cc. of corn syrup (karo) for two days. The patient re
in poor condition in spite of frequent transfusions
Bleeding from the bowel continued and she fe'lM “
strength. Although she was given liquid petrolatum a >
enemas were effective at least every other day and fr J
examinations for fecal impaction gave negative re f". ' . . , er y

of restlessness, morphine sulfate 10 mg. was adrmni
four hours for a few days. After seven days of ‘realm
the constant drip the abdomen . became distended a nd i
stalsis was heard. A diagnosis of intestina j, an d

made. Suction was applied to the tube in re duced

1,900 cc. of greenish yellow fluid was obtaine , ' t ; on 0 f a

the distention slightly. An enema, causec 1 . becanie

moderate amount of tarry material. Her
progressively worse and she died a few 10Ur * a . rter josclerotic

At necropsy the characteristic changes s ,i g htl;
cardiovascular-renal disease were noted. . .■ c ) ia nges in

enlarged and there were moderate atherosc t ler in

the arteries. Immediately adjacent to the p q 4 cm-

the duodenum there was an ulcer n\ easl, ™ g ' m were dis-
The jejunum and proximal two thirds of t 1 • of t |,c

tended with gas. Beginning »^ a, r*jJ. e ,rScriai wM*
ileum, the lumen contained a semisoft puty. K ., firm casts
in the distal portion became more inspissated,^
of the 'bowel were formed which cause _ ‘ globular

Immediately distal to the ileocecal valve was ^ bloc 4
mass of the same material mixed .: , cas f 0 f the cecum-
approximately 7 by 8 cm forming ; • “to ^ pre^n

Lumps of similar material about 2 by 6 cm Begin""’-?

in the remainder of the.cecum and ‘nansverse , ta r<!

at about the midportion of the 5 an.

reddish black masses measuring colon, *-S-

present, and these became larger in the desc
moid flexure and rectum.

cate in Peptic Ulcer, Am. J- nisesr.

Volume 113
Js’umber 17

CARCINOMA— BROWN

1565

about 5 per cent aluminum hydroxide, which, combined with
the astringent effect produced, may favor constipation, espe-
cially when there is blood in the intestine. It is possible that
the frequent use of liquid petrolatum and enemas by the vigor-
ous young adult may lessen the danger of this complication,
but there appears to be a danger in administering aluminum
hydroxide to older or very ill patients, whose energy is depleted
and whose intestinal tract may lack normal tonus. As a further
precaution, morphine sulfate, because of its alleged depressant
action on the bowel, should be used only with caution. It is
possible that the gelatin given together with the aluminum
hydroxide aided in forming firm masses.

Special Clinical Article

THE SURGICAL ASPECTS OF CAR-
CINOMA OF THE STOMACH

CLINICAL LECTURE AT ST. LOUIS SESSION

ALFRED BROWN, M.D.

OMAHA

Over the seven year period from Jan. 1, 1931, to Jan.
1, 1938, there have been 10,458 deaths from cancer of
all forms in the state of Nebraska. The figures for
1938 are not yet available. Of these deaths cancer of
the digestive tract and peritoneum furnished 5,519, or
a little more than half the total deaths from cancer
(table 1). The facilities of our state health department
do not enable a complete breakdown of site and organ,
but it is ■ reasonable to assume that from one third to
one half of the deaths from cancer of the digestive tract
and peritoneum are due to cancer of the stomach. This
makes approximately 2,000, or one fourth, of the deaths
from cancer of all forms due to carcinoma of the stom-
ach. With these facts in mind, it seemed worth while
to make a study of the situation regarding cancer of
the stomach as we see the disease in the Hospital of the
University of Nebraska School of Medicine, as this
institution receives patients from the entire state.

In order to evaluate these cases, the histories of all
cases of cancer of the stomach in the University Hos-
pital between Jan. 1, 1931, and Jan. 1, 1939, were gone
over and classified under headings that were selected
to give the best idea of the condition of the patient at
the time of admission and discharge. The histories in
these cases were taken by first year interns who are
serving on a one year general rotating intern service.
Consequently the histories are not particularly detailed
or directed especially to obtaining symptoms due to
disturbance of the gastrointestinal tract and are in no
way specialized along this line. They do, however, give
interesting information and should be a true comparison
with histories which could be elicited by the general
practitioner.

There have been eighty cases of cancer of the stom-
ach admitted to the University Hospital during the eight
year period and the statistics regarding these cases have
been arbitrarily divided into two periods. The first,
from Jan. 1, 1931, to Jan. 1, 1936; the second, from
Jan. 1, 1936, to Jan. 1, 1939. This arbitrary line was
chosen for two reasons: first, because the first division
represents a five year period and, second, because 1936
represents the first year in which a patient suitable for
resection of the growth in the stomach entered the Uni-

Read in the Surgical Division of the General Scientific Meetings at
, ' Ninetieth Annual Session of the American Medical Association, St.
L °"is. May 16, 1939.

versity Hospital. All the cases in the first five year
period were so far advanced that resection was tech-
nically impossible.

In the first group there were thirty-two males and
nine females, and in this group it will be noted that the
greater percentage occurred in the 50-59 year decade
(table 2). In the second group there were twenty-five
males and fourteen females (table 3). When, however,
all cases were classified according to sex it will be noted
that the majority of our cases in women occurred
during the sixth decade while during the preceding and
following decades the number is markedly diminished
(table 4). In men the occurrence of the disease is
spread over the sixth and seventh decades with a
marked falling off toward the earlier decades and a
lesser falling off in later years.

In tlie largest percentage of cases the cancer was in
the prepyloric region of the stomach, the lesser curva-
ture was next and the cardia and greater curvature in
the smallest percentage of cases.

In the first group, seventeen of forty-one patients
complained of premonitory symptoms over periods of
from six months to twenty-five years. This period ivas
computed from the time the patients were admitted to
the University Hospital and a definite diagnosis, of
cancer was made.

The premonitory symptoms are shown in Table 5 and
only those symptoms which were directly' referable
either to cancer or to some abdominal condition were
selected to be included in the summary.

In the second group of thirty-nine patients, thirty-one
complained of premonitory symptoms over periods
varying from five months to thirty years (table 6).
The larger percentage of patients complaining of pre-
monitory symptoms in this group may be. due to the
fact that the interns were more careful in history taking
because, knowing of this investigation, they were more
alert in inquiring about gastric symptoms. The type

Table 1. — Cancer Deaths in the State of Nebraska

Cancer Cancer ol Digestive

Tear (All Forms) Tract and Peritoneum

1931 1,420 ’ 090

1032 1,424 814

1933 1,432 783

1934 1,545 824

1935 1,511 7J8

1936 1,509 832

1937 1,557 79S

of premonitory symptoms calls attention to the. con-
troversy as to whether or not cancer develops on ulcer.
This question has in past years divided pathologists into
two groups : those who believe that cancer develops on
an ulcer base and those who believe the contrary. It is
not in the province of the clinician to enter into this
discussion from the histologic basis. From the clinical
standpoint this investigation shows that of a total series
of eighty patients forty-eight, or more than 50 per cent
of the patients, complained of definite or indefinite
abdominal symptoms over a period of from five months
to thirty years. In some of the cases a diagnosis of
ulcer of the stomach or duodenum had been made and
in some the statement had been made that this ulcer
had been cured. Consequently, from the clinical stand-
point the active symptoms of carcinoma of the stomach
are preceded in many instances by a train of either
definite or indefinite abdominal symptoms over a con-
siderable period of months or vears preceding the devel-
opment of cancer itself.

1566

CARCINOMA-BROWN

Jous. A. M. A
Oct. 21, 1911

Our results show that the patient with cancer of the
stomach who presents the classic symptoms and clinical
evidences of the disease at the time of entrance into the
hospital usualfy has a carcinoma so advanced that sur-
gical aid is at the best extremely hazardous and in the
great majority of cases any surgical attack is contra-
indicated.

Table 2. — Sex and Age Incidence in Forty-One Cases of
Carcinoma of the Stomach, Jan. 1, 1931, to Jan. 1 , 1936

Males 32 cases

Females 1) cases

Youngest patient 37 years

Oldest patient ! . . . 81 years

By decades:

30 to 39 years lease

40 to 49 years 7 cases

30 to 59 years 17 oases

GO to G9 years H can's

70 to 79 years 4 oases

SO years and oror 1 ease

In the first five year series of forty-one cases we were
unable to find any case suitable for radical resection
of the carcinoma.

In the second group, of thirty-nine cases over a
period of three years, radical operation was performed
on seven patients. One of these patients was still living
ten days ago:

A man aged 74 had had abdominal pain off and on for thirty
years and entered the hospital because he had had nausea
accompanied by vomiting of everything he ate for six weeks
and during this period had been bedridden. During his period
of bed confinement he had lost between IS and 20 pounds
(7 to 9 Kg.). He had only a moderate grade of anemia, with
80 per cent hemoglobin. He had some free hydrochloric acid
in the last three specimens of the fractional gastric test. He
had a palpable mass in the abdomen, and at operation what
was thought to be an annular carcinoma of the prepyloric
region was found. A Billroth I operation was performed. The
operation was complicated by a parotitis which did not require
surgical drainage and he was discharged from the hospital after
a six weeks stay. A report from his physician states that on
May 6, 1939, he weighed 146 pounds (66 Kg.), a gain of 16
pounds (7 Kg.) over his hospital admission weight. At the
present time he has occasional attacks of abdominal cramps
which yield to digestive remedies.

Table 3. — Sex and Age Incidence in Thirty-Nine Cases of
Carcinoma of the Stomach, Jan. 1, 1936, to Jan. 1, 1939

Matos 25 cascs

Females M cases

Youngest patient 14 years

Oldest patient 19 years

By decades:

10 to 19 years 1 case

40 to 40 years - eases

SO to 59 years 14 cases

00 to 69 years 11 cases

70 to 79 years 11 cases

Unfortunately, the specimen removed from this
patient was lost and a histologic examination was not
made. It must, therefore, remain a question as to
'whether this was actual cancer or callous ulcer without
malignant .change. The other surgical patients all died
within a year and there were three postoperative deaths
in periods of from three to ten days following
operation.

. One other case appeared to be suitable for resection
but operation was refused. In six' cases exploratory

operation was performed and an inoperable carcinomi
found. In two cases gastro-enterostomy was performed
and death occurred in one three months after operation;
the other has not been traced. Consequently the result
of surgery in these eighty cases reveals one patient
alive and apparently ivell ten months alter operation,
and _ there is some doubt whether this patient had a
carcinoma.

METHODS OF TREATMENT

The operations performed in these cases were differ-
ent types of procedure and were directed toward the
mechanical condition of the carcinoma when examined
with the abdomen open. In one case the lesion was
thought to be benign at the time of operation and a
gastro-enterostomy was performed for what was con-
sidered to be a prepyloric ulcer. A resection was not
performed at the time because of the poor condition
of the patient but examination of the specimen showed
definite adenocarcinoma. After a further period oi
preparation a resection of the pylorus was performed
and the patient lived for eight months. Autopsy showed
metastatic carcinoma of the liver. In two cases the
Billroth I operation was performed. One of these
patients died from peritonitis six day’s after operation.
Autopsy showed an unsuspected Krukenberg tumor of

Table 4. — Sex and Age Incidence in Eighty Cases of Carcinomi
of the Stomach, Jan. 1, 1931, to Jan. 1, 1939

Males 57 euscs

Youngest pntieDt 37 years

Oldest patient 79 years

By decades:

30 to 39 years lease

40 to 4» years 5 cases

50 to 59 years 21 eases

00 to 09 years 18 cases

70 to 79 years 12 cases

Females 23ta ’ ,!

Youngest patient Usetn

_ Oldest patient SI jew

By decades:

10 to 19 years lta!

« to 49 years

50 to 59 years I0 ";

CO to 09 years

70 to 79 years 3 w

SO years and over...

e ovary, with peritonitis clue to perforation at the ■ s >| e
operation. In the remaining cases subtotal
my of the Polya type was performed. Tie
riod of life after this operation was nine i nwni ■
iring this period the patient had had _prac ica )
stric symptoms. He had gained, weight u .
mbed to kidney complication following acute pr
struction for which lie refused operative fe ' e ' , an
:d at his home in the western part of the state a
topsy was not obtained. . , ( j, e5C

A prominent symptom in the great majori }
ses in which blood examinations are at ai ^
in a grade of anemia which could not be ^
on the basis of hemorrhage. This finding . ^ 3
constant that the presence of a marked a ^
Idle aged person without definite cause
antion to the stomach as a point of attack 0 j

estigation. Other symptoms stu ie P ' j ( | !e
ight, absence of free hydrochloric bed

learance of occult blood in . the s oos orj j 0 n
:sent in this series of cases in the san p
in other series. . . • 0 e case?

\ study of the observations in ““fitment oi
;es the question whether the medical t of life
trie ulcer is justified from the {oltr f ] t nlC di d{

Every patient is entitled to one attempt at n flf
e of gastric ulcer. A recurrence of
:r after one medical regimen should j \jon- 1
> as to the advisability of surgical *P> 01 ™ c

— i is carried out and a J-

Volume 113
Number 17

CARCINOMA-BROWN

1567

ulcer found it should be removed if technically possible
in preference to the performance of a palliative drain-
age operation. We have a specimen in our laboratory
of the development of carcinoma in the base of a healed
ulcer. We have many specimens of carcinoma devel-
oped on ulcer. Consequently it still remains a question

Table 5 . — Premonitory Symptoms in Seventeen of Forty-One
Cases, Jan. 1, 1931, to Jan. 1, 1936

No.

Age

Sex

Character of Symptom

3

ss

9

Acanthosis nigricans

4

50

3

Indigestion for 25 years

5

37

3

Ulcer 4 years ago cured (?) 2 years

7

47

9

Intestinal “flu” 0 months ago

8

42

3

Ulcer for 4 years

9

53

3

Ulcer for 38 months

10

55

9

Stomach distress for 12 years

11

02

3

Stomach trouble for 20 years

12

52

3

Epigastric discomfort 2 years

10

42

3

Intestinal “flu” for 1 week 5 months ago

21

53

3

Heaviness in stomach 5 years ago

30

DO

9

Weakness, abdominal pain, sore tongue
for 5 years

31

41

3

Stomach trouble for 5 years

32

49

3

Abdominal pain and jaundice 3 years ago,
lasting C weeks

34

52

9

Occasional stomach upset

37

59

3 Col.

Dizzy, nauseated one year

3S

04

3

Weakness and fatiguo 10 months ago

whether ulcer remaining in the stomach, even though
it gives no symptoms, may not be a source of potential
danger to the patient.

The type of operation performed should be the one
most suitable to the type of ulcer encountered at opera-
tion. As an illustration I cite two cases which are my
oldest living examples of patients in the cancer age
whom I have recently followed up.

A woinan, married, a school teacher, 52 years of age at
the first admission, who was admitted to the hospital Aug. 14,
1926, at that time complained of indigestion, ushered in with
an attack of intense nausea three years previously. A few
months after the onset she complained of severe pain of the
hunger type. She entered the hospital for Sippy treatment.
On admission, free hydrochloric acid was 67, total 93. On
discharge, free hydrochloric acid was 45, total 59. She had
occult blood in her stool on two examinations, none for the
remainder of her stay. She was discharged seventeen days after
admission in an improved condition. She reentered the hospital
Aug. 12, 1927, with the history that after leaving the hospital
' she felt much better. She had a gastric hemorrhage in the
spring of 1927 followed by tarry stools. She had been on a
diet for four years and she thought that these attacks were
brought on by worry. Blood examination revealed 4,580,000
erythrocytes, 10,200 leukocytes, hemoglobin 79 per cent. A
fractional gastric analysis showed an increase in free hydro-
chloric acid. The stool showed constant occult blood varying
from 2 to 4 plus. X-ray examination showed an ulcer of the
perforating type in the middle third of the lesser curvature of
the stomach. The duodenal cap was deformed by scars resulting
from old ulcers. August 22, a V shaped resection of the lesser
curvature of the stomach including an ulcer of the perforating
type about 1 inch by 1 inch in size was performed. Following
operation the patient developed bilateral suppurative parotitis
necessitating opening of both parotid glands. She finally made
n good recovery and was discharged Oct. 12, 1927. She reentered
the hospital Dec. 21, 1929, with the symptoms of hyperthyroid-
ism. The goiter was removed by subtotal thyroidectomy and
she made an uneventful convalescence. So far as gastric symp-
toms are concerned, she remains well today and carries on her
work as a teacher. It is now eleven years and nine months
after her gastric operation. A roentgenogram of the patient’s
stomach taken one year ago shows a markedly shortened lesser
curvature, but it is apparently functioning sufficiently well to
carry on normal digestion. It is to be noted that this was an
ulcer in a woman in the sixth decade of life, at the time when

most carcinoma develops. No evidence of carcinoma, however,
was present in the ulcer removed at operation and no glandular
enlargement was demonstrable.

A man aged 61 at the time he was first seen in June 1930,
married and an educator, complained of severe pain in the
epigastrium coming on in attacks which simulated gallbladder
colic. X-ray examination showed no shadow of the gallbladder
with the Graham Cole test, and the gastrointestinal tract
appeared to be normal. Temperature, pulse and respirations
were normal. The heart and lungs were normal. There was
moderate tenderness in the epigastrium. No respiratory catch
occurred on inspiration, and no masses were felt in the abdo-
men. In June 1930 he was operated on. The gallbladder was
found to be normal with no adhesions. There were dense
adhesions between the hepatic flexure and the liver. Beneath
these the great omentum was plastered to the upper surface
of the pylorus and the under surface of the liver. Beneatli
these there was an area on the prepyloric surface of the stomach,
one-half inch in diameter, surrounded by an area of redness
and infiltration. Palpation through the stomach wall revealed
the crater of an ulcer in the area of redness. In the gastro-
hepatic omentum was a lymph gland, intensely hard and about
the size of a buck shot. Under local anesthesia a “Finney”
pyloroplasty, including the ulcer and a considerable area around
it in the incision, was performed. The lymph gland was also
excised. From all indications this appeared to be a case of
prepyloric ulcer but the pathologic examination showed in the
sections of the ulcer “evident induration which was the result
of dense overgrowth of connective tissue, everywhere diffusely,
and near the surface focally, infiltrated with leukocytes. There
was no evidence of epithelial infiltration, and the gastric mucosa
on each side of the ulcerated area appeared normal. The lymph

Table 6. — Premonitory Symptoms in Thirty-One of Thirty-
Nine Cases, Jan. 1, 1936, to Jan. 1, 1939

No.

Age

Sex

Character of Symptom

1

05

3

Dull uclio 1 year

2

54

3

Lumbosacral pain, 5 months

3

50

9

Nausea and pain, 17 months

4

70

3

Operation for stomnch trouble 8 months
ago

0

71

3

Sickness 3 years

7

50

9

Nausea and vomiting, 5 months

8

52

9

Eight upper abdominal pain, 4 years

9

09

9

Peptic ulcer 10 years ago

11

77

9

Indigestion 17 years

12

52

3

Bloating and belching 3 years

15

70

3

Nausea 2 years

10

G3

3

Gas on stomach 0 months

17

04

3

Distress 1 year

18

72

3

. Weakness 7 months

19

79

3

Pain 7 months, relieved by eating

21

05

3

Indigestion 5 years

22

05

3

Diarrhea 10 months

23

42

9

Pain 4 years

24

70

9

Palpitation 2 years

25

45

9

Vomiting and distress 1 year

20

59

3

Sore spot in stomach 20 years

27

5S

9

Cholecystectomy 5 to G years ago; pain
not relieved

23

09

3

Dyspepsia 20 years

29

OS

9

Weakness past several years

31

73

3

.Vomiting, pain, loss of weight 4 months

GO

9

Weakness, loss of weight, 0 months

33

53

3

Weakness is months

34

52

3

Pain and weakness 4 years

30

74

3

Abdominal pain 30 years

37

73

3

Ulcer pain 13 years

3S

53

9

Weakness, loss of weight, 1 year

gland told another story; despite its small size it showed the
presence of numerous masses of undelimited epithelial cells, in
part with a fairly definite tubular arrangement, in part* as
utterly unformed groups. Despite the negative evidence of the
sections directly through the ulcer' there was undoubtedly car-
cinomatous change somewhere in the ulcer.” This patient is
still living at the age of 70 and still carrying on his work as
an educator.. His stomach, as that of the previous patient,
showed considerable deformity at the pyloric region on x-ray
examination one year ago, but it is functioning sufficiently well
to carry on approximately normal gastric digestion. ,

156S

Jot’S. A. 1!. A
Oct. 21, 1939

COUNCIL ON PHYSICAL THERAPY

The point brought out by the three cases I have cited
is that even with the abdomen open and the stomach
accessible to sight and feel it is extremely difficult to
differentiate between benign gastric ulcer and early car-
cinoma. For this reason I advocate the removal of
prepyloric ulcer, in whatever portion of the stomach
it is situated, by the method applicable to the individual
case with or without gastric drainage by gastro-enteros-
tomy. In the early stage, with the patient in good con-
dition, the operation does not carry a high mortality
and removal of the ulcer and the surrounding area is
radicalism on the side of safety.

CONCLUSIONS

The development of surgery initiated by the dis-
covery of anesthesia and asepsis has passed through
two definite phases and we should now be entering on
its third phase.

The first phase was that of anatomic surgery. The
attention of surgeons was directed toward developing
methods of attack on the different organs of the body.
During this phase the various operations were devised
and surgical thought was directed almost exclusively to
anatomic and mechanical methods.

The second phase was ushered in by the increase in
the knowledge of bacteriology and biochemistry. The
condition of the patient’s body was more carefully
evaluated, and preoperative and postoperative care of
the patient as a whole was taken into consideration.
The physiology of the different organs of the body was
studied and surgical attack directed toward conditions
which were previously out of reach because of the
inability of the unprepared patient to stand the shock
of surgical attack.

The third phase, into which we are now entering, is
the phase of preventive surgery. The great mass of
evidence accumulated over the past three quarters of a
century has shown definite conditions amenable to sur-
gical attack which we know, if left alone, will result in

Council on Physical Therapy

The Council on Physical
OF THE FOLLOWING REPOST.

Therapy has authorized publication
Howard A. Carter, Secretary.

HARRIS OXYGEN REGULATORS, No. 92SC
ACCEPTABLE

Manufacturer : The Harris Calorific Company, 5505 Cass
Avenue N.W., Cleveland.

The Harris Oxygen Regulator, No. 92SC, is used to meter
the flow of oxygen into tents, catheters, anesthesia apparatus or
similar oxygen therapy chambers. It is a two-stage regulator,
which is designed, in contradistinction
to single-stage regulators, to reduce
pressure in two steps.

The firm claims that this type of
apparatus is more efficient than a
single-stage regulator, in which the
high pressures encountered in the oxy-
gen cylinders are both held and con-
trolled at one point, namely where the
nozzle meets the seat. It is stated that
this dual function cannot be efficiently
maintained by one such control. That
is, in the two-stage mechanism a more
Harris Oxygen Regulators steady and rigid means may be pro-
msc. vided to “hold" the pressure by means

of a separate first stage, and a nwie
accurate and stable control is made possible by the presence of
a second stage. The first is achieved by a metallic diaphragm
set to hold the pressures roughly at from 150 to 200 pounds.
Gas at this pressure is then led into the second stage, "here a
flexible diaphragm functions in connection with a scat to regu-
late the gas more accurately. Furthermore, it is said that t
second stage diaphragm is so made that no harm would ensu-
if a nurse should inadvertently leave the second stage seat open
and then open the valve on the oxygen cylinder, allowing 4
pounds of gas pressure to rush directly onto the more de irate

serious disability, if not death, in a moderately short
time. In this group can be placed thyroid disease,
which tends constantly to become more and more severe.
Gallbladder disease, which tends to create economic
inefficiency in later life, also may be included. The
wisdom of surgical removal of the various so-called pre-
cancerous conditions is now recognized. It would
appear from the evidence offered by this study, as well
as by that offered by others, that gastric ulcer belongs
to this group if we are to succeed in the surgical cure
of cancer of the stomach.

Cancer of the stomach sufficiently advanced that a
definite diagnosis of cancer can be made is, as shown
by this series and series reported by others, a condition
which is practically incurable by surgical treatment.
Recurrences are common. In many cases metastases
exist which cannot be recognized at operation. At best,
in the advanced case, operation gives the patient only a
few more months of life. In the majority of cases life
is made more comfortable and consequently operation
is justified.

The accepted method of cure, if the word can be used
of carcinoma of any form, is the early removal of the
growth itself with the removal of adjacent lymph
glands. From the standpoint of the surgeon the treat-
ment of carcinoma of the stomach consists in the
removal of gastric lesions which we know may result
in carcinoma during the stage when, if carcinoma is
already present, it is in an early stage and localized in
the stomach and adjacent glands.

1618 Medical Arts Building.

second stage diaphragm.

In this unit there is also a screen through which gas
the regulator is subjected to filtering prior to entering the <£
pressure gage and the seat. A safety valve has been pf0 'L' c
to vent to the atmosphere undesirably high gas pressures. ‘
noise of the operation of the unit has also been reduce 0
minimum. _ .

The firm submitted tests made in its engineering depar
to substantiate claims that the regulator will hold and
control 2,000 down to 100 pounds pressure. The delivery
minute was set at 20, and the results were as follows .

Evidence obtained by the Council for the clinical \ a! r( j.
unit demonstrated that it performed adequately an

nee with the claims of the firm. Physical

In view of the foregoing report, the C °uncil on No.
'herapy voted to accept the Harris Oxygen , ,j cv iccs.
2SC, for inclusion on the Council's list of acc p

Volume 113
Number 17

COUNCIL ON PHARMACY AND CHEMISTRY

1569

Council on Pharmacy and Chemistry

REPORTS OF THE COUNCIL

The Council has authorized publication of the following report.

Paul Nicholas Leech, Secretary.

BISMUTH ETHYL CAMPHORATE
(UPJOHN COMPANY)

Preliminary Report of the Council on Pharmacy
and Chemistry

The Upjohn Company presented for the Council’s considera-
tion, Bismuth Ethyl Camphorate, stated to be a liposoluble
bismuth salt of ethyl camphoric acid having the formula
(CsHu.COOCiHs.COOJjBi. The preparation is proposed for
intramuscular injection to obtain the systemic effects of bismuth
in the treatment of syphilis. The proposed adult dose is 1 cc.
by intramuscular injection for a course of twelve injections.
The firm states that the drug is usually administered in courses
alternating with arsenic preparations. It is marketed in ampules
of 1 cc. and vials of 30 cc., each cubic centimeter containing
40 mg. of elemental bismuth, 0.010 Gm. of camphor and 0.025 cc.
of benzyl alcohol dissolved in sweet almond oil. These dosage
forms have not been checked by the Chemical Laboratory of
the American Medical Association.

The Upjohn Company submitted evidence to show that the
minimum lethal dose for the bismuth-methyl-campliorate was
350 mg. of metallic bismuth per kilogram of rat, while that for
bismuth-ethyl-camphorate was 250 mg. of metallic bismuth per
kilogram of rat.

The firm submitted a reprint entitled “Bismuth Ethyl Cam-
phorate, clinical observations on a new oil soluble bismuth in
the treatment of syphilis,” by Francis M. Thurmon representing
work done in the Department of Dermatology and Syphilology
and the Division of Research of the Boston Dispensary. The
statement is made that oil soluble preparations possess an opti-
mum rate of absorption and elimination and a superior ability
to penetrate the tissues. No proof for this statement is given.
Investigation included 230 patients who received 2,444 intra-
muscular injections, extending over a period of eighteen months.
There were nineteen patients with primary lesions, thirty-six
with secondary, ninety-one with tertiary asymptomatic, sixty-
three with tertiary symptomatic, and twenty-one with congenital
syphilis. There were 146 males and eighty-four females (of
the latter fourteen were pregnant). Each patient had frequent
chemical and microscopic studies of the urine. Occasionally
phenolsulfonphthalein excretion tests were used, and determina-
tions of the nonprotein nitrogen and urea content of the blood
were carried out. Likewise, complete blood counts, icteric index
and like tests were made in numerous instances. In these tests
no significant variations from normal were observed which
might be attributed to Bismuth Ethyl Camphorate. It was found
that the patients best tolerated the 1 cc. dose of the compound
given intramuscularly. Higher doses of 1.5 cc. and 2 cc. were
well tolerated by some patients, while others manifested local
pain, gingivitis, occasionally a mild dermatitis, and seldom evi-
dence of a transient renal irritation.

The technic employed in the foregoing clinical study consisted,
in early syphilis, in each patient receiving three injections of an
arsphenamine for the first two weeks, two injections a week for
the next two weeks and one injection a week for the succeed-
ing two weeks, so that at the end of the first six weeks of
treatment each patient had received twelve intravenous injec-
tions. Then without a rest period intramuscular therapy was
instituted, the patients receiving an injection of bismuth ethyl
camphorate at seven day intervals for a total of twelve injec-
tions. Following this the patient was once more put back on
the arsenical therapy, and this continuous alternation of courses
was kept up until the patient had received thirty-six injections
each of an arsenical and of a bismuth preparation. The seventy-
two injections were considered the minimum therapy for any
paUent with primary or secondarj - syphilis.

The author states that occasionally prolonged treatment with
bismuth ethyl camphorate was necessary because of sensitivity
to other preparations, so that twenty-one patients received from
fifteen to twenty consecutive injections, and another group of

fifteen patients received from twenty to twenty-five injections
without toxic effect. One patient, a man aged 20, sensitive to
all arsenicals, developed an acute interstitial keratitis, for which
he received twenty-nine consecutive injections without toxic
effect and with a clearing of the eye situation in six weeks.
In fourteen cases of pregnancy, five, of them in the secondary
stage in which it was possible to administer treatment through
the last five months of pregnancy, each of the patients produced
a full-term child without stigmas of congenital syphilis.

The firm submitted a table comparing the toxic effects of
bismuth ethyl camphorate with that of bismuth subsalicylate.
According to this table, if anything, more toxic effects were
noted from bismuth subsalicylate than from bismuth ethyl cam-
phorate, there being a comparison of 230 cases under the bis-
muth ethyl camphorate, with 180 under the bismuth subsalicylate.
As to local irritation from the preparation, in only eight
instances of the 230 was it necessary to transfer the patient to
some other form of treatment. It is stated that during the
early period of the study when larger amounts of the drug,
from 60 to SO mg., were used, the drug seemed to possess
potential possibilities of toxicity. Later and more complete
evidence would indicate that Bismuth Ethyl Camphorate can
be used in 2 cc. (80 mg.) doses, as are other liposoluble com-
pounds on the market, though one consultant reports that some
of the patients under such a regimen develop a bismuth line
within a matter of two or three weeks. Otherwise there seems
to be no reason why a 2 cc. dose should not be considered safe.

No studies were submitted on the absorption and elimination
of this product. Evidence is presented to show that it is impos-
sible by means of x-ray examination to study the rapidity of
absorption of Bismuth Ethyl Camphorate when administered
intramuscularly. The x-ray films show no evidence of any
opaque material.

The Upjohn Company was informed that the Council has
already gone on record as being opposed to development of
further bismuth preparations for the treatment of syphilis unless
they represent something new and of an unusual type. Bismuth
ethyl camphorate can hardly be called a new or unusual type of
preparation. Sufficient data are not furnished to allow proper
evaluation of the effectiveness of this product in the treatment
of syphilis. Studies on the absorption and elimination of the
preparation in human subjects are lacking. Some data are
furnished on animals. It is understand that the investigation
of the former is in progress. For one of the first requisites
to evaluation of an antisyphilitic preparation, the rapidity of
disappearance of spirochetes from primary and secondary lesions,
insufficient data are at hand. Thus far they consist of but one
case of Dr. Carroll Wright’s, in which the spirochetes dis-
appeared from a penile chancre in approximately sixty hours,
and eight cases submitted by Dr. Francis Thurmon, the spiro-
chetes disappearing from the primary lesions in one, two and
three days respectively, and from secondary lesions, several of
them being extensive condylomas, in extremes of two and four-
teen days, with a mean of thirteen days. In view of the lack
of sufficient data to warrant inclusion in N. N. R. at this time,
the Council authorized publication of the foregoing preliminary
report.

NEW AND NONOFFICIAL REMEDIES

The following additional articles have been accepted as con-
forming TO THE RULES OF THE COUNCIL ON PHARMACY AND CHEMISTRY
of the American Medical Association for admission to New and
Nonofficial Remedies. A copy of the rules on which the Council

BASES ITS ACTION WILL BE SENT ON APPLICATION.

Paul Nicholas Leech, Secretary.

SULFANILAMIDE (See New and Nonofficial Remedies,
1939, p. 463).

Tablets Sulfanilamide , 5 grains .

Prepared by Smith-Dorsey Co., Inc., Lincoln, Neb. No U. S patent or
trademark.

IMMUNE GLOBULIN (HUMAN) (See New and Non-
official Remedies, 1939, p. 412; The Journal, April 1, 1939
p. 12 d7).

The National Drug Co,, Philadelphia.

immune isiooutm (tinman /.- — Also marketed in packages of one 2 cc
ampule-vial and in packages of one 10 cc. ampule-vial.

1570

EDITORIALS

THE JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION

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SATURDAY,

OCTOBER 21, 1939

HEAD INJURIES

In recent years two dominant influences have pre-
vailed in the treatment of trauma to the brain. The first
is the demonstration of the four classic stages of brain
compression by Kocher and Cushing. The second is the
observation of Weed and his collaborators that increased
intracranial tension can be influenced by changing the
osmotic pressure of the blood through the agency of
hypertonic and hypotonic solutions. The treatment of
cerebral injuries has been designed also on the concept
that cerebral compression is the prime factor in the pro-
duction of the symptoms. The application has resulted
in treatment by cerebral decompression — by lumbar
puncture and by dehydration. Thus Battle, 1 after a
recent study of 200 cases of traumatic injuries of the
head, has reported that the lowest mortality in the seri-
ously injured occurred in the cases treated by repeated
lumbar punctures and dehydration.

Now, however, comes evidence that the postulates on
which therapy has rested are neither wholly complete
nor wholly accurate. Shapiro and Jackson, 2 for example,
in studies of normal human brains and those which had
suffered traumatic injury, found that in the traumatized
head the brain is swollen but not edematous. This
swelling is not due to increased water but to increased
blood content, although the ventricular fluid is increased
in the presence of internal traumatic hydrocephalus.
The lines of therapeutic effort suggested by their study
show, these investigators believe, that lumbar puncture
and dehydration are indeed indicated but have probably
been carried as far as possible. Ventricular drainage
may be useful but emphasis may be placed on measures
to reduce parenchymatous hemorrhage within the brain
substance. Similarly. Browder and Meyers 3 have
previously expressed inability to interpret clinically the
altered brain functions of many traumatic cases in

x. Battle, Newsom P.: Traumatic Injuries to the Head, Am. J. Sure.

■43: 66 (fan.) 1939. . .

9 Shaoiro Philip, and Jackson, Harry: Swelling of the Brain in
Cases of IuTurj- to tfc Head, Arch. Sur E . 38 : 443 (March) 1939 .

3. Browder, Jefferson, and Meyers, Russel: Observations on Behavtor
of the Systemic Blood Pressure, Pulse andSpmai ,V u ' d TUA'A F °
ing Craniocerebral Injury, Am. J. Surp. ~1:403 (March) 1936,

Jour, A. M. .1
Oct. 21, 191)

terms of the classic teachings. This led to their inves-
tigation of the behavior of the blood pressure, pulse,
respiration, state of consciousness and cerebrospinal
fluid pressure following craniocerebral injury. Measur-
ably increased intracranial tension rarely, however,
produced the classic pattern of signs; they therefore
expressed the conviction that, whether singly or in
combination, the blood pressure, pulse rate, respiratory
rate and state of consciousness cannot be reliably
regarded as an index of intracranial tension. Three
lines of evidence concerning the factor of cerebral
compression — that derived from observations on the
behavior of the systemic blood pressure, pulse and
spinal fluid pressure following craniocerebral injury;
that from alterations in vital signs associated with
changes in intracranial tension experimentally produced
by an external pressure agent, and that from the
alterations in vital signs associated with changes in
intracranial tension experimentally produced by the
application of an intraventricular pressure agent— lend
strong support to the view that the changes in the con-
stitutional, neurologic and psychologic states of patients
showing evidence of severe trauma of the brain are not
applicable in terms of increased intracranial tension
per se.

Their extensive experiments on this problem
involved also observations on the effects of various
hypertonic solutions on the intracranial tension as
measured by the cerebrospinal fluid pressure and aero-
graphic roentgenologic studies of the head in relative)
new injuries demanding prompt and precise diagnosis
as a basis for therapy. All these observations point to
the conclusion that the traditional account of the mam
festations of craniocerebral trauma in terms of bram
compression cannot be reconciled in the majority
cases with the data derived from clinical, P a ^ ,o0 “f
and experimental investigations. The evidence avai a > e
rather indicates the necessity of experimental, inquirj
into the nature of the more subtle pathologic infra
cerebral disturbances, particularly of the derangemen^
of the physiochemical constitution of nerve cel
their processes. Until precise knowledge along J
lines is acquired, Browder and Meyers say,, bring
with it an understanding of the pathogenesis o ^
majority of severe cerebral injuries cotnparabe to ^
at present possessed in connection with epidura , ^
dural and intracerebral hemorrhages, just so ong ^ ^
treatment remain empiric. The proper manage” 1 cn ^
a head injury, they say, requires the clinician to
mine whether or not there are present any lesions ^
as depressed fractures of the vault and epidtmw ^
dural or intracerebral hematomas. These a o
benefited by surgical procedures. Other p a 1
processes call for the institution of supportive !51C ‘ ( j, c
Differential diagnosis is often rendered di cu ^
frequent coexistence of gener alized cerebra tnsu — _____

4. Browder, Jefferson, and Meyers,

Treatment of Head Injuries, Ann. Surg. 110.35/ w I •

Volume 113
Number 17

EDITORIALS

1571

surgically amenable conditions. In such cases cerebral
aerography may help to clarify the diagnosis. Certainly
the severe traumatic head injuries still constitute a
sufficiently dangerous group to necessitate extensive
further studies on the pathophysiology in order to
furnish a foundation on which to base more rational
and effective therapy than is at present available.

POTASSIUM IN MUSCLE

The concentration of the electrolytes in the various
tissues of the body is maintained by a variety of
intricate mechanisms, not all of which are well under-
stood. The electrolytes of muscle, in particular, have
attracted much attention ; the extensive literature cover-
ing research studies made in this field was recently
reviewed by Fenn. 1 The important observations of
numerous investigators which give evidence that under
certain conditions muscles lose potassium on stimula-
tion have made studies concerning this element of
special interest. A recent investigation by Heppel, 2
who used potassium deficient rations, is noteworthy
because it adds to our knowledge of the interrelations
of potassium and sodium in muscle. Restriction of
rats to such an experimental diet results in a striking
alteration in the potassium and sodium content of their
muscular tissues. As compared to normal animals,
those deprived of potassium show a decrease of almost
. 50 per cent in the potassium of muscle and a con-
comitant rise in the level of sodium ; indeed, in some
cases the muscles become richer in sodium than in
potassium. Particularly worthy of note is the observa-
tion that in the muscles of the deficient animals most
of the sodium is confined to the intracellular phase,
whereas it is known that in the muscles of normal rats
almost all the muscle sodium can be assigned to the
extracellular space. It might be recalled here that
Eppright and Smith, 3 in a study of the changes in the
water of tissue induced by diets containing various
. mineral supplements, also reported the probable occur-
rence of intracellular sodium in the muscles of rats
under a particular dietary regimen.

Although the livers of rats deprived of potassium
examined by Heppel showed no large changes in the
electrolyte picture, the possible importance of the liver
m the potassium economy of the body is suggested by
the recent work of Fenn. 4 He has reported the results
of an extensive study which was carried out to deter-
mine the fate of potassium liberated from muscles
during activity. His observations indicate that the liver
is involved in a manner not suspected heretofore. The
blood, muscles and other tissues of cats were analyzed
for water and potassium before and after stimulation

’• Eenn . W. O.: Physiol. Rev. 1G: 450 (July) 1936.

_?■ Heppel, L. A.: Am. J. Physiol. 127: 385 (Sept.) 1939.
re l\ Erpr!sht ' E - S " an< i Smith, A. H.: Am. J. Physiol. 121:379
ueb.) 1933; j. jjiol. Chcm iis- 679 (May) 1937.

4. Fenn, \V. O.: Am. J. Physiol. 127: 356 (Sept.) 1939.

of certain muscles. The data show that one hour after
stimulation the increase in potassium concentration in
the blood is such as to indicate that more than half of
this element is no longer located in the interstitial or
circulatory fluids but must have penetrated into some
cells of the body. Analysis of tbe liver indicates that
this organ takes up 31 per cent of the potassium liber-
ated from active muscles, although it accounts for less
than 3 per cent of the bod}' water.

The experiments would seem to indicate that a part
of the potassium liberated by muscular activity is taken
up by the liver ; in recovery the reverse change occurs,
since it has been shown that the muscle regains the
potassium which it has lost. Thus there are indications
of a potassium cycle that is somewhat comparable to
the classic carbohydrate cycle, the potassium being pos-
sibly transported as potassium lactate. As recognized
by Fenn, additional evidence is needed before the exis-
tence of such a cycle can be stressed. However, if
further work proves that this cycle exists, the impor-
tance of the discovery to our knowledge of tissue*
electrolytes is evident. The involvement of the liver in
the cycle would also serve to emphasize once more the
manifold function of this organ in metabolism.

HEMOCONCENTRATION AS A DIAGNOSTIC
SIGN OF SHOCK

Observations on shock during the World War seemed
to show that substances absorbed from injured tissues
were responsible for the circulatory failure which fol-
lowed. The British Medical Research Council organ-
ized an investigation on the nature and appropriate
treatment of shock. Eminent surgeons, physiologists
and pharmacologists of England, France and the United
States cooperated in this endeavor. The accumulated
experience and experimental evidence, summarized by
Cannon, indicated that secondary shock is due to a
toxic factor absorbed from injured tissues which causes
an increase in permeability of the capillary walls and
a consequent reduction in blood volume through the
escape of plasma into the tissues. In a large series of
cases of hemorrhage and of shock in which hemorrhage
was insignificant, Cannon, Fraser and Hooper 1 found
that the blood showed dilution in the former propor-
tional to the amount of blood lost, while in the latter
there was concentration of the blood. The first note-
worthy feature in severe traumatic shock was a high
red cell count. These investigators attributed this
phenomenon to stasis of blood in capillary areas, accom-
panied by transudation of the plasma into the tissue
spaces, with resulting concentration of the corpuscular
elements of the blood. The hemoconcentration was
progressive and tended to be proportional to the degree
of shock.

1. Cannon, W. B.; Fraser, John, and Hooper, A. N.: Some Altera-
tions in the Distribution and Character of the Blood. T A M A 70 -

'>1\ 1010 ’ J - 1 ** ■***

1572

CURRENT COMMENT

Knowledge concerning the function and reactions .of
the capillaries has been extended since the World
War. It has been shown (Ebbecke , 2 Lewis 3 ) that
normal cytoplasmic substance, released from cells by
injury of any kind, causes dilatation and increased
permeability of capillar}' endothelium. Cytoplasm is
not toxic in the sense commonly implied by that term.
According to Moon , 4 secondary shock is the result of
capillary atony caused by many agents, such as cyto-
plasmic substances, anoxia, certain chemicals, metabo-
lites and various protein substances. The phenomena
which accompany capillary atony are hemoconcentra-
tion, dilatation, stasis and permeability of capillary
endothelium. These result in a decrease in both the
actual and the effective blood volume. The volume flow
is thereby reduced and deficient delivery of oxygen
causes tissue anoxia. Capillary dilatation combined
with loss of plasma volume causes disparity between
the volume of blood and the volume capacity of the
vascular system. For a time arterial constriction will
. compensate this disparity. This compensation is at
the expense of volume flow. The peripheral parts
become relatively bloodless and vital organs suffer lack
of oxygen. When this mechanism of compensation is
no longer effective, the blood pressure declines progres-
sively. At this stage the condition is usually irreversible.

Moon and his associates claim that shock is accom-
panied regularly by hemoconcentration, and they have

Jons. A. M. A
Oct. 21, 19J)

Moon 5 points out that hemorrhage and shock may
be differentiated readily by observations made on the
concentration of the blood. A loss of blood by hemor-
rhage results in dilution of the blood because fluid is
absorbed rapidly from the tissues to restore the blood
to its normal volume. The hemodilution is propor-
tional to the amount of blood lost. Moon compared
the hemoconcentration with blood pressure readings in
a number of clinical cases during the development of
circulatory deficiencies of the shock type. In each
instance, examination of the blood forecast the develop-
ment of the shock from several hours to several days
before the blood pressure declined notably. He there-
fore concluded that arterial blood pressure is not an
accurate criterion of the presence of shock. The latter
may be present while the blood pressure is well main-
tained or when it is even at its highest recorded point.
Hemoconcentration is progressive ; it is an index of
the degree of shock, and it subsides to normal as shock
is abated. Hemoconcentration is therefore offered as
the earliest clinical sign of shock. It is easily detected,
is regularly present before other signs appear and
results from the same mechanism that causes shock

Current Comment

adopted hemoconcentration as a criterion rather than
changes in blood pressure. They produced shock in
dogs without hemorrhage or trauma by introducing
muscle substance intraperitoneally, by injecting extracts
of tissue, by injecting bile and by other procedures.
Hemoconcentration was a regular feature in all the
experiments, sometimes developing within an hour after
implantation of muscle. It occurred before the arterial
blood pressure began to decline and was progressive.
The degree of concentration was proportional to the
apparent illness of the animal. A condition of collapse,
relaxation and stupor preceded death.

Moon and his associates found that hemoconcentra-
tion develops gradually after severe trauma, operations,
intestinal obstructions and burns but that it results
immediately after the injection of bile, peptone, hista-
mine, emetine and other substances which cause damage
to endothelium. A rise from 5,000,000 to 6,000,000
red cells represents a concentration of 20 per cent.

' Such a result, according to Moon, indicates that the
total blood volume has been reduced about 10 per cent
and the plasma volume about 20 per cent. A hemo-
concentration of 20 per cent is ominous, for it indicates
that the mechanism of shock is in operation even though
no decline in arterial pressure or other evidence of

circulatory deficiency is shown.

2. Ebbecke, Ulrich: Ueber Gewcbsreizung und Gefassreaktion, Arch.
f ’ < 3. S LewTs! 3 Thomasf ’ Btood^Vessds of the Human Skin and Their
V.' Hi: ^Shock^ and ^ela^al "Capillary Phenomena, New York,

Oxford Press, 1938.

MASSACHUSETTS COMES CLEAN
At long last the Commonwealth of Massachusetts
has taken measures for the protection of its citizens m
medical affairs comparable to those of other states. °|
years the output of graduates of low grade me jO
schools unable to obtain licenses in any other state ws
flocked to Massachusetts. Two such schools not rcc< jf
nized in any other state have flourished almost un c
the shadow of the State House. In theory peopc
protected by the licensing examination ; it is w el vl10 ' '
however, that competence to practice medicine
be determined by a written examination alone. - "
ten examination might as well be expected to test a ^
to paint a picture or to shoe a horse. The sta e
provided no machinery for a practical exan11 ".. jn ’
which is the only kind of examination worth wr
ascertaining fitness for medical practice. °''» .g
ever, by the Acts of April 30, 1936, and i W
amending section two of chapter 11/ o t i ic

Laws, it has been decreed that no one may e ^ ^
licensing examination who is not a gra ua .

“approved” medical school. There has also e ^

an “Approving Authority” which is to e e . ^
request whether any medical school fulfils ..

ments formulated and published by it. _ t |, e

now clear to enforce a standard for a nuss
practice of medicine at least as high as State;-

prevailing generally throughout the 111 doI1 ,p-
After 1941 Massachusetts should cease to be t
ng ground of unqualified practitioners.

3 0 * .

5. Moon, V. H/: Early Recognition of Shocked .15 D,fr "
m Hemorrhage, Ann. Surg. 110:260 (Aug.)

Volume 113
Number 17

MEDICAL NEWS

1573

SUPPLY OF OPIUM IN THE
UNITED STATES

According to official reports, opium and its deriva-
tives are now available in the United States in quantities
sufficient to meet legitimate medicinal requirements for
about three years. Disturbed conditions in Europe and
the Orient afford, therefore, no justification for pur-
chasing and boarding supplies of these drugs, either
by physicians, hospitals, wholesale druggists or phar-
macists. Narcotic pedlers, however, who cater unlaw-
fully to addicts, seem to feel already the pinch of
restricted transoceanic commerce. The importation of
opium and its derivatives by international smugglers
apparently has diminished along with the number of
vessels engaged in transoceanic commerce. The increas-
ing difficulty of obtaining narcotics to satisfy the
demands of addicts probably accounts for the increase
in the number of thefts of narcotics from physicians’
offices and from pharmacies. Addicts and pedlers who
cater to them are likely to resort with increasing fre-
quency to this method of replenishing their stocks.
Physicians, pharmacists and institutions who may legiti-
mately possess narcotic drugs should take extra pre-
cautions to prevent their being stolen. Access to such
drugs should be limited to the smallest possible number
of persons. In event of theft of narcotics, the person
from whom they were stolen should make immediate
report in writing to the local police and also to the
narcotic agent in charge of the district in which the
theft occurs. Such reports are necessary for physicians
in presenting a correct inventory of their narcotic sup-
plies when called on to do so.

Medical News

(Physicians will confer a favor by sending for

THIS DEPARTMENT ITEMS OF NEWS OF MORE OR LESS
GENERAL INTEREST.* SUCH AS RELATE TO SOCIETY ACTIV-
ITIES, NEW HOSPITALS, EDUCATION AND PUBLIC HEALTH.)

CALIFORNIA

Annual Symposium on Heart Disease. — The tenth annual
postgraduate symposium on heart disease, given by the heart
committee of the San Francisco County Medical Society, will
be held at the University of California Hospital, Stanford
University Hospital and San Francisco Hospital, San Fran-
cisco, November 16-18. The course will include demonstration
of patients, ward rounds and special instruction in roentgen
examination and electrocardiography. At the dinner meeting
the opening night Dr. William Dock, professor of pathology
at Stanford, will speak on “The Treatment of Heart Disease
Since Queen Bess.”

Resolutions of an American Legion Post. — Service Clubs
Post No. 546 of the American Legion of the Department of
California, at Los Angeles, comprising mostly men of execu-
tive rank in their own organizations who are former officers
'n the military service, has unanimously adopted two resolu-
tions. In the first resolution, the post stated that military
mobilization would require thousands of doctors and, since only
about 20 per cent of those applying for admission to medical
schools at present are admitted, in selecting students for admis-
sion to medical schools adaptability for military service should
be considered along with the other requirements; that R. O.
T. C. graduates be given preference if otherwise equally
qualified; also that the number of admissions to medical schools
annually should be increased to provide enough doctors of
medicine to serve the military forces in time of war and leave
a surplus sufficient to serve the needs of the civilian popula-
tion. The other resolution adopted by the post provided that
further to improve the medical department of the U. S. Army

and Navy a study be made to determine the feasibility of
requiring all applicants for admission to the dental corps to
be doctors of medicine specializing in dentistry. This resolu-
tion pointed out that at present in the medical department of
the U. S. Army and Navy there are about 400 officers of the
dental corps whose professional training is along the lines of
medical officers but whose effectiveness is limited almost
entirely to their technical ability.

COLORADO

Annual Session. — The Colorado State Medical Society will
hold its annual session in Glenwood Springs Sept. 11-14, 1940,
with headquarters at the Hotel Colorado.

Society News. — Dr. John Alexander, Ann Arbor, Mich.,
discussed “Surgery of Bronchiectasis and Abscess of the Lung”
before the Medical Society of the City and County of Denver
October 3. Dr. Elliott P. Joslin, Boston, addressed the society

September 3 on “Treatment of Diabetes — 1898-1939.” The

Pueblo County Medical Society was addressed September 19
by Dr. Arthur J. Markley, Denver, on “Basic Factors of the
Syphilis Control Program.” Dr. Paul S. Wolfe addressed the
society recently on craniocerebral injuries.

CONNECTICUT

Changes in Health Officers. — The Connecticut Health
Bulletin announces the following changes in health officers ;
Dr. Homer C. Ashley, New Hartford, of Barkhamsted, filling
the vacancy caused by the resignation of Marshall Case; Dr.
Norman H. Gardner, East Hampton, succeeding Dr. John D.
Milburn, resigned; Dr. Howard S. Allen of Woodbury, suc-
ceeding Dr. Frank Reichenbach, and Dr. William L. Higgins,

South Coventry, of Columbia. Dr. Daniel E. Shea, formerly

director of the bureau of venereal diseases of the Hartford
department of health on a part time basis, has been appointed
full time director.

Society News.— The Yale Medical Society was addressed
in New Haven October 11 by Walter R. Miles, Ph.D., on
“The Polarity Potential of the Human Eye” ; Dr. Robert M.
Thomas and Frederick Dessau, “Experimental Tuberculosis in
Mice”; Bert G. Anderson, D.D.S., “Developmental Enamel
Defects; Clinical Descriptions and Classification,” and Robert

M. Lewis, “Use of a Synthetic Preparation Replacing Estrin.”

Dr. Milton C. Winternitz, New Haven, addressed the

Fairfield County Medical Association in Greenwich October
17 on “Infecting Agencies and Pathology.” At a joint meet-

ing of the Hartford Medical Society and the Hartford County
Medical Association October 16 Dr. Foster Kennedy, New
York, discussed “Emotional Unrest in a Restless World.”

ILLINOIS

New District Health Units. — The state department of
health announces the establishment of four new district health
units. There are now nineteen of these units offering full time
service to ninety-six of the 102 counties in the state. The
medical officers in charge of the new units are Drs. Abraham
J. Levy, Gilman; Cecil A. Z. Sharp, Macomb; Clair L. Johns,
Mount Sterling, and Jerome J. Sievers, Pana.

Symposium for Industrial Nurses. — The first annual
symposium for industrial nurses will be presented by the state
department of public health at the University of Illinois College
of Medicine, Chicago, October 26-28. Collaborating organiza-
tions are Chicago Industrial Nurses Association, Greater Chi-
cago Safety Council, Illinois Manufacturers Association,
American Industrial Hygiene Association, American Medical
Association and the University of Illinois College of Medicine.

Society News. — At a meeting of the Adams County Medi-
cal Society in Quincy September 11 Dr. Nathan S. Davis III,
Chicago, spoke on "The Care of the Aged.”- — -Dr. Carolyn

N. MacDonald, Chicago, addressed a public meeting in Charles-

ton September 28 on “The Importance of Prenatal Care” ; the
meeting was sponsored by the Coles-Cumberland County Medi-
cal Society and the Charleston Woman’s Club. At a meet-

ing of the Rock Island County Medical Society in Rock Island
September 26 Dr. Abraham F. Lash, Chicago, discussed “Pre-
vention and Treatment of Abortion.” Dr. Archibald L.

Hoyne, Chicago, discussed scarlet fever before the Kankakee

County Medical Society at Kankakee September 14. At a

meeting of the Bureau County Medical Society September 12
in Princeton Dr. Roger T. Vaughan, Chicago, discussed “Dif-
ferential^ Diagnosis _ and Treatment of Acute Abdominal
Lesions.”-; — Dr. William J. Morginson, Springfield, addressed
the Christian County Medical Society, September 6, on “Diag-
nosis and Treatment of Some Common Skin Diseases.”

1574

MEDICAL NEWS

Jour. A. M. A.
Oct. 21, 1939

Chicago

The Belfield Lecture. — Dr. Samuel R. Meaker, professor
of gynecology, Boston University School of Medicine, will
deliver the eleventh annual William T. Belfield Memorial Lec-
ture of the Chicago Urological Society at the Palmer House
October 26. His subject will be “Male Infertility from a
Gynecologic Viewpoint.”

Society News. — At a meeting of the Chicago Pathologic
Society October 9 the speakers were, among others, Dr. Samuel
A. Levinson, who delivered the presidential address on “His-
tory and Progress of the Scientific Work of the Cook County
Coroner's Office” and Dr. Edith L. Potter, “Disseminated Gan-

ghoneuroblastoma in a Stillborn Fetus.” Dr. Walter C.

Alvarez, Rochester, Minn., addressed the Chicago Society of
Allergy October 16 on “Gastrointestinal Allergy” and Dr.
Charles K. Maytum, Rochester, Minn., spoke on “Oxygen

Therapy and X-Ray Therapy in Asthma.” At a meeting of

the Chicago Pediatric Society October 17 Drs. Arthur F. Abt
and Heyworth N. Sanford spoke on “Hemolytic Disease in
Infants” and “Nuclear Icterus” respectively.— —The Chicago
Gynecological Society was addressed October 20, among others,
by Drs. Eustace L. Benjamin and William C. Danforth, Evan-
ston, 111., on “Bipartite Uterus” and Robert M. Grier and Her-
bert O. Lussky, Evanston, 111., “Premature Infant Mortality.”

INDIANA

Memorial to Physician. — A memorial to the late Dr. St.
Clair Darden, South Bend, superintendent of Healtlnvin Hos-
pital from 1920 to 1932, was unveiled recently. The monument
is a large granite boulder, bearing a bronze plaque, given by
persons who attended Camp Darden. Dr. Darden died Nov. 15,
1932.

Marihuana Eradication. — A program of eradication of
marihuana and education of the public to the dangers of the
weed has been launched in Indiana by Dr. Verne K. Harvey,
secretary, state board of health, in compliance with a recent
law. Gene Ryan, Indianapolis, formerly a state police detec-
tive, has been appointed state narcotic inspector in charge of
marihuana eradication and enforcement.

MASSACHUSETTS

Society News. — Gregory Pincus, Sc.D., visiting professor
of experimental zoology, Clark University, Worcester, dis-
cussed “Sex Hormones in Cancer” before the Worcester Dis-
trict Medical Society in Worcester September 13. At a

meeting of the Pentucket Association of Physicians September
14 in Haverhill, Dr. William Dameshek, Boston, spoke on
“Lessons from the Blood Applicable to Problems of the Gen-
eral Practitioner.”

The New England Postgraduate Assembly. — The New
England Postgraduate Assembly, sponsored by the state medi-
cal societies of Massachusetts, New Hampshire, Rhode Island,
Maine and Vermont, will be held at the Sanders Theater,
Harvard University, Cambridge, October 31-November 1. Lec-
turers will include :

Dr. Jesse G. M. Bullowa, New York, Basis of Specific Therapy in the
Management of the Pneumonias.

Dr. Roscoe R. Graham, Toronto, Ont., Canada, Chronic Cholecystitis.

Dr. Albert C. Furstenberg, Ann Arbor, Mich., Acute Suppurations of
the Mouth and Pharynx.

Dr. Janies S. McLester, Birmingham, Ala., The Role of the Vitamins
and Other Essential Substances in Human Nutrition.

Mr. H. H. Clegg, federal bureau of investigation, U. S. Department of
Justice, Washington, D. C., The War on Crime.

Dr. Benjamin W. Carey, Detroit, Pyelitis in Children.

Dr. Eldridge L. Eliason, Philadelphia, Team Work in the Treatment

Diagnosis and

of Gallbladder Disease.

Dr. Joseph E. Moore, Baltimore, Latent Syphilis.

Dr. Harvey B. Matthews, Brooklyn, Pelvic Infection:

Management. . . . t .

Dr. Maurice C. Pincoffs, Baltimore, Clinical Varieties of Hypertension.
Dr! Charles C. Higgins, Cleveland, Prevention of Recurrent Renal

Sir Thomas Lewis, Rickmansworth, England, Venous Congestion and
Its Measurement.

MICHIGAN

State Medical Election.— Dr. Paul R. Urmston, Bay City,
was chosen president-elect of the Michigan State Medical
Society at its recent annual session and Dr. Burton R. Corbus,
Grand Rapids, was installed as president.

Goiter Prevention.— A statewide educational program to
nromote the use of iodized salt as a preventive of simple
2 r j s being sponsored this month by the state department
of health the state medical society and the Salt Producers
Association of Michigan. The work will be earned on prin-

cipally through the schools. Physicians, health officers and
nurses who wish copies of the folder “Michigan Children Need
Iodized Salt” for distribution may obtain them from the state
department of health, Lansing.

The Max ' Ballin Lectures. — The North End Clinic,'
Detroit, announces the Dr. Max Ballin Memorial Lectures to
be given at the Detroit Institute of Art. The following
speakers will discuss “Newer Applications - of Practical Sur-
gical Physiology” as applied to the listed .topics :

Dr. Isidore S. Ravdin, Philadelphia, Gallbladder and Biliary Tract,.
November 1 .

Dr. Charles F. Geschickter, Baltimore, The Breast, November 8.

Dr. Edward. William Alton Ochsner, New Orleans, Preoperative and
Postoperative Care, November 15.

New Virus Research Center. — The National Foundation
for Infantile Paralysis has awarded an annual grant of $12,9(10
to the laboratories of the' state department of health to estab-
lish in Lansing a virus research laboratory. A special grant
of $5,000 has been given by the U. S. Public Health Service •
to aid in providing necessary laboratory facilities where this •
research work may be carried on. Dr. Sidney D. Kramer,
formerly of Brooklyn, executive secretary, general advisory
committee. National Foundation for Infantile Paralysis, has
been appointed director of the state department’s new division
of virology, which will supervise the new laboratory. Dr.
Henry E. Cope, Detroit, has been appointed to the staff of
the bureau of laboratories to take charge of the division of
clinical pathology. He will be associated with Dr. Kramer
it is reported.

MISSOURI

Jackson County Health Forum.— Announcement is made-
of the 1939-1940 season of the Jackson County Health-Forum
sponsored by the auxiliaries of the accredited h° 5 Pj|. as i .°
Jackson County. The preliminary notice lists the fbllowmg
speakers :

Dr. Louis J. Karnosh, Cleveland, September 20, Medicine and Cn™j
Dr. Rock Sleyster, Wauwatosa, Wis„ President of the American iiie
Association, October 18, What Price Depression? >

Dr. Philip Lewin, Chicago, November 15, Your Feet D

Dr° Thurman B. Rice, Indianapolis, December 20, Mental and Emotional

Fnmkl'irfc. Bing, Ph.D., Secretary, Council on Foods, American Metof
Association, January 17, Vitamin Fellies. « v t0 Avoid

Dr. Henry F. Helmholz, Rochester, Minn., Fekn!, ary Z1 » n
and Care for the Diseases of Infancy and Childhood.

Dr? Elliott P. Joslin, Boston, March 20, Diabetes. j 7 , Fron-

Dr. Morris Fishbein, Chicago, Editor of The Jour >

NEBRASKA

. l Thp seventh

Annual Clinical Assembly ??'. c 0C ; e ty will

nual assembly of the Omaha Mid- West C m . p ax ( 0n .
held October 23-27 with headquarters at the note ^ k
lere will be general assemblies each morning, . The
Id each afternoon and scientific sessions ea
est speakers will be : , Anoro aties of

Dr. Clarence Rutherford O’Crowley, Newark, N. J.,

Kidney and Ureter; Polycystic Kidney D ‘“ as £. eatme nt of N'P hn " S

^ Deficiency; «* *«*

D Genmat e i r ve S T h rac e t;' SaVSSjllto pft/Tntsdnal Malig^f '

- William Wayne Babcock, . Treeing

Ocular Evidences of Intracranial D*

Clinical Methods as a Guide
Various Surgical Affections.

iSfc LS'aK^e^B^^hlatric »—
in General Practice. ’

3Eft

Selected Fracture Cases. Acute Nonpenetrating r

: william L. Estes Jr., Bethlehem, Pa., Acute wo i

Ser, Boston, Incomplete Intestinal
' ! A. Levine, Boston.. Rheumatic Hear. Disease,
Diagnosis of Cardiac Arrhythmias. d Reactions.

. William R. Houston, Austin, Texas, Learn pos ium

-iday morning October 27 there wi presen tcd by D rs :

perative and postoperative treatment present L , d

P h H. Major, Kansas Oty, Mo ; John Arb*-
ilousel, Rochester, Minn.; Walter G. ,’ s .

, ; John R. Paine, Minneapolis, and Dr. hstes

Volume 113
Number 17

MEDICAL NEWS

1575 '

NEW JERSEY

Society News. — Dr. Emil Novak, Baltimore, addressed the
Hudson Comity Medical Society, Jersey City, October 3, on

"Endocrine Aspects of Gynecology.” A symposium on

“Newer Aspects of Preoperative and Postoperative Care” was
presented before the Bergen County Medical Society, Hacken-
sack, October 10, by Drs. Harry A. D. O’Connor, who dis-
cussed thyroid cases; John A. Lawler, abdominal cases; John
H. Mulholland, intestinal obstruction, and Samuel Standard,
fluid balance. All are members of the faculty of New York

University College of Medicine.- -Dr. Jesse Lynn Mahaffey,

state health officer, Trenton, addressed the Atlantic County
Medical Society October 13 in Atlantic City on diagnosis and
treatment of syphilis.

NEW YORK

New Division of Cancer Control. — A new division of
cancer control has been created in the state department of
health with Dr. Louis C. Kress, Buffalo, as director. Organi-
zation of a statewide program of cancer control, authorized
by legislation this year, will begin immediately under the direc-
tion of Dr. Kress, The law creating the new division includes
an appropriation of §35,000 for the conduct of three major
activities: statistical, clinical and educational. The headquar-
ters of the division are to be in Albany in the New York
State Teachers’ Association building. The law makes cancer
a reportable disease upstate and provides for study of cancer
distribution and study of the disease according to age, type
and other characteristics. Tumor clinics are to be established
in recognized general hospitals and consultants will be pro-
vided to aid in the establishment of clinics and their proper
functioning. In addition a special effort will be made to study
all possible relations between occupations and cancer. Dr.
Kress since 1932 has been assistant director of the old division
of cancer control in the state department.

District Meetings. — The Seventh District Branch of the
Medical Society of the State of New York held its annual
meeting at Canandaigua September 28. Four sound motion
pictures portraying the work of Dr. Ephraim MacDowell, the
story of Jenner and vaccination, discovery of insulin by Banting
and Best, and the work of Semmelweiss on sanitation in child-
birth were shown. Addresses were made by Drs. Nathan B.
Van Etten, New York, President-Elect of the American Medi-
cal Association, on “The Quality of Medicine” ; Edward S.
Godfrey Jr., state health commissioner, Albany, "Our Health,”
and Terry M. Townsend, New York, president of the state
society, “Political Medicine.” Demonstrations were presented
as follows : surgical emergencies, Dr. John J. Moorhead, New
York; care of premature infants, Dr. Burtis B. Breese Jr.,
Rochester; peripheral vascular diseases, Dr. Herman E. Pearse
Jr., Rochester; physical therapy, Dr. Louis V. J. Lopez,
Canandaigua, and occupational therapy, Dr. Raymond F. Wafer,

Canandaigua. The annual meeting of the Eighth District

Branch of the Medical Society of the State of New York was
held in Batavia October 5. Speakers on the program were:
Dr. Grover C. Penberthy, Detroit, Trauma and Low Back Pain.

Dr. George F. Cahill New York, Hematuria: Its Clinical Significance.
Dr. Albert D. Kaiser, Rochester, The Problem of Rheumatic Infection
in Childhood.

Dr. Merrill C. Sosman, Boston, Roentgenology as an Aid in the Diag-
nosis of Heart Disease.

There was a discussion on “The Diagnosis and Therapy of
die Frequent Gastro-Intestinal Lesions Met With in General
Practice,” with Dr. Abraham H. Aaron, Buffalo, as chairman.
A discussion of the Western New York Indemnity Plan was
opened by Dr. George R. Critchlow, Buffalo.

New York City

William H. Welch Lectures. — Dr. Herbert M. Evans,
of the Institute of Experimental Biology, University of Cali-
fornia, Berkeley, will deliver the second of the William H.
Welch Lectures at the Mount Sinai Hospital October 24 on
Unsolved Problems in Anterior Pituitary Physiology.” The
first of this group was given October 20 on “New Light on
the Biological Role of the Antisterility Vitamin E.”

Personal. — Dr. Oswald S. Lowsley was made an Officier
de 1 Ordre National de Honneur et Merite by the president of
Haiti September 12 in recognition of his services in instruct-
'i’g the Haitian medical profession in urologic surgery. He
was also made an honorary professor in the medical school.
"—-It is reported that the “Manual of Diseases of the Eye”
27 Hr. Charles H. May is being translated into Urdu by the
Usmama University, Hyderabad, India, the tenth translation of
the book into a foreign language. The sixteenth American
edition has just been published.

Conference on Convalescent Care. — The committee on
public health relations of the New York Academy of Medicine
in cooperation with the Josiah Macy Jr. Foundation will hold
a two day conference on convalescent care, at the Academy
November 9-10. The purpose of the conference is “to redefine
the problem of convalescence in the light of recent progress
in medical science and to explore the need for further research
into the socio-economic and medical aspects of convalescent
care.” Admission to the conference sessions will be by invita-
tion. A meeting will be held Friday evening November 10,
at which the discussions will be summarized. Persons inter-
ested are invited to the evening meeting.

Regional Meeting of Railway Surgeons. — The New York
and New England Association of Railway Surgeons will hold
its forty-ninth annual meeting November 2-3 at the Hotel
Commodore. The first day will be given over to clinics at
the New York Post-Graduate Hospital under the direction of
Dr. Thomas H. Russell. Speakers for the second day include :

Dr. Thomas Parran, surgeon general, U. S. Public Health Service,
Washington, D. C., Railway Surgeons and the Public Health.

Dr. Fred W. Geib, Rochester, N. Y., Acute Craniocerebral Trauma.

Dr. William E. Mishler, Cleveland, Trauma in Transportation.

Dr. Tom Outland, Sayre, Pa., Treatment of Fractures of the Spine.

Dr. Albert B. Ferguson, New York, X-Ray Differentiation of Trau-
matic and Nontraumatic Lesions.

OKLAHOMA

New Health Officers. — Dr. John A. Morrow, Sallisaw, has
been appointed deputy health commissioner of the Oklahoma

State Health Department. Dr. Joe Dorrough, Haileyville,

has been appointed health superintendent of Pittsburg County
and Dr. Weldon K. Haynie, Durant, of Bryan County.

Annual Clinical Conference. — The Oklahoma City Clini-
cal Society will present its ninth annual fall clinical conference
October 30 to November 2. The lecturers will be :

Dr. Albert II. Aldridge, New York, obstetrics.

Dr. Edgar G. Ballenger, Atlanta, urology.

Dr. Lewellys E. Barker, Baltimore, internal medicine.

Dr. Lowell S. Coin, Los Angeles, roentgenology.

Dr. Harry S. Gradle, Chicago, ophthalmology.

Dr. John A. Kolmer, Philadelphia, pathology.

Dr. Frank II. Lahey, Boston, surgery.

Dr. Joe V. Meigs, Boston, gynecology, _

Dr. Albert Graeme Mitchell, Cincinnati, pediatrics.

Dr. Emil Novak, Baltimore, endocrinology-gynecology.

Dr. Hobart A. Reimann, Philadelphia, internal medicine.

Dr. Erwin R. Schmidt, Madison, Wis., surgery.

Dr. Herman C. Schumm, Milwaukee, orthopedic surgery.

Dr. Rock Sleyster, Wauwatosa, Wis., President, American Medical
Association, psychiatry.

Dr. Marion B. Sulzberger, New York, dermatology.

Dr. William A. Wagner, New Orleans, otolaryngology.

PENNSYLVANIA

New Medical Directors.— Dr. Harry L. Baker, Catasau-
qua, has been appointed medical director for Lehigh County,
succeeding Dr. Eugene H. Dickenshied, Allentown. ——Dr.
Alfred L. Hoffmaster, New Castle, has succeeded Dr. Paris
A. Shoaff, New Castle, as medical director of Lawrence

County.- Dr. James B. Heller, Pottsville, has been appointed

medical director of Schuylkill County.

Psychiatry Society Organized. — The Pennsylvania Psy-
chiatric Society was organized at a meeting in Pittsburgh
October 5. Dr. William C. Sandy, director of the state bureau
of mental health, Harrisburg, was elected president and Dr.
Henry I. Klopp, Allentown, president-elect. Dr. Leroy M. A.
Maeder, Chancellor Hall, 206 South Thirteenth Street, Phila-
delphia, is secretary. In a statement at the organization meet-
ing Dr. Sandy observed that the new society should exercise
a statewide general leadership in psychiatry, being a coordi-
nating body to which controversial and other questions of psy-
chiatric interest may be referred for an authoritative opinion,
should encourage general medical ■ interest by participation in
society meetings and should assist in developing and support-
ing proper psychiatric standards.

Philadelphia

Surgical Positions Filled at Jefferson.— Dr. Thomas A.
Shallow, professor of surgery at Jefferson Medical College,
has been appointed to the Samuel D. Gross chair of surgery
at Jefferson, a position vacant since the death in 1933 of
Dr. John Chalmers DaCosta. Newspapers also announce the
appointment of Dr. George P. Muller, also professor of sur-
gery, to the Grace Revere Osier chair of surgery. The Gross
professorship was established in 1910 by Mrs. Maria Gross
Horwitz, Baltimore, in honor of her father, professor of sur-

1576

MEDICAL NEWS

gery at Jefferson from 1856 to 1882. Dr. DaCosta held the
chair from 1910 to his death in 1933. Dr. Shallow graduated
at Jefferson in 1911 and Dr. Muller at the University of
Pennsylvania School of Medicine in 1899.

Society News.— Dr. Alfred Blalock, Nashville, Tenn., gave
the forty-fifth Mary Scott Newbold lecture of the College of

Physicians of Philadelphia October 4 on “Shock.” Drs.

Albert E. Botlie and Benjamin Lipshutz addressed the Phila-
delphia Academy of Surgery October 9 on "Renal Hyperten-
sion” and “Regional Enteritis” respectively. Drs. Albert B.

Ferguson, New York, and George E. Pfahler addressed the
Philadelphia Roentgen Ray Society October 5 on “Character-
istics of Bone Tumors” and “Treatment of Bone Tumors”

respectively. Speakers before the Obstetrical Society of

Philadelphia October 5 were Drs. Walter Meredith Heyl on
‘Experiences with the Placental Blood Bank” and Edward F.
McLaughlin, “Intermenstrual Bleeding, A Surgical Condition.”

Pittsburgh

Hospital News. - — Mercy Hospital celebrated its annual
“Mercy Day” September 28. Dr. John H. Musser, New
Orleans, spoke on coronary occlusion.

Society News. — The Pittsburgh Otological Society held a
joint meeting with the Cleveland Otolaryngological Club Sep-
tember 27, with Dr. Charles T. Porter, Boston, as the guest
speaker on “Orbital Cellulitis.”

UTAH

Special Assessment for Insurance Unit. — At a meeting
of the house of delegates of the Utah State Medical Associa-
tion September 4 the articles of incorporation of the Utah
Physicians Service Company were approved and an assessment
of §15 was levied on each member of the society to provide
for preliminary expenses. The work was carried out by the
Medical Service Bureau and the medical economics committee
of the society under authority given by the house of delegates
at a special session Dec. 10, 1938. According to the Rocky
Mountain Medical Journal, the action was taken to enable the
profession to meet the demands for hospitalization on a pre-
paid basis and if possible at least partial medical reimbursement.

WISCONSIN

State Medical Election. — Dr. Ralph P. Sproule, Mil-
waukee, was chosen president-elect of the State Medical Society
of Wisconsin at the annual meeting in Milwaukee September
13-15 and Dr. Ray G. Arveson, Frederic, was installed as
president. The next annual meeting will be held in Milwaukee
September 18-19, 1940.

GENERAL

White House Conference on Child Health. — A recom-
mendation that President Roosevelt be asked to call the White
House Conference on Children into session January 18-20 was
adopted at a special meeting of the planning committee of the
conference in Washington October 6. The final session was
originally scheduled for next spring.

Examination in Surgery. — The American Board of Sur-
gery will hold an examination in Part II November 15 in
Atlanta, Ga. The candidates will include only those living in
the South. Additional information may be obtained from Dr.
John Stewart Rodman, 225 South Fifteenth Street, Philadelphia.

Session on Medical Hydrology Postponed.— On account
of the war in Europe the International Society of Medical
Hydrology has postponed indefinitely its annual meeting which
was scheduled to be held in Italy during October. Since the
membership of the society is distributed largely through the
countries now at war, it has been necessary to reduce the activ-
ities of the International Society of Medical Hydrology to the
minimum. In keeping with this policy, the Archives of Medical
Hydrology for October will not be issued at present. Corre-
spondence addressed to the society at its regular address will
receive attention, 22 Bedford, London, \\ C.I.

Positions for Graduate Training in Obstetrics and
Gynecology.— The American Board of Obstetrics and Gyne-
cology receives from time to time information regarding avail-
able internships and assistant residencies. A number of such
positions are available each year to men who wish to place
their names on file with the board. In all instances a pre-
liminary internship, preferably of the general, rotating type is
necessary, and special internships or assistant residences should
be ?ou-ht at least one year in advance. It is suggested that
■hospitals having positions open and men .seeking such positions

Jobs. A. M, A.
0ct.-2I, 19]}

for training communicate with the secretary. Applicants should
subnut names, addresses and brief biographic data. Address
the American Board of Obstetrics and Gynecology, 1015 High-
land Building, Pittsburgh (6). °

Warnings Against Swindlers.— Harvard Medical School
Boston, has received reports that a magazine salesman has
been soliciting subscriptions alleging that he is a student at
Harvard and is attempting to earn money for further medical
study. The medical school reports that this man, who call;
himself Chester Wainwright, is not known and has never been

a student there. Reports have recently come from Missouri

of a man who has swindled ophthalmologists in various towns
by ordering glasses and making a check for a larger amount
than the price. The physician makes change and the man
never returns. The swindler has used the name W. C. Curran
and appears to be a farmer. The check is usually for $30.
The man is about 5 feet 10 inches tall, weighs about 155 pounds,
has light sandy hair and blue eyes and is smooth shaven with
a ruddy complexion.

Meeting of Association of Medical Colleges. — The
fiftieth annual meeting of the Association of American Medi-
cal Colleges will be held at the Netherland Plaza Hotel, Cin-
cinnati, October 23-25, under the presidency of Dr. Willard
C. Rappleye, New York. The speakers will include:

Dr. Walter Bauer, Boston, The Tutorial System in the Harvard Medical
School.

William II. Welker, Ph.D., Chicago, Graduate Medical Education.

Dr. Ararion A. Blankenhorn, Cincinnati, Graduate Training in Internal
Medicine in a Municipal Hospital. <

Dr. Albert Graeme Mitchell, Cincinnati, Graduate Training in Pedi-
atrics at the University of Cincinnati. .

Dr. Mont R. Reid, Cincinnati, Training of Surgeons: Method m Use
at the Cincinnati General Hospital.

Orren W. Hyman, Ph.D., Memphis, Tenn., Further Attempts to Reane
the Methods of Selecting Medical Students.

Dr. Robin C. Buerki, Chicago, Internships and Residencies.

A symposium on student health service will be presented b)
Drs. John Sundwall, Ann Arbor, Mich., Nathan T. Milnken.
Hanover, N. H., Edward S. Ryerson, Toronto, and Harold
S. Diehl, Minneapolis.

Fund to Aid Infantile Paralysis Victims.— A gib w "
§50,000 to aid handicapped children who are sufferers from
infantile paralysis in twenty-five cities of the country has been
announced by the Will Rogers Memorial Commission, are° r
ing to the New York Times October 6. The funds were co -
lected last spring from theater-goers in an appeal made m
principal theaters of the country. , The gift is being na
available through the local chapters of the National rounffi-
tion for Infantile Paralysis for emergency needs and for reco
ery treatment for handicapped children in the chapter ar •
Of the shares distributed October 6 New York receive :
largest, amounting to §14,595. Other cities in which disB -
ment took place are Los Angeles, San Francisco, tin '
Springfield, Boston, Kansas City, Hoboken, Cleveland,
homa City, Tulsa, Houston, Dallas, Milwaukee, and ror
Cities to receive their allotments later are Chicago. A c '',. '
New Orleans, St. Louis. Cincinnati, Detroit, Phua c P-
Pittsburgh, Seattle and Washington. The commission
supports the Will Rogers Memorial Hospital. Saranac ;
N. Y., and an emergency ward in the French Hospua ,
York, for the use of theatrical people. . .

Society for Prevention of Blindness. — The
Society for the Prevention of Blindness will hold is
meeting at the Hotel Astor, New York, October 2o- >
the presidency of William Fellowes Morgan. Am

speakers will he :

Dr. Joseph Minton, London, England, What Treatment o .

trial Eye Injuries Has Taught Us. . n C. F;

Verne A. Zimmer, U. S. Department of Labor, V aslungtcm. g 0 ;
Interest of the Federal Government in Conserving
Industrial Workers. Affecting

Dr. Leonard Greenburg, New York, Poisonous Sub --ain't F"

T- • ■ f.- T J.. \\Tr.rlr*rc find TfoW tO GUarU fib

Growing Hazard- _ . r f u._ r v e.

Dr. Willis S. Knighton, New York Development of the *? EycMu ;c.<

Dr. Otis J. Douphinett, Portland, Me., Early Super*

Dr C °Ph7lip M. Stimson, New York, What the Pediatrician » *»

Dn Jam« v'/ Cassady, South Bend tot. Prevention of J

grams Developed by State Medical Soc.rtj«- s rising
Dr. Vonnie M. Hicks, Raleigh. N. C- W . ,.-

mologists Are Doing in the Prevention for Prevents c -

Dr. Carl E. Rice, Washington, D. C-. Possibility

Blindness. _ t . T • . Distribution of

r. Harry S. Cradle, Chicago, Incidence and JJtsir

in the United States. nr

)r. James G- Townsend, Washington, V. c-,

Treatment of

Volume 113
Number 17

FOREIGN LETTERS

15 77

Foreign Letters

LONDON

(From Our Regular Cot respondent)

Sept. 27, 1939.

Medical Arrangements in Time of War
In a letter to the Times, Lord Dawson, late president of the
Royal College of Physicians, discusses the problem of making
the best use of the medical profession during a war which
presents novel features. The task of registering physicians for
varied duties has been performed by the British Medical Asso-
ciation during the past twelve months with conspicuous success.
The Ministry of Health took the hospitals under its direction
and mobilized physicians to staff them. It had the difficult task
of urgent preparation for massed air attacks, involving rapid
evacuation of casualties from the center to the periphery, side
by side with care for the hospital needs of the civil population.
For a time the latter faded and the big voluntary hospitals
were denuded. But now organization is taking the place of
improvisation. The Ministry of Health has taken steps to enable
consulting physicians and surgeons to transfer from whole time
to part time services in order that hospital and private patients
may be served. It has to be remembered that, after the chil-
dren, with those in charge of them, and the aged and infirm
had been evacuated, the great majority of the citizens had to
live and work and therefore required their hospitals. Services
have been resumed with a proportion of the staffs.

Lord Dawson suggests the following modifications : 1. A por-
tion of each hospital must always be available as a casualty
clearing station. 2. The average stay in the hospital should
be shorter. 3. Serious cases should also be provided for in the
proximal outside hospital of the sector. (The dividing of London
into sectors with' the great hospitals at the center and affiliated
hospitals in the country, into which the patients were evacuated
for safety from air raids, has been described in a previous
letter.) On the other hand, patients requiring special treatment,
such as highvoltage roentgen therapy, must be gathered wher-
ever such treatment is located. It has been agreed in principle
that there is to be a united hospital service for the whole
country. The army will provide directly for its sick and
wounded in the theater of war, but in England they could be
treated in the same hospitals as civilians, except slight and con-
valescent cases, which can be aggregated in convalescent hos-
pitals subject to military discipline. This system would result
in better service and save cost.

The supply of physicians is limited and has called for careful
allotment. In particular the skill of specialists should not be
wasted by needless duplication. Head and chest injuries are
examples. Centers for both are being organized where not only
they can be treated to the best advantage but where men of
selected ability are being constantly trained to fill posts at home
or over sea. If arrangements are left to military or civilian
authorities, confusion will result, especially if a key man is put
to wrong use. A small “intelligence” committee consisting of
representatives of the army and its civilian medical services
could act as a clearing house. Success in war depends more
and more on knowledge and its application not only to medicine
but to every other aspect of the struggle.

The Fate of Swallowed Foreign Bodies
Although many cases of swallowed foreign bodies have been
reported, little has been written on the question whether they
should be removed. At the Section of Surgery' of the Royal
Society of Medicine Mr. A. M. H. Siddons endeavored to
answer this question by means of the records of three London
hospitals — St. George’s, the Royal Waterloo and the Belgrave,
which have a high proportion of children's beds. It is children

and the insane who most frequently swallow foreign bodies.
He collected records of 126 patients admitted to these hospitals.
It should be borne in mind that these patients were selected by
surgeons as sufficiently dangerous to require treatment as
inpatients. It is not possible, therefore, to draw conclusions
from them as to the percentage of all swallowed foreign bodies
which require removal. Indeed, this cannot be ascertained, as
many cases never reach the physician. In 107 of the 126 cases
(85 per cent) the foreign bodies were passed naturally, and in
only four did perforation or obstruction occur. The remaining
thirteen foreign bodies were removed, as the surgeon considered
it dangerous to leave them or because it did not appear to him
that they would be passed naturally. These figures may be
compared with American ones reported by Henderson and
Gaston in the Archives of Surgery in January 1938. They
found nine instances of perforation in about 800 cases, most
of which were not admitted to the hospital. They emphasize
that many of the patients never seek medical aid and that there-
fore this figure of about 1 per cent for perforation is too high.

Siddons divided his cases into three groups: blunt objects
(sixty), long objects (eighteen), sharp objects excluding open
safety pins (forty) and open safety pins (eight). It is interest-
ing how long blunt objects stop in one place in the alimentary
canal, only to progress again for no apparent reason. It might
be expected that objects which failed to pass the pylorus for
a whole day would never do so, but in some cases they were
watched in the stomach for weeks and then went on their way.
The average time for the object to pass in the entire series was
six days and in each group about the same. What is more
important, they did not seem to do any harm while stationary.
There are many records of insane persons and professional
swallowers who have retained objects in their stomachs for
long periods without ill effects. In only one case of the series
was a body arrested at the ileocecal region, causing intestinal
obstruction. In the sixty cases of blunt objects there were
eight operations for removal. Excepting the case mentioned
there were no symptoms of harm. The operations were per-
formed because the surgeons thought that the object would not
pass, and had they been left probably most of them would have
been passed naturally. Siddons thinks that there are very few
objects able to pass down the esophagus which will not pass
through, provided they are not sharp or unduly long. After
the pylorus, the ileocecal region- seems to be the only other likely
site of arrest.

Long blunt objects include screws, nails and Kirby grips.
They usually pass the pylorus but find the curves of the duo-
denum difficult. After this they usually find no obstruction. In
the eighteen cases only one operation was performed: removal
of a nail from the cecum on the second day. Siddons believes
that it would have been passed naturally if it had been left.
All the other objects were passed.

Sharp foreign bodies include needles, pins and open safety pins.
Excluding the last there were forty cases, of which the object
was passed naturally in thirty-seven. Not one perforated. In
three cases the object was removed from the stomach because
the surgeon did not think it safe to leave. The open safety pin
presents a special problem. In four of the eight cases it was
removed by operation, with one death. Of the other four, one
perforated the stomach and was removed safely; the other three
were passed naturally. Eight cases are not enough to form a
basis for evaluating the risks, but there is no doubt that they
are greater than with any other object. Siddons thinks, how-
ever, that they should be given a chance to pass, like other
objects. Nearly all blunt objects pass naturally and should be
given from four to six weeks. He does not agree with the
recommendation to give bulky foods, as they may hasten obstruc-
tion and even in the case of sharp objects do not serve any
useful purpose. He advises an ordinary diet and no purgatives.

1578

FOREIGN LETTERS

Alterations in Medical Journals

As in the case of the lay press, medical journals have been
obliged by the war to reduce the number of pages. The British
Medical Journal has ceased to print its Key to Medical Litera-
ture. To economize, the Supplement will no longer appear as
a separate inset. In it will be published information from the
Central Emergency Committee of the British Medical Associa-
tion, which was created to supply the medical needs of the
fighting forces and civilians injured in air raids. It is probable
that increasing economy of space will be necessary, so con-
tributors are asked to be sparing of their words.

Jour. A. M. A.
Oct. 21 , 1939

several weeks are organized which permit the students to get
ready for examinations before examiners who, likely enough,
will consider emergency conditions. Precautions have been
taken for laboratories. Fragile instruments, museum collec-
tions, ornamental objects and rare books have been stored in
protected cellars. The Faculty of Medicine of Paris continues,
but its activities have been largely curtailed. War destroys
not solely human lives and human works. .It undoes spiritual
and moral values often more difficult of replacement than a
railroad bridge or a model factory.

Defensive Measures Against Air Bombardments

PARIS

( From Our Regular Correspondent)

Sept. 13, 3939.

French Medical Mobilization

Long before the war, France had prepared its medical mobili-
zation. Without describing the medical organization in the
army, I should like to show how the major health problems
have been attacked and what has become, in the present war,
of medicine and the medical profession.

A large number of France’s 28,000 physicians have been
drafted for the army. In fact, a law passed last year permits
the government to commandeer the services of every French-
man 18 years and over, including female physicians. The char-
acter of modern warfare is different from that of previous
centuries. Until the French Revolution, war was a vocation
and mercenary soldiers fought on limited territories. Their
wounds were treated by “surgeons,” one of whom was
Ambroise Pare, the father of French surgery. Many others
have left their mark in the history of medicine. Today the
entire nation, except women and children, is engaged in war.

Few physicians have been exempt from military duty: 72
per cent serve in the national defense; 67 per cent of these
wear uniforms; S per cent are civilians who function partly
under army orders or those of the civil government. Accord-
ingly, there remain about 6,000, many of whom are elderly or
infirm. In consequence, many small towns and country regions
have no medical service. Formerly, armies carried with them
not only their "surgeons" but also their ambulances and to a
certain degree their hospitals. Nowadays, except for establish-
ments at the front which are, above all, centers of first aid
and subject to quick changes, military health service coincides
with civil health service. It includes large medical centers the
equipment of which has been planned in times of peace and
which utilize the hospital resources of peace times. Besides
the wounded, the sick such as tuberculous persons have to be
taken care of. From the medical point of view, both the tuber-
culous soldier and the tuberculous civilian are the same. Shifts
of specialists have therefore been provided who look after
civilian and military tuberculous patients in the existing sana-
toriums, look after their recovery and follow them up after
they leave the army.

What becomes, under these circumstances, of medical instruc-
tion? Students continue to enroll to the extent to which
mobilization permits young men to undertake university studies,
but the means of instruction have been greatly reduced. In
large cities hospital training has reached a stage of anemia,
partly because of the reduced population evacuated in large
numbers and because of the abandonment of many class
rooms as too exposed to the dangers of bombardment. The
Faculty of Medicine of Paris had to move to Nantes to remain
until further orders. Fifty-two per cent of its professional
staff, 75 per cent of the agreges, or assistants, and 90 per cent
of the heads of laboratories or prosectors have enlisted. The
students called to the colors there receive credits correspond-
ing to their medical standing. Not only are arrangements
made for examinations and thesis preparation but, in certain
towns farther back from the front, courses of studj lasting

In spite of all the measures provided to prevent hostile
aircraft from releasing bombs over civil populations, some,
estimated at 30 per cent, may reach their mark. Many, but
not all, of these bombs will fall outside houses. A committee
of passive defense, therefore, has been set up by law presided
over by Marshal Petain. Professor Tanon, of the department
of health of the Faculty of Medicine, has been placed in charge
in Paris, where every one has been removed from the city
whose presence can be dispensed with, reducing the population
from three million to somewhat more than one million. These
will be protected, in case of bombardment, in subterranean
shelters capable of supporting the shock at least of a bomb of
50 Kg. or a crumbling of 2,000 Kg. per square meter of sur-
face. Against gas, masks have been distributed sufficient to
protect against all known gases but offering no aid against
carbon monoxide or hydrocyanic acid and perhaps equally
insufficient against new gases which modern war chemistry
may evolve. Most of the shelters are gas tight. However,
medical aid stations have been prepared against possible gas
infiltrations, “cave ins” and resulting panics. These medical
aid stations cover extensive subterranean spaces, generally store-
rooms or former quarries specially made over for their new
use. They are supplied with small outside stations designed
for those who have been infected with caustic gas. Aid sta-
tions are gas tight. Since gas might penetrate during the
reception of patients, ventilation has been provided for from
the outside air taken at a great altitude and above the gas
level. This ventilation causes a higher pressure that protects
the station against vitiated air. The output of the apparatus,
eacii of which furnishes 600 cubic meters of air per hour, is
calculated to carry 2 cubic meters of air hourly per cubic mete
of the volume of space. The higher pressure, under ties

The
oi a

conditions, reaches between 2 and 6 mm. of mercury,
ventilators are set in motion by electricity, but, in case ^
break in the current, apparatus with pedals resembling t o

of bicycles can assure functioning of the pumps.

The air taken

from the outside is analyzed every quarter of the hour^ f
means of simple and rapidly functioning apparatus. ^

found vitiated — a thing of scant probability because

height at which the air is taken— every one puts on his m-
The patients, brought in by special outside crews, are ass ^
to one of three fundamental divisions: the woun c '
asphyxiated and the gassed. The wounded receive
sary surgical attention in a simple operating room.

asphyxiated are treated by the classic methods, | n ' ia | a . ( ; on .
oxygen or carboxyl, camphorated oil or artificia r ^

Those overcome by mustard gas are copiously a ^

washed with chlorinated lime (10 per cent), un r
douched with soap. The aids who have charge o After
garments that protect them completely against yP«n •
receiving first aid, the patients are assigne to sp ^pltal
in Paris hospitals. Several kilometers from Pan ^
with 5,000 beds receives the gassed whose tr = atm “ f yic w
to be prolonged. It is a model hospital from the P
of perfect equipment for these treatments. • c p rcn cb
thus organized are repeated on a smaller sea e ,n
cities. They seem to be adapted to all emergencies.

of

Volume 113
Number 17

FOREIGN LETTERS

1579

Primal Sutures of Wounds

Vassitch of Belgrade presented before the Academy of Sur-
geons an analysis of more than 19,000 traumas observed during
1929-1935, of which about 20 per cent were treated by primal
suture. This operation does not entail grave accidents; how-
ever, it is necessary to take account of the object that caused
the wound and whether the wound is clean or not. Vassitch
adopts the classification proposed by Braine for flesh wounds.
In wounds associated with fractures or complicated by osseous,
articular or vascular lesions, bacterial virulence must be reck-
oned with. The essential prerequisite of the treatment of the
wound is always its cleansing and the excision of contused
tissue.

BERLIN

(From Our Regular Correspondent)

Aug. 30, 1939.

Congress of Surgeons

The opening address of this year’s meeting of the Deutsche
Gesellschaft fur Chirurgie was by the chairman, Professor
Nordmann, who is director of a hospital in Berlin. He cau-
tioned against the exaggerated tendency toward new divisions
of medicine. The efforts of neurologic surgeons to organize
a distinct group was thwarted only by ministerial interference
and by uniting them 'into a subdivision of the society.

The first paper was read by K. H. Bauer, of Breslau, on
fractures of the base of the skull. Animals scarcely ever are
subject to them and almost never through a fall. Such frac-
tures are a “tribute to the progress of mechanics and traffic.”
Of those injured, 59 per cent were hurt in traffic accidents;
31 per cent of these died before medical attention could be
given them; 66 % per cent of all skull fractures affect the
base. The mortality in 4,200 observed cases was 39.2 per
cent. The important diagnostic factor was the evidence of
fracture revealed by the x-rays, and this was not so simple
a matter. Three roentgenograms are required, especially the
axial photograph with drooping head. Pressure on the brain
can be relieved by intravenous injection of hypertonic salt and
sugar solutions. Lumbar punctures in nearly all cases afford
subjective and objective relief. Dandy and others, however,
reject lumbar puncture in fractures of the base, on the ground
that the brain may suffer further injury through change of posi-
tion and because of the danger of secondary hemorrhages. As
a last recourse trepanation is employed. Cushing ascribes to
its early use the reduction of from 50 to 15.5 per cent in the
mortality rate of fractures of the base of the skull. In about
10 per cent of the cases trepanation is indicated; extradural
bleeding is a strong indication. In cases of subdural hematoma
the mortality in surgical intervention is considerably higher.
Of 512 subdural hematomas, fifty-two could not be diagnosed.
According to recent statistics (2.5 per cent in 430 cases) danger
of meningitis is low. Prognosis of employability after frac-
tures of the base of the skull is discouraging. Frequently,
according to the speaker, paralyses of the nerves and injuries
of the organs of sense can be proved; psychic disturbances
are rare. Scar tissue formations of the brain may appear as
a retarded injury and may induce epileptic hemiplegias. In
the discussion of the paper Tonnis, a Berlin surgical neurol-
ogist, pointed out the results achieved in treating late epilepsy
due to accidents. Success depends on selecting cases suitable
for surgery. Only such epileptic patients should be operated
on who have a dural bone callus; eleven of the twelve patients
operated on did not suffer subsequent attacks. Of thirteen
patients with skull fracture, eleven were permanently cured of
^ surgery. In his paper on osteomyelitis Laewen, of
Konigsberg, pointed out that of late there has been a marked
tendency to conservative therapy. Blood transfusion, suitable
nutrition and rest are the most important conservative curative
measures. Maggot therapy is also used.

Wilbolz, of Berne, read a paper on urogenital tuberculosis.
He called attention to the fact that this was an open tuber-
culosis and dangerous for those in attendance on the patient.
Hematogenic infection was here as significant as canalicular.
Tubercle bacilli confined to the urogenital tract always seek,
to return. The seat of urogenital tuberculosis must be sought
in the kidneys. The speaker favored early recourse to nephrec-
tomy, which yielded permanent recovery in 80 per cent of the
cases. Delayed surgery reduced this favorable proportion to
50 per cent. Consequently, early diagnosis of urogenital tuber-
culosis was of the greatest importance. Examination of the
urine for tubercle bacilli often furnishes the answer, for tuber-
cle bacilli are never excreted from a nontuberculous kidney.
Tuberculous bacilluria is always the forerunner of tuberculosis
of the kidney that is characterized by caseous cavities. If
pyuria appears, nephrectomy must be performed. In benign
cases tuberculosis will assume the “fibrous form,” that is, con-
traction without caseation localized under the renal cortex;
fibrous cortices without pyuria may cicatrize. Delay under
medical observation was therefore advisable. If pyuria and
slight functional disturbances accompany bacilluria, the caseous
form of tuberculosis of the kidney is to be assumed and nephrec-
tomy is in order. Bacilluria is almost always unilateral. This
justifies the assumption that tuberculosis of the kidney is
almost always unilateral.

Fromme, of Dresden, gave an exhaustive account of gastric
ulcers, which have become more numerous and their seat nowa-
days is in the duodenum rather than in the stomach. Resec-
tion of ulcers of this type ought not to be insisted on as
imperative, because of the danger of severing the clioledochus.
In 5 per cent of the cases, duodenal fistulas set in with a
mortality of 50 per cent. The roentgenogram does not always
clearly indicate whether an ulcer is operable. In nonoperable
ulcers, resection for the purposes of elimination (according to
Finsterer), also gastro-enterostomy, could be recommended.
The disadvantages of this operation were that the ulcer
remained, inviting the danger of hemorrhages and perforation.
Likewise malignant degeneration constituted a possibility,
though not a grave one. In the discussion that followed this
paper, the greatest emphasis was put as usual on the results
achieved by the different methods, but without agreement.
Haberer, of Cologne, gave a report of his 3,373 resections of
the stomach, of which 435 constituted corrective surgery. In
16 per cent of the cases, 211 extirpations of peptic ulcers of
the jejunum resulted fatally. Peptic ulcers of the jejunum
cannot be avoided in cases of gastro-enterostomy. He achieved
the best results with the second procedure of Billroth, with
anastomosis according to Roux.

Professor Lehmann, of Rostock, treated the problem of the
relations of surgical clinics and x-ray institutes. Roentgenol-
ogy is not a separate specialty but a medical ally. The type
of men who are merely roentgenologists will disappear. X-ray
institutes conducted independently easily lose contact with the
clinics and yet the work done in the x-ray laboratory is part
and parcel of the work done in the clinics. The directors of
x-ray divisions should be members of the clinical staffs. He
admitted the great difficulties of an organizational nature. For
special examinations such as those of pyelography, ventricu-
lography and myelography, the ward system of hospitals with
central x-ray institutes was not practical. Roentgenologists
should not by themselves determine indications. Lehmann thinks
that the x-ray department of a hospital should be in charge
of a roentgenologist who is subject to the director of the
surgical division. This position was challenged by the chair-
man of the society of German roentgenologists, who stated
that the greatest importance was attached to close cooperation
but that the problems discussed by Lehmann were still too
unclarificd to permit the roentgenologists to make a final deci-
sion. The comments of Professor Gotze, surgeon in Erlangen,

1580

MARRIAGES

on the degree to which specialization was being carried on
deserve mention. In a general hospital, young physicians no
longer had an opportunity to become acquainted with a large
number of diseases requiring surgery, because these were taken
care of by specialists. However, he continued to say, it was
necessary that general surgery and the special fields of medi-
cine supplement one another. Surgical clinics of universities
should control all special fields of medical surgery, especially
those that deal with accidents, fractures, orthopedics, urology
and roentgenology, if for no other reason, at least for the
training of students and assistants.

Professor Konig, of Wurzburg, read an exhaustive paper on
surgery and cancer control in which he took issue with those

Jobs. A. M. A,
Oct. 21, 1939

Robert Beall Hightower, Washington, D. C. to Mbs
Rossell MacDonald of Norton, Va., July 20.

Frederick R Dettloff, Cloverdale, Ind., to Miss Kath™
Atkinson of Bloomington, September 30.

Donald Lurton Arey, Danville, Va., to Miss Beverly Jeanne
Barclay at Hempstead, N. Y., August 2.

Fred G. Patterson, Chapel Hill, N. C., to Miss Julia Baylor
bhirley of Richmond, Va., September 5.

Lewis Earl Fraser, Edmonton, Ky.,' to Miss Alice Jean
Keith in Carthage, Miss., September 20.

Herman W. Farber, Weldon, N. C., to Miss Henrietta
Salsbury of Richmond, Va., August 30.

William Raymond Hawkins to Miss Hiawatha Louder,
both of South Fork, Pa., September 4.

who were too pessimistic of the situation. Cancer of the
stomach has the highest rate of cancer mortality with about
50 per cent. According to his computations, surgery performed
on stomach cancers reduces mortality to 10 per cent. From
50 to 60 per cent of stomach carcinomas and 80 per cent of
carcinomas of the rectum admit of surgical therapy. The
important thing was to treat the disease in its early stages.
The reason why results were reported covering only relatively
short periods was principally that statistics do not extend suf-
ficiently over larger periods of time. According to recent
statistics based on investigations and inquiries made by seven
well known hospitals, 424 of 1,260 former carcinomatous
patients were designated as cured and free from ailments after
from ten to twenty-five years. In considering these figures,
one ought also to take account of the fact that a considerable
number of those operated on for carcinoma had in the mean-
time died of other diseases. The number of those surgically
cured of cancer would therefore be greater. The figures fur-
nished by Professor Laewen, of Konigsberg, by way of illus-
tration are illuminating. Between 1935 and 1939, 18,864 female
patients were examined serially for carcinoma of the breasts.
Only 800 had new cancerous growths. In 3,767 gynecologic
examinations, only four new carcinomas of the collum, one of
the rectum and 106 suspected cases of the portio were discov-
ered. Guleke, of Jena, found only thirteen verified cancerous
formations in 200 similar examinations. A motion to organize
special tumor clinics in Germany did not meet with the approval
of the society. Other papers dealt with arthritis deformans,
with treatment to be employed in bone fractures and with
orthopedic problems.

Marriages

William Thomas Hendrix, Spartanburg, S. C., to Miss
Mary Emily Parker at Emory University, Ga., July 22.

Richard Philip Custer, Philadelphia, to Mrs. Claire Pay-
zant Lohrke of Dartmouth, N. S., Canada, recently.

Roger Sherman Downs, Saratoga Springs, N. Y., to Dr.
Elinor Whitney Fosdick of New York, recently.

James Robert Fitzgerald to Miss Myra Marcelle Sullivan,
both of Chicago, at Davenport, Iowa, August 7.

William C. Huffman, Clarksburg, W. Va., to Miss Hen-
rietta Claxon of Lawrenceburg, Ky., August 29.

Walter Watslo Anthony Vinks to Mrs. Almary Seifert
Lee, both of Lincoln, Calif., in Chicago, June 12.

' John Winston Adams Jr., _ Chandler, Okla., to Miss Mar-
gret Emily Harvey of Memphis, Tenn., July 17.

Clarence Alexander Kinney, Florence, S. C„ to Miss
Rosalie West Parks of Bennettsville, August- 26.

Bernard B. Neuchiller, Woodstock, 111., to Miss Doris
Purcell of Equality in Chicago, September 2.

William S. Muse, Lexington, Tenn., to Miss Loretta
Greaney, of Worcester, Mass., September 2.

Thomas A. Gonder Jr., Milton, Mass., to Dr. Sarah Hig-
ginson Bowditch of Oakland, Md., recently.

Robert George Heasty, Wichita, Kan., to Miss Harriet
Taliaferro Allen of Danville, Ky v July 22.

Stephen T. Manong, Chamberlain, S. D., to Miss Gertrude
Miriam Roe of Jackson, Mich., July 9.

John Cole Burwell Jr., Greensboro, N. C., to Miss Jean-
nette Dorst of Austin, Minn., July 22.

James Edwards Cameron, Alexandria City, Ala., to Miss
Edith Ellison at Hurtsboro, August 1.

William Ray Moore to Miss Elizabeth Anderson Mason,
both of Louisville, Ky., September 8.

Norman E. Basinger to Miss Rosemary Williams, both of
Elyria, Ohio, in Cleveland, June 26.

Robert Monroe McMillan, Candor, N. C., to Miss Dorothy
Burchfield of Danville, Pa., July 12.

John D. Fitzgerald, Roxboro, N. C., to Miss Betty Kathlyn
Offerman of Durham, September 5.

Robert F. Dearborn, Orangeville, 111., to Miss Barbara
Burritt of Rockford, September 2.

Edwin Hale Thornhill, Durham, N. C., to Miss Pah ,£
Marie Sills of Nashville, July 21.

Ruth Evans Brinicer, Keokuk, Iowa, to Mr. Dan R-
Hamady of Flint, Mich., July 29.

Randolph Patton Moore, Lisbon, Ohio, to Miss Caro
Barthelmez of Cleveland, July 22.

Theodore J. Bruegge, Kokomo, Ind., to Miss Catherine
Lynch in Indianapolis, August 5.

George Street McReynolds Jr. to Miss Sheddie Usieb
both of Philadelphia, August 29. ,

James Homer Leigh to Miss Kathryn Parks, boti o
Philadelphia, Miss., August 17. _ .

Joseph L. Hunsberger to Miss Elizabeth Williams,
of Norristown, Pa., August 26.

Robert E. S tone, Chapel Hill, N. C., to Miss Franro
Blakeney of Monroe, July 31. ...

Walter Lee Brandon to Miss Christina Ann Stewart,
of Poplar Bluff, Mo., July 7. . . .j,

Luke Dennis Garvin to Miss Helen Jane Chisbo m,
of Bradford, Pa., October 7.

Russell L. Finch, Lansing, Mich., to Miss A t M
Wysong of Holt, August 12. ... 0 j

William Louis McLeod to Miss Margaret Blan ,

Bures Creek, N. C., July 15. . , . 0 ;

John W. Bradbury to Miss Octavia Martinet ,
Galveston, Texas, August 5. . c j

Frank A. Inda, Omaha, to Miss Margaret M.

Little Falls, N. Y., recently. , ,. or

D. Forest Moore, Shelby, N. C-, to Miss L ean0

Morton of Terrell, July 26.

Henry Edward Hengen, Amherst, Ohio, to J- s
Null of St. Louis, July 24. William?,

Leroy W. Childs, Atlanta, Ga., to Miss Nano
Lake Kerr, Fla., August 5. . _ . r . 3 . ne Coan

Willard E. Fischer, Detroit, to Miss Barbar J
cf Gladwin, Mich., July 29. n , prt y ®

Timothy F. P. Lyons, Boston, to Miss Anna
Milton, Mass., recently. _ \r„rphy cf

Julius Foldes, Nanticoke, Pa., to Miss Mary
Oak Lane, August 19. . p raz kr

William J. Donald, Brewton, Ala., to Miss
of Mobile, August 4. . ho!( , 0 f Mc-

Arthur Feitell to Miss Freda Joyce Pnc p,

York, September 12. , , vw VcrV.

Harold Abramson to Miss Lucy Kahn, bot
August 10.

Volume 113
Number 17

DEATHS

1581

Deaths

Algernon Coolidge ® Boston ; Harvard Medical School,
Boston, 1886; clinical instructor of laryngology, 1893-1906, assis-
tant professor, 1906-1911, professor, 1911-1925, and since 1925
professor emeritus at his alma mater; professor of laryngology
emeritus at the graduate school ; member of the New England
Otological and Laryngological Society and the American Clini-
cal and Climatological Association ; past president of the Ameri-
can Laryngological Association; fellow of the American College
of Surgeons; for many years on the staff of the Massachusetts
General Hospital; author of “Diseases of the Nose and Throat”
published in 1915; aged 79; died, August 16, of heart disease
and arteriosclerosis.

Wilbur Ashley McPhaul ® Jacksonville, Fla. ; University
of Nashville (Tenn.) Medical Department, 1904; state health
officer; served as health officer of Robeson County, N. C. ; in
1919 was director of rural sanitation work with the Alabama
State Board of Health, becoming in the same year health
officer of Montgomery; in 1920 was appointed health officer
of Charlotte, N. C. ; in 1931 he resigned to become field direc-
tor of the U. S. Public Health Service; health officer of
Pensacola for many years ; at one time member of the state
legislature of North Carolina; past president of the Florida
Public Health Association ; aged 60 ; died, August 1, in a local
hospital.

Lawrence Taylor Price ® Richmond, Va. ; Medical Col-
lege of Virginia, Richmond, 1903 ; emeritus professor of clini-
cal urology at his alma mater ; president of the Virginia
Urological Society; member of the American Urological Asso-
ciation; urologist to the Johnston Willis Hospital; on the
staffs of the Memorial, St. Philip, Dooley and City Home
hospitals, Retreat for the Sick Hospital and Tucker Sanato-
rium; consultant urologist to the Pine Camp Hospital, Brook
Hill, Southside Community Hospital, Farmville, and the West-
brook Sanatorium; aged 58; was killed, August 15, when he
fell from a fifth story window.

Maurice Joseph Gelpi, New Orleans; Medical Depart-
ment of Tulane University of Louisiana, New Orleans, 1911 ;
fellow of the American College of Surgeons ; past president and
secretary of the Orleans Parish Medical Society; instructor
and assistant professor of gynecology at his alma mater, 1911-
1916; professor of surgery, Loyola Post Graduate Medical
School in 1921 ; editor in chief of the Nczv Orleans Medical
and Surgical Journal from July 1922 to June 1923; aged 56;
served in various capacities on the staffs of the Charity Hos-
pital and the Hotel Dieu, Sisters’ Hospital, where he died,
August 9, of cardiovascular disease and cerebral hemorrhage.

Frederick Stauffer, Monterey, Calif. ; Kentucky School of
Medicine, Louisville, 1893 ; member and past president of the
Utah State Medical Association; formerly member and presi-
dent of the Utah State Board of Health and Salt Lake County
Medical Society ; member of the American Academy of Ophthal-
mology and Otolaryngology; member and past president of the
Pacific Coast Oto-Ophthalmological Society ; fellow of the
American College of Surgeons; surgeon to the Dr. W. H.
Groves Latter-Day Saints Hospital, Salt Lake City, for many
years; aged 72; died, July 20.

Pio H. Laporte, Edmundston, N. B., Canada ; School of
Medicine and Surgery of Montreal, Faculty of Medicine of the
University of Laval at Montreal, 1901; minister of health and
labor for the New Brunswick government ; past president of the
New Brunswick Medical Society; New Brunswick representa-
tive on the Medical Council of Canada ; for many years mayor
of the town and chairman of the school board ; aged 59 ; died,
July 29, in a hospital at St. Basile, of injuries received in an
automobile accident.

Louis Mervin Maus ® Colonel, U. S. Army, retired,
Rockville, Md. ; University of Maryland School of Medicine,
Baltimore, 1874; entered the army as assistant surgeon in
1874 and rose through the various positions to that of colonel
in the medical corps in 1907 ; veteran of the Spanish-American
and World wars ; was awarded the Distinguished Service
Medal for service among the Indians ; retired May 8, 1915,
by operation of law; aged 88; died, August 3, of obstructive
jaundice.

Frederick Eugene Trotter ® Honolulu, Hawaii ; Univer-
sity of Virginia Department of Medicine, Charlottesville, 1895 ;
member of the House of Delegates of the American Medical
Association in 1924 and 1930; commissioner of the Hawaii
Board of Health and past president; past president of the State
and Provincial Health Authorities of North America; veteran

of the Spanish-American War; formerly surgeon in the U. S.
Public Health Service; aged 66; died, August 7, of heart
disease.

John Andrew Evert ® Glendive, Mont.; University of
Minnesota Medical School, Minneapolis, 1913; past president
of the Medical Association of Montana and past president and
secretary of the Eastern Montana Medical Association ; fellow
of the American College of Surgeons ; served during the World
War; chief surgeon of the Northern Pacific Hospital; aged 54;
died, August 17, of plasma cell myeloma.

James Homer Buckley ® Fort Smith, Ark. ; Tulane Uni-
versity of Louisiana School of Medicine, New Orleans, 1896;
member of the American Academy of Ophthalmology and Oto-
laryngology; past president of the Sebastian County Medical
Society; on the staffs of St. Edward’s Mercy and of the
Sparks Memorial Hospital; aged 64; died, July 31, of heart
disease.

William Lytle Ross ® Omaha; Rush Medical College,
Chicago, 1883; Bellevue Hospital Medical College, New York,
1887; member of the Radiological Society of North America;
professor of dental neurology at the Creighton Dental College,
1905-1922; aged 80; died, August 26, in the Nicholas Senn
Hospital of carcinoma of the head of- the pancreas.

Graham Wall Diggs, Wetumka, Okla. ; Vanderbilt Uni-
versity School of Medicine, Nashville, Tenn., 1905 ; member
of the Oklahoma State Medical Association; formerly secretary
of the Hughes County Medical Society; mayor of Wetumka;
served during the World War; aged 59; died, August 18, in
the Veterans Administration Facility, Muskogee.

Robert Swan Killough ® Amarillo, Texas; Eclectic Medi-
cal Institute, Cincinnati, 1896; fellow of the American College
of Surgeons ; past president of the Potter County Medical
Society; aged 72; on the staffs of the Northwest Texas Hos-
pital and St. Anthony’s Sanitarium, where he died, August 24,
of a fractured hip received in a fall.

Thomas Sampson jRoyster ® Henderson, N. C. ; Univer-
sity of Pennsylvania School of Medicine, Philadelphia, 1916;
fellow of the American College of Surgeons ; at one time
passed assistant surgeon lieutenant in the United States Navy;
on the staff of the Maria Parham Hospital ; aged 48 ; died,
August 1, of coronary thrombosis.

John Buis ® Pender, Neb.; University of Nebraska Col-
lege of Medicine, Omaha, 1907 ; past president of the Cedar-
Thurston-Wayne-Dixon-Dakota Counties Medical Society;
served during the World War; aged 60; died, August 7, in
the Immanuel Deaconess Institute, Omaha, of Hodgkin’s disease
and cerebral hemorrhage.

Robert Lee Kunkle, Piqua, Ohio; Ohio Medical Univer-
sity, Columbus, 1902 ; member of the Ohio State Medical
Association; served during the World War; formerly city
physician and health officer ; aged 63 ; on the staff of the
Memorial Hospital, where he died, August 2, of cirrhosis of
the liver.

Barrick Samuel Rankin ® Kingwood, W. Va. ; Baltimore
Medical College, 1907;. past president of the Preston County
Medical Society; at one time member of the state legislature;
served during the World War; formerly superintendent of the
state hospital at Spencer ; aged 67 ; was drowned, August 22.

Frederick William Hagney ® Newark, N. J. ; College of
Physicians and Surgeons, Medical Department of Columbia
College, New York, 1893; aged 71; on the staff of Hospital
of St. Barnabas and for Women and Children, where he died,
August 26, of chronic myocarditis and arteriosclerosis.

Joseph Hubbard Saunders ® Williamston, N. C. ; Uni-
versity College of Medicine, Richmond, 1905 ; past president
of the Martin County Medical Society; served during the
World War; formerly county health officer; aged 56; died,
August 3, in a hospital at Richmond, Va., of hepatitis.

Thomas Leo Caldroney, Ridgefield Park, N. J, ; Univer-
sity and Bellevue Hospital Medical College, New York, 1917 ;
member of the Medical Society of New Jersey; on the staff
of the Hackensack (N. J.) Hospital ; aged 46 ; died, August 2.
in Pompton Lakes of acute coronary thrombosis.

Alden J. Brace, Vici, Okla.; Kansas Medical College, Medi-
cal Department of Washburn College, Topeka, 1900; member
of the Oklahoma State Medical Association; aged 66; died,
August 7, in the Shattuck (Okla.) Hospital following an
operation for ruptured appendix.

Emil George Vrtiak ® Chicago; Rush Medical College,
Chicago, 1920; associate clinical professor of medicine at his
alma- mater; on the staff of the Lutheran Deaconess Home
and Hospital ; aged 48 ; died, August 7, in the Presbyterian
Hospital of coronary thrombosis.

1582

DEATHS

John H. Colay, Morrilton, Ark.; University of Arkansas
School of Medicine, Little Rock, 1911 ; member of the Arkansas
Medical Society; aged 58; on the staff of St. Anthony’s Hos-
pital, where he died, August 16, of injuries received when he
fell down an elevator shaft.

John Thomas Denton, Sanford, Fla.; Memphis (Tenn.)
Hospital Medical College, 1902; member of the Florida Medi-
cal Association; formerly secretary of the Seminole County
Medical Society; aged 60; died, August 3, in the Greenville
(S. C.) General Hospital.

Robert Newhall Smith, Hollis, N. Y. ; Columbia Univer-
sity College of Physicians and Surgeons, New York, 1897 ;
aged 67; died, July 30, of a streptococcic infection resulting
from a fall which forced the pipe he was smoking through
the back of his throat.

Joseph Ambrose Brady, New York; Long Island College
Hospital, Brooklyn, 1903; member of the Medical Society of
the State of New York; on the staffs of the Misericordia
Hospital and St. Vincent’s Hospital; aged 62; died, August
26, of heart disease.

Gaston Day, Jacksonville, Fla. ; Johns Hopkins University
School of Medicine, Baltimore, 1906; member of the Florida
Medical Association and the American Society of Anesthetists ;
served during the World War; aged 57; died, August 5, of
coronary occlusion.

Edward Augustus Stratton © Danbury, Conn. ; University
of the City of New York Medical Department, 18S3; fellow of
the American College of Surgeons ; surgeon to the Danbury
Hospital; aged 77; died, July 9, of carcinoma of the stomach.

Henry William Held, Vincennes, Ind.; Medical College
of Ohio, Cincinnati, 1894; member of the Indiana State Medi-
cal Association; formerly county coroner; aged 69; died,
August 9, in the Good Samaritan Hospital of diabetic gangrene.

Robert Lee Cater Jr., Greensboro, N. C. ; Emory Univer-
sity School of Medicine, Atlanta, Ga., 1916; member of the
Medical Society of the State of North Carolina; aged 44;
was found dead, August 8, of acute dilatation of the heart.

John Frederick Cumming, Morris, Minn.; University of
Toronto Faculty of Medicine, Toronto, Out., Canada, 1922;
member of the Minnesota State Medical Association ; aged
41 ; died, July 12, of hypertension and cerebral hemorrhage.

James Allen Ballard, San Francisco ; University of Min-
nesota College of Homeopathic Medicine and Surgery, Minne-
apolis, 1904 ; served during the World War ; on the staff of the
Veterans Administration Facility; aged 54; died, July 5.

Edward B. Kaple, Camillus, N. Y. ; Cleveland University
-of Medicine and Surgery, 1895; past president of the Onondaga
County Medical Society; for many years on the staff of the
Syracuse Memorial Hospital ; aged 66 ; died, July 26.

Hudson D. Bishop ® Cleveland; Homeopathic Hospital
College, Cleveland, 1890; formerly professor of surgery at his
alma mater; for many years on the staff of the Maternity
Hospital; aged 72; died August 17, of heart disease.

Oliver James Wood, Cleves, Ohio; Miami Medical Col-
lege, Cincinnati, 1883 ; past president of the county board of
health and the Cleves-North Bend school district ; aged 87 ;
died, August 8, of arteriosclerosis and heart disease.

Rufus Joel Danner, Terre Haute, Ind.; Kentucky Uni-
versity Medical Department, Louisville, 1901 ; member of the
Indiana State Medical Association; served during the World
War ; aged 65 ; died, August 26, of heart disease.

Joseph Maurice Allen, Rosholt, S. D.; Hamline Univer-
sity Medical Department, Minneapolis, 1901; aged 72; died.
August 8, in St. Francis Hospital, Breckenndge, Minn., of
gangrenous appendicitis and coronary occlusion.

Oliver S. Olson, Gary, Ind.; University of Illinois Col-
lege of Medicine, Chicago, 1912; member of the Indiana State
-Medical Association; served during the World War; aged oi,
• died, August 20, of carcinoma of the intestine.

Delbert Frederick Dumas, Bemidji, Minn. ; College of
Physicians and Surgeons of Chicago, School of Medicine of the
. University of Illinois, 1902; aged 60; died, August 8, of hyper-
tensive heart disease and cerebral thrombosis.

Nathan Browne Hammond, Philadelphia; Hahnemann
Medical College and Hospital of Philadelphia, 1903; demon-
strator of pharmacy, 1905-1910, and lecturer, 1910-1911, at Ins
alma mater ; aged 62 ; died, July 18.

. Calvin Ashley Traver, North Little Rock, Ark. ; Bennett
College of Eclectic Medicine and Surgery, Chicago, 1897;
:aged 66; died, July 30, of pneumonia, intestinal obstruction
and appendicitis.

Jons. A. SI. A
Oct. 21, 19;)

Michael A, Cohn, San Diego, Calif.; College of Physician;
and Surgeons, Baltimore,' 1893; member of the Medical Society
of the State of New York; aged 71 ; died, July 10, at La Jolla.

Albert E. Hussey, Cincinnati; Medical College of Ohio,
Cincinnati, 1901 ; formerly connected with the U. S. Veteran;
Bureau ; aged 59 ; died, August 1, of cerebral hemorrhage.

Frederick Walter Mason, Brandon, Vt. ; Keokuk (Iona)
Medical College, 1897 ; aged 64 ; died, August 7, in a hospital
at Rutland of gastric hemorrhage and diabetes mellitus.

Clarence Earl Hamel, Katispelf, Mont.; College of Physi-
cians and Surgeons of Chicago, School of Medicine of the
University of Illinois, 1906; aged 66; died, July 29.

Frederick Elisher Salvage, La Moure, N. D.; Rush Medi-
cal College, Chicago, 1892 ; member of the North Dakon
State Medical Association; aged 72; died, July 14.

Ida Rebecca Brigham, Brookline, Mass.; University of
Michigan Department of Medicine and Surgery, Ann Arbor,
1884; aged 89; died, July 3, of coronary sclerosis.

James Cannon Greene, Greenville, N. C.; Medical College
of Virginia, Richmond, 1900; aged 70; died, August 15, in
the Pitt General Hospital, of chronic myocarditis.

Henry John Abele, Lakewood, Ohio; Fort Worth School
of Medicine, Medical Department .of Fort Worth University,
1S9S; aged 80; died, August 4, of heart disease.

William Albert Berry, Chicago; Rush Medical College,
Chicago, 1903 ; aged 60 ; on the staff of St. Bernard’s Hospital
where he died, August 26, of angina pectoris.

William G. Ferguson, Rockville Centre, N. Y.; F° r j
Wayne (Ind.) College of Medicine, 1891 ; formerly school
physician in Fort Wayne, Ind. ; died, July 31.

Arthur Peter Shellman, Binghamton, N. Y. ; University
of the City of New York Medical Department, 1891; ag
69; died, July 16, of coronary thrombosis.

Louis H. Graham, Waxahachie, Texas! Louisville (M)
Medical College, 1889; member of the State Medical Assoc
tion of Texas; aged 76; died, August 6.

Robert Brown Whiteside, Lott, Texas; College of PMj
cians and Surgeons, Baltimore, 1889; aged 73; died, Juy- ,
cerebral hemorrhage and arteriosclerosis.

La Forest Ethelbert Phillips ® Palo Alto, Calif.; Cooper
Medical College, San Francisco, 1899 ; on the staff ot tli
Alto Hospital ; aged 63 ; died in July.

Adam Henry Straub, Brooklyn ; Long Island Cmkge »
pital, Brooklyn, 1889; aged 73; died, July Z, in tl' e
Heights Hospital, of diabetes mellitus. . .

John Darius Jackson, Perryville, Texas; ' i cm

versity School of Medicine, Nashville, Tenn., loot , S
died, July 25, in Terrell of senility. . c j

Noble Hind Hill, Boston; Boston University SOioo
Medicine, 1892; aged 79; died, July 13, in the no
Hospital, of cerebral thrombosis. . „ - a \

Frank Walters Stuart, Seattle; Homeopathic ° , ra j
College, Cleveland, 1890; aged 82; died, July Z6, ot
hemorrhage and hypertension. . ,; rt i

Henry^ Hertel, East , St. Louis^ UU f St. { Louis

College, 1878; member of the Illinois State
aged 89; died, August 22.

Calii-I

Mary Elizabeth Rosenberg Nelson, San JDieff®,
University of Nebraska College of Medicine, U
aged 83; died, July 15. „ r ,. . rn iw of

William D. Mace, La Fayette, Ind.; Medjca acu t, ;
Indiana, Indianapolis, 1889; aged 71; died, Juh >
dilatation of the heart. , <jer

Sae T. Greenberg, Cleveland; Medizinische ® ot -
Universitat, Wien, Austria, 1908; aged 59; die , J
coronary thrombosis. . , ,. .i Col-

Frank R. Falby, Charlotte, Vt.; Baltimore - u enl orrhM e
lege, 1897; aged 72; died, July 30, of cerebral hem
and arteriosclerosis. . -city

David Scott Hoig, Oshatva, Ont., Canada,

Toronto Faculty of Medicine, 1880; aged 85, • j q 0 \.

Moses Wiesh, Sail Antonio, Texas; Missouri-
lege, St. Louis, 1897; aged 85; died, August 4, ot m ^

C. C. Witt, Lake City, Fla.; Hedical Cofcsy 1 f Julv 19.
of South Carolina, Charleston, 1909; aged 55, ateo,

Moses Wiesh, San Antonio, Texas; "myocarditis

ge, St. Louis, 1897; aged 85; died, August 14, ot m ^

C. C. Witt, Lake City, Fla. ; Medical C ° Ucl $J j„!v 19.
of South Carolina, Charleston, 1909 ; aged 55, am *
Charles Warwick Me Vi car, Winnipeg, - m^ ust j l.
Manitoba Medical College, 1924; aged 3S, d , /vflepe

Sidney A. Hoesman, Cozaddale, O’ 1 ' n^AuSuM 4.
of Medicine and Surgery, 1901 ; aged /9; died, Angus

Volume 113
Number 17

BUREAU OF INVESTIGATION

1583

Bureau of Investigation

TWO ABORTIFACIENTS BARRED
1. Cosmo Carrano and His D. M. C. Pills
From New Haven, Conn., Cosmo Carrano, a quack said by
government officials to have a criminal record, did a medical
mail-order business under the trade style "Occanvicw Medical
Products” selling “D. M. C. Pills.” In the opinion of Judge
Vincent M. Miles, Solicitor for the Post Office Department, it
was apparent that the advertising of this product indicated that
it was an abortifacient. As he put it : “The evidence in this case
shows that it is the promoter’s [Cosmo Carrano’s] intention
to hold out his preparation as an abortifacient and that lie
is selling it through the mails for that purpose.”

Carrano, according to Judge Miles’s memorandum, had
■previously been convicted on five different occasions of

FREEDOM.

ratfr .oasa**

Sfev

f 29M31 •

PILLS

Qre

I Helping Thousand?
of Women!

If vou ere Troubled wilh Delay, do not take chances wilhyour*

lice'll r> a i. J Y'*-' ••• w — - ““

Full 5lrengU\^2o6'a Box cr two Boxes for ^3.00 Special
formula double slrcnglh for ©bsKnale cascs^300a
For^S.OO Will be sent to you postpaid in sealed yjBk
package same day order received. COD orders 1S*1 J j j

extra.Send cosh with order and save COD fee.

HEALTH INSTRUCTIONS Sent With Each Order.

CLIP THIS COUPON AND MAIL NOW

OCEANVIEW WEDICAL PRODUCTS.
BOX 1709. NEW HAVEN. CCNN.

Gentlemen :

n Full Strength
Q Double Slrcnglh

Enclosed find „___Tcr_

Hame ,

Address -

City... . Slate.

Oceanview Medical Products

Box 1703, New Havfen, Conn.
Ladies Dept. IW 3-1-DP.

Some of Carrano’s advertising.

possessing, selling or shipping obscene matter. According to
the same memorandum, the Post Office Department issued a
fraud order against Carrano in March 1936 for operating a
mail-order swindle in the sale of books, pictures and cartoons.

In 1937, according to material in the files of the Bureau of
Investigation of the American Medical Association, Carrano
entered into a stipulation with another government agency, the
Federal Trade Commission, to “discontinue representing directly
or by reasonable implication that his preparation [D. M. C.
Vegetable Pills] is an abortifacient." But Carrano was still
selling his D. M. C. pills in 1939 when the Post Office Depart-
ment again took a hand. He was called on to show cause on
' Feb. 23, 1939, why the postmaster at New Haven should not
he instructed to stamp all mail addressed to Oceanview Medical
Products “fictitious” and return ail such mail to the senders
or else send it to the Division of Dead Letters at Washington.

On February 21 Carrano’s attorney, Walter J. McCarthy
of New Haven, addressed a letter to the Post Office Depart-
.ment, stating that his client would be willing to sign a
stipulation — another one! — agreeing to discontinue his scheme.

Naturally the Post Office officials took the attitude that, as
they put it, “no reliance might be placed upon any promise”
made by Carrano. Mr. McCarthy was notified that a hearing
would be held at Washington on February 28. On that date
Mr. McCarthy appeared on behalf of Carrano and a hearing
that consumed half a day was held.

As Judge Miles brought out in his memorandum to the
Postmaster General, Carrano’s published testimonials were
“shown to be from married women and indicate that the
preparation [D. M. C. pills] sold in this scheme had relieved
cases of delayed menstruation of two months and over, the
inference being throughout such testimonials that the prepara-
tion [D. M. C.] actually accomplished abortion in such
instances.” The memorandum further stated that in a num-
ber of instances Carrano had sent his D. M. C. pills through
the mails in cases in zvliich they were expressly ordered for
the purpose of effecting an abortion. (Italics ours — Ed.)

The evidence showed, according to the memorandum, that
Cosmo Carrano was violating 18 U. S. Code 339 and 334,
statutes that specifically prohibit the advertising and sale
through the mails of any matter to be used for the purpose
of producing abortion. On March 6, 1939, the mails were
dosed to Oceanview Medical Products.

2. “Bornock’s Tablet Treatment”

On Jan. 21, 1939, Olaf M. Bornstad of Minneapolis was
called on by the Post Office Department to show cause why
the postmaster at Minneapolis should not be instructed to stamp
all mail addressed to Bornstad’s “Bornocks Company” as
"fictitious” and either return it to the senders or direct it to
the Division of Dead Letters at Washington.

On January 28 Bornstad’s attorney, Olaf L. Bruce of Minne-
apolis, wrote the Post Office Department a letter in which he
transmitted a statement from Bornstad, waiving a hearing and
indicating a willingness to have ail mail addressed to his com-
pany returned to senders. In the memorandum to the Post-
master General from the Solicitor of the Post Office Department,
Judge Vincent M. Miles, it is brought out that Olaf M.
Bornstad under the Bornocks Company trade style had been
advertising and selling through the mails “Bornock’s Tablet
Treatment” as a means of producing abortion.

Bornstad solicited business, stated Judge Miles, “by the use
of newspaper advertisements” and letters. Unfortunately the
names of the newspapers that became particcps criminis with
Bornstad were not given. On Feb. IS, 1939, the mails were
closed to Bornstad’s trade style, Bornocks Company, and its
officers and agents as such, because the business was a violation
of 18 U. S. Code 339 and 334.

THE INDIAN DRUG STORE FRAUD

From March 1934 until Jan. 17, 1939, Armon S. Compton
of Philadelphia, who is said to claim that he is a pharmacist,
had been selling two nostrums through the mails. The “patent
medicines” in question were called, respectively, “Presta
Tablets” and “Re-Gens Tonic Compound.” These were sold
not under Compton’s own name but under the trade style “Indian
Drug Store.” The location was 1440 South Street and it
appears that it was a small “botanical drug store” from which
Compton also sold locally a general line of herbs.

Presta Tablets were supposed to restore lost sexual vitality,
while Re-Gens Tonic Compound was apparently recommended
for everything from hot flashes to cold feet. When analyzed
the tablets were reported to contain damiana, strychnine, zinc
phosphide, iron (ferric) oxide and a small amount of the
inevitable cantharides (Spanish flies). The tablets were sup-
posed to cure lost sexual vitality whether the condition was due
to tuberculosis, diabetes, venereal disease, old age or to psychic
causes.

The Re-Gens Tonic was reported on analysis to contain
gentian, iron (ferric) oxide, salicylic acid and cpsom salt—
especially epsom salt— and a little calcium, sodium and potas-
sium. The stuff was essentially a laxative. As such a mixture
would not “keep your Blood, Stomach, Liver, Kidneys and
Bowels in good condition” and would not enable persons to

1584

QUERIES AND MINOR NOTES

“avoid Constipation, Dyspepsia, Sour Stomach, Bad Breath,
Malaria, Sick Headache, Kidney Troubles, Liver Complaint,
Loss of Appetite, Rheumatism, Lame Back, Impure Blood,
Pimples, Eczema, Boils and so on, the scheme was declared
a fraud and the mails were closed to the Indian Drug Store
on the date given in the opening paragraph.

Queries and Minor Notes

The answ ers here published have been prepared by competent

AUTHORITIES. TllEY DO NOT, HOWEVER, REPRESENT THE OPINIONS OF
ANY OFFICIAL BODIES UNLESS SPECIFICALLY STATED IN THE REPLY.

Anonymous communications and queries on postal cards will not

BE NOTICED. EVERY LETTER MUST CONTAIN THE WRITER^ NAME AND
ADDRESS, BUT THESE WILL BE OMITTED ON REQUEST.

HYPOTENSION

To the Editor : — A woman of 45 who is otherwise healthy has a blood pressure

of 80/42. What should be don. to raise this blood pressure? Would

thyroid extract be indicated? M.D., Newark, N. J.

Answer. — It has been customary to separate chronic arterial
hypotension into two types (primary, or essential, and secon-
dary), but such distinction is largely arbitrary. The patho-
geneses and disturbed homeostatic mechanisms arc alike; the
conditions differ only in obviousness of etiology. In some
instances of habitual hypotension the causation is fairly obvious
and in others obscure. The etiology of hypotension involves
numerous factors. These are divisible into predisposing (consti-
tutional) factors and provoking (initiating) influences. In clinical
instances in which the provoking factors are obscure the pre-
disposing causes usually predominate (Stieglitz, E. j. ; Abnor-
mal Arterial Tension, New York, National Medical Book
Company, Inc., 1935).

To be effective, therapy must be based on correction or
amelioration of the cause. In the present instance it must be
assumed that no obvious intoxications, infections, dehydration
or metabolic disturbances exist and that the hypotension is
habitual and continuous rather than merely evidence of a tran-
sient depression of vascular tone. Careful search for sources of
intoxication such as foci of infection, prolonged fatigue, tuber-
culosis and habitual use of depressant drugs should be conducted.
Excessive self medication with any of the many generally avail-
able barbiturates, bromides and other sedatives is not an infre-
quent factor in habitual hypotension, but it is rarely admitted
by the patient. The cardiac reserve is an important considera-
tion, and one would wish to know the circulatory response to
effort and the character and rate of the pulse. Should such
clinical studies fail to elicit evidence as to the causation of the
hypotension, then and only then supportive and stimulative
therapy is justified.

Hypotension per se is not a disease. It is a physiologic state
deviating from the accepted normal. Moderate hypotension may
be and often is perfectly compatible with health and well-being.
Only when hypotension is sufficient to impair circulatory effi-
ciencj' and cause symptoms is one justified in instituting therapy;
it is with the patient and not with the level of arterial tension
that one should be concerned. Rest is probably the most effec-
tive measure. Hypotensive persons have a distinctly lowered
endurance. Fitting the pace of living to the patient’s capacity
of activity can often do more good than any other measure.
This applies to mental and emotional as well as physical strains.
The program of daily routine can often be modified to yield
short rest periods.

Improvement of nutrition is important. Many of these patients
are grossly undernourished, while others are flabby and over-
weight. A diet planned to prevent constipation is desirable.
Anemia, even of minor degree, should be energetically com-
bated. Hypotension is frequently associated with deficient
oxygenation. Apocamnosis encourages sedentary habits. Fresh
air and exercise appropriate to the patient’s strength arc

valuable. , . , ,

Drugs are but auxiliaries in the management of habituai hypo-
tension and must not be relied on to the exclusion of other
measures. Strychnine sulfate (0.6 mg.) or the oldfashioned but
effective elixir of iron, quinine and strychnine before meals may
be continued profitably for weeks. Epinephrine has too fleeting
an action to be applicable to the control of chronic hypotension ;
furthermore, it must be administered parenterally. Ephednne
salts and benzedrine have undesirable side effects such as msom-

Jovx. A. M. A.
Oct. 21 , 1939

ilia, cardiac excitation and excessive cerebral stimulation and
are thus best avoided. Thyroid extract is definitely indicated
when the basal metabolic rate is low. It should never be pre-
scribed without controlling observations of the basal metabolic
rate, the pulse rate and the sense of well-being of the patient.
Frequently it is tolerated surprisingly well by those whose
metabolic rate is normal, and although the rate is but littie
increased considerable clinical benefit is obtained. The precau-
tion of repeated observations of such patients should not be
neglected. Appreciation of the fact that the discovery and
correction of the causal influences is of major importance in
treatment will insure better therapeutic results. The therapy
required for each patient must be individualized.

BILE SALTS

To the Editor : — Could you give me a formula for a preparation of tile
salts to be used in coses of chronic cholecystitis?

Albert Kaplan, M.D., Koch, Mo.

Answer. — Normal human bile obtained from the common
or hepatic duct contains approximately 1 per cent of bile salts;
in the bile in the gallbladder the concentration is from six to
ten times greater. These bile salts consist chiefly of sodium
glycocbolate, sodium taurocholate, sodium cholate, sodium cliole-
atc and some sodium desoxycholate. Other bile salts are present
in minute traces and there may also be small amounts of the
free bile acids themselves. Ordinarily the ratio between sodium
glycocbolate and sodium taurocholate in normal human bile is
about 3:1.

Ox bile, from which most commercial preparations of bile
salts are made, does not differ greatly in composition Iron
human bile in respect to the glycocholate : taurocholate ratio.
Theoretically it would be possible to prepare a mixture of 1*
salts which would correspond closely in composition to that ot
normal human bile but to do so would be an expensive and
difficult process.

Schmidt and his associates (Schmidt, C. R.; Beazcll, J- - •>
Atkinson, A. J., and Ivy, A. C. : The Effect of Therapeutic
Agents on the Volume and the Constituents of Hue, / ’

Digest. Dis. & Nutrition 4:613 [Nov.] 1938), working on dogs,
found that preparations of conjugated bile acids are supe
stimulants to the flow of bile and produce an increased »
tion of normal biliary constituents. The oxidized uncotijiiK
preparations increase the aqueous fraction of bile but rcau
an absolute decrease in the output of natural bile acid.

DUCT

FORMATION OF GALLSTONES IN COMMON
To the Editor : — At a recent meeting the following question! * iu ‘ Lj oul |j
sidcrable discussion: Do stones form in the common “ tjcr , ® jj sc0Y erei
cholecystectomized patients or were such stones present an nounte cl
at the time of operation? Why is symptomatic relief mo p . ont )e$s**
when the gallbladder with stones is removed than when i
or nonfunctioning gallbladder is taken out? ,

j. E. Morgan, M.D., Ch«la«i

Answer. — It is probable that most stones found j 5Cn t
mon duct of previously cholecystectomizcd pitta B . t pe
stones that were present and undiscovered at tlie lonB
original operation. There is conclusive evidence - ( j ]a ,
may grow in the common duct and reach a large .. | ar gc
then, following their removal, a recurrence < pi feen

stones may take place, even though the gallbladde
previously removed. . . „ so i, n and

According to the observations of Phemistcr. A^ form3 [;«i

Pepmsky (Ann. Surg. 109:161 [Feb.] ^ 0 ne formation w
in the common duct is usually preceded by s , j |ll0 the

the gallbladder and is set up after calculi have pass
common duct with the resultant obstruct! j uet indc-

Rarely, stone formation may occur in the commo
pendent of cholelithiasis, as m cirrhosis 0 ... System. ' a
Mclndoe and Marshall : Surgery of the "iharj ^ p r ior
Lewis’s Practice of Surgery, Hagerstown Al .. ' - ^,,,^

Company, Inc., 1929 vol .7 chapter 2) or « «« cFctr j xto
obstruction of the ducts (Lamport, R, P < jj C p 0r t of

Elizabeth M.: Carcinoma of the Hepatic Due , Marshall,
Additional Case, Am. J. Carreer 21. :534 IMV™ ■ Jfev0 C l«.
J. M.: Tumors of the Bile Duct, Proc. Staff Ncc ., . „

6:191-192 [April 1] 1931), and the stones maj« t! , a
the intrahepatic ducts. Pliem.stcr and Ins assocw,
the stones which form in the biliary ducts ar p , v a t race
entirely of cholesterol and bile pigments vutli sw for pi

of calcium. This is in sharp contrast to ; s c oinn» n f'

in the gallbladder, in which calcium carbonate
present in varying amounts.

Volume 113
Number 17

QUERIES AND MINOR NOTES

1581

Symptomatic relief is usually more pronounced when the
gallbladder with stones is removed because in this case it is
much more probable that the gallbladder was the original cause
of the distress. In many cases, so-called functional intestinal
distress or hyperirritability of the colon may quite accurately
mimic the symptoms of classic gallbladder disease, and of course
these symptoms then persist after the removal of the gallbladder.

The syndrome of biliary dyskinesia is not clearly defined, but
it is quite possible that subjective symptoms might be produced
by disturbance in the motility of the gallbladder or of the com-
mon duct and the sphincter of Oddi, in the absence of stones.
The removal of such a gallbladder would clearly not give the
relief that is commonly obtained in the presence of cholelithiasis.
It is probable that, in most cases in which symptomatic relief
is not obtained following cholecystectomy in the absence of
gallstones or evidence of cholecystitis, the diagnosis is wrong.

CHORDOTOMY FOR PAIN

To the Editor : — For painful stump of an amputated thigh a patient was given
paraspinal injection, presumably of alcohol. This was made at the third
or second lumbar vertebra. The pain in the stump was almost entirely
relieved, but in its place there are severe paroxysms of stabbing pain
originating at the twelfth thoracic vertebra and radiating along the border
of the last rib on both sides. Their severity demands constant sedation
with opiates. Will you kindly inform me of the results of laminectomy
and of chordotomy, or fell me where I can find these results summarized.

H. A. Haskell, M.D., Windsor, Calif.

Answer. — Properly done by one experienced in procedures
of neurologic surgery, chordotomy should completely relieve the
patient of the pain. A small laminectomy should be done and
a chordotomy performed at least four cord segments above the
highest segment of pain distribution. With bilateral section of
the pain-conducting pathways, between the dentate ligaments
and the anterior roots, there will be a loss of pain and tem-
perature sensibility below the level of the section but touch,
pressure, position and vibratory sensibilities will not be impaired.
The knife should pass completely through the white matter,
between the landmarks named and well into the gray matter
of the cord. With a careful operation, avoidance of hemorrhage
around or in the cord and proper closure of the dura mater and
muscles, there should be no loss of sphincter control or any
motor weakness. In such a case chordotomy is no doubt prefer-
able to posterior rhizotomy.

RHEUMATIC FEVER AND APHONIA

To the Editor:- -A 4 year old girl has acute rheumatic fever of ten days'
duration. She has received methyl salicylate externally and sodium sali-
cylate internally in 5 grain (0.3 Gm.) doses four times a day, which has
produced mild gastric symptoms and ringing in the ears when increased to
five times a day. A slight but definite aphonia and some difficulty in
swallowing has developed, the vagus being probably involved. There is no
evidence of cardiac involvement other than rapid pulse. It would be
greatly appreciated if you could suggest any therapy other than what
is being given for the general condition and likewise any suggestions as
to the mechanism of the vagus involvement and its treatment.

Charles H. Morhouse, M.D., Mitchelfild, L. I.# N. Y.

Answer. — None of several authorities consulted have noted
aphonia as a complication of rheumatic fever. In the presence
of aphonia a reconsideration of the diagnosis may be in order ;
perhaps rheumatic fever exists coincidentally with some other
condition that causes aphonia. Although salicylates in toxic
doses may produce a number of neurologic symptoms, aphonia
was not included in the list of Hanzlik (1927). Assuming that
rheumatic fever with a related aphonia is present, the latter
may be due to some local involvement and not necessarily to
a disturbance of the vagus, or other cranial nerves may be
responsible. Laryngitis occasionally occurs early in the course
of rheumatic fever. Rheumatic nodules of microscopic size
have been found in almost every tissue of the body. Occa-
sionally, discrete nodules appear on the vocal cords. A serious
and rare complication may be an acute diffuse edema of the
epiglottis and vocal cords, which at times results in obstructive
dyspnea. Aphonia may result from auricular enlargement or,
assuming that no other central nerves are involved, one might
link of a central (vascular embolic) lesion affecting the
nucleus of the vagus nerve in the medulla; but this would
necessitate the presence of frank endocarditis. In chorea, which
■s frequently associated with rheumatic fever, lesions of blood
Tpssels and focal areas of encephalitis may occur. The data
BHCii by the correspondent are insufficient for one to make
r conjectures as to the diagnosis.

■ salicylates are not well tolerated when administered orally,
le - can be given in water by rectum 10 grains to the ounce

(0.65 Gm. in 30 cc.) or in a weak solution of starch. If sal icy
Iates are not effective in controlling fever and the articula
disease, aminopyrine may be effective. A complete review o
the current methods of treatment of rheumatic fever can b
found in the Fifth Rheumatism Review (Ann. Int. Med. 12
1005 [Jan.] 1939).

DILUTION TEST OF KIDNEY FUNCTION

To Me Editor: — Kindly give me the details of the kidney function test i

which eight glasses of water are given. Also the interpretation of thi

fes f* C. G. Bower, M.D., Galesburg, III.

Answer. — In carrying out the dilution test for kidney func
tion, according to Volhard’s technic, the patient empties th
bladder on arising and then drinks eight glasses (1,500 cc.'
of water or weak tea in the course of from thirty to forty
five minutes. He must remain in bed during the test perioi
of three or four hours and refrain from food or drink. Hi
is asked to urinate every half hour, keeping each urine ii
a separate container. The volume and specific gravity o
the individual urines are measured. Normally, excretion of th
ingested fluid is complete within two or three hours, at tht
most in four hours. More important as an index of norma
renal function is the variation in the volume and specific graviti
of the half hour urines. The largest half hour output mai
reach from 500 to 1,000 cc. (1 pint to 1 quart), with the specifii
gravity as low as 1.001. With impairment of renal functioi
the first change is the reduction of the maximum half houi
output and failure of a sharp fall in the specific gravity. Latei
the total four hour volume falls below the intake of fluid, and
finally, the half hour samples become small and uniform botl
in volume and in specific gravity.

While the test is exceedingly simple, interpretation may bi
difficult in the case of an abnormal outcome, because the responst
of the body to a single large volume of water is determined bj
extrarenal as well as by renal factors. Thus, in the presencf
of cardiac or renal edema and even when there is only a ten'
dency to edema, as in early cardiac failure and in the latei
months of pregnancy, much of the ingested fluid may be retained
although there may still be considerable variation in the hall
hour urines. Any form of dehydration preceding the dilutior
test may seriously disturb the results. Thus fever, diarrhea
excessive perspiration and other conditions must be taken intc
account. The amount of salt in the diet on the day preceding
the test may also affect the excretion of the water given. Ir
most cases it becomes necessary to carry out a concentrator
test in order to obtain a reliable measure of renal function. Il
is evident that the dilution test may be a dangerous procedure
in cases of increasing cardiac failure and pulmonary congestion,
or with severe hypertension and symptoms of encephalopathy,
or in acute nephritis with oliguria and progressive edema. Or
the whole, the dilution test is not reliable and should be sup-
planted by the concentration test.

PROLONGED CARDIAC INVALIDISM IN CHILDREN

To the Editor : — I would appreciate your advice and your listing of schools,
if any, for a boy aged 16 with rheumatic heart disease who is mentally
alert but rebels daily that he cannot work. The condition of his heart
is poor. At present he is in bed with rheumatic fever. His parents, not
too wealthy, are willing to do anything to alleviate his boredom. I sug-
gested a cardiac school, but I don't know whether there arc any, and,
if there are, where they arc. Thank you for any help you can give me
The boy lives in Vermont. M.D., Lynn, Mass.

Answer. — One of the difficult problems that has faced those
treating prolonged rheumatic infections in childhood has been
to maintain the morale and relieve the boredom of the children
who have to stay in bed for months or even years.

There are certain hospitals where such children are well cared
for over periods of time with an excellent environment and
attention to the medical needs of the child. During convalescence
recreational therapy and occupational therapy are instituted,
but it is not necessary for children to be in such hospitals.
They can be adequately taken care of- at home if there is
an understanding of their needs. The pioneer work of Miss
Edith Terry and her associates at the Children's Heart Clinic
of the Massachusetts General Hospital (with the help of the
Committee for the Home Care of Children with Heart Disease)
has resulted in the development of great advances in this field.
Information can be obtained from Iter about the measures which
she has introduced.

Among such measures are the establishment of the “In Bed
Club with its magazine, its jacket, its badge and other attri-

15S6

QUERIES AND MINOR NOTES

Jon. A. SI. A.
0«. 21, us

butes. Miss Love, who is one of Miss Terry’s associates, has
become expert in developing the use of the leisure time when
the chiidren are not too sick. Although care must be exercised
as to the amount of activity of the children in bed in relation
to the severity of their acute illness, it is even possible for them
while still in bed to earn funds for their family, especially
helpful if other members of the family are out of work.

URINARY INCONTINENCE AFTER PROSTATECTOMY

To the Editor ; — A white man aged 73 had a transurethral prostatectomy
in October 7938. Since then his general condition has been good,
except for a generalized arteriosclerosis. Follow-up examinations in the
hospital seem to show normal progress. However, a postoperative incon-
tinence developed with a highly alkaline urine. Acidifying agents have
failed so far to render the urine acid. The patient has been compelled
to wear a urinal, but during the day only. At night he does not wet
his bed, even though he is not wearing the urinal. The output during
the night (12 midnight to about 9 a.m.) has been much higher than
during the day. There is no infection. Since androgenic substance has
been found valuable in the treatment of prostatic hypertrophy l should
like to know whether it would be of help in correcting the incontinence
also. Exercising the sphincter having been suggested already, what else

can be done?

M.D., New York.

Answer.-— The history given indicates that there is probably
a urea-splitting organism in tile urinary tract. As this con-
taminant is probably responsible for considerable bladder irri-
tability attention should first be given to its eradication. Since
it is almost impossible to acidify the urine in the face of this
group of organisms the drug of choice is sulfanilamide, as its
best action is in urine of alkaline reaction. Frequently, how-
ever, such patients become afflicted with alkaline encrusta-
tions on the operative site, which may necessitate instrumental
removal either transurethrally or by means of cystotomy. In
any event, diagnostic cystoscopy and a gram stain of the cen-
trifuged specimen of urine, or even cultures of the urine, are
indicated.

Although many claims have been advanced for androgenic
substance it is doubtful if treatment of postoperative incon-
tinence with this agent has ever been successful. However, if
the patient does not have hypertension, epliedrine in three-
eighths grain (0.024 Gm.) doses once or twice a day may be
effective in stimulating the sphincter. Other agents of this
type are strychnine in small doses (%> o grain [0.00054 Gm.])
and benzedrine sulfate. Of course it is necessary to calibrate
tlie urethra so that it will accommodate at least a 24F
catheter, as strictures are frequent following transurethral
resections and may be productive of incontinence. Exercising
the sphincter is of definite value. If all of these means are
of no avail it may be more convenient for the patient to use
a Cunningham clamp than the more cumbersome urinal.

THROMBOSIS OF AXILLARY OR SUBCLAVIAN VEINS

To the editor : — A man aged 54 sustained a contusion on the left upper
arm. Five days later the basilic vein was enlarged and ropelike through-
out its entire course. A few days later the entire left arm was cyanotic
and swollen, especially the upper arm and hand. The cephalic vein was
enlarged and varicosed and the veins on the anterior surface of the chest
were olso enlarged. After eight weeks of complete rest in bed the basilic
vein became normal, but the entire left arm and hand are still generally
enlarged and slightly cyanotic, especially when held in a dependent posi-
tion. The cephalic vein is still enlarged and varicosed and the veins
on the chest, while less pronounced, ore still enlarged. From the symp-
toms, it appears that the thrombosis has extended to and involved the
axillary or subclavian vein. The patient has been given increasing doses
of potassium iodide and is now permitted to use the left arm for light
duty. As the original injury occurred four months ago, what should be
the prognosis and what treatment should be prescribed? May the moderate
use of alcohol and tobacco be permitted? M.D., Missouri.

Answer.— The description of the case permits the diagnosis
of a thrombosis of the axillary or possibly subclavian vein with
the characteristic collateral circulation on the chest wall and an
increase of venous pressure in the superficial veins of the arm.
It would be advisable to determine the location of the venous
obstruction by an intravenous injection of an opaque, iodine-
containing solution such as neo-iopax or hippuran. A block ot
the sympathetic fibers going to the arm might be done to see
how much of the swelling and cyanosis is due to a reflex vaso-
constriction maintained by the thrombosed venous segment. By
far the most satisfactory treatment is the resection of the
occluded vein, which is most often exposed by a subclavicular,
transpectoral incision. Relief from edema and cyanosis may
occur spontaneously, but the process is unpredictable and may
end up in severe neuralgia on exercise, a type of intermittent

^^u'sdoubtful whether the moderate use of alcohol and tobacco
would influence this condition.

ASTHMA AND MENSTRUATION

To the editor:— A white woman aged 36 has had ollergic aslhmo since ft.
onset of menstruation of the age of 12. In the beginning it would truth
her only for a few days before the menstrual period be) new it it trisect
in mild form (easily controlled by symptomatic treatment) throughout
the cycle but becomes almost intractable a few days before the period
and is relieved only with the onset of bleeding. She is the mother ol sis
children, the youngest 2 years of age. Each pregnancy has resalferf ra
complete remission of all asthmatic attacks after the first one to three
months. ^ She has had no miscarriages or abortions. General physiccl
examination, including a check of the sinuses, a blood count, o Wasser-
mann test and urinalysis, revealed no significant indications except for a
moderately emphysematous chest. Pelvic examination was not remarkcble.
The sputum during attacks shows abundant eosinophils, and difeirtirf
counts done at these times have shown moderate (from 6 to 10 per cent)
cosinophijia. She wifi not submit to skin testing. The pofienf ftas
arranged to moke the bedroom as nearly dust free as possible and li«
been on elimination diets but has not been benefited. 1 have treated her
now for one year on theophylline with ethylene diomine by mouth up to
15 grains (1 Gm.) in twenty-four hours and occasional doses of epinephrine
3 minims (0,2 cc.), which gives good symptomatic control in the intro-
menstrual period — much better than larger and more frequent dosage of
epinephrine without theophylline with ethylene diamine or with ephedrjne
and phenoborital compounds had previously done. The premenstrual
attacks are, however, becoming more severe. Intravenous theophylline
with ethylene diamine (7 Vi grains [0.5 Gm.]) with 3Q cc, of 50 per cent
dextrose, frequent epinephrine, rare doses of morphine and sodium pento-
barbital up on 3 grains (0.2 Gm.) see her through this hectic period. On
several occasions she has seemed practically moribund. It has been Tiolti
by the patient that any febrile state was followed by a period of portin'
or complete remission of symptoms. Fearing to use ony kind of fever
therapy at my disposal except autogenous blood, I have on two occcstoiu
induced mild fever (102 F.) by repeated injections of her blood intramus-
cularly. This empirical treatment has resulted in temporary improvement.
The questions I now wish to ask are: 1. What would be the result cf
x-ray castration? Would such a procedure be justified? 2, Hoyc you
confidence in endocrine therapy? If so, what? (This has been suggested
by a consultant.) 3. Have you any additional suggestions 'os to V[*P*
fomafic treatment? Would you advise the trial of epinephrine in oil
place of regular 1:1,000 epinephtine?

R. E. Shaw, M.D., CfarksWtfe, taw

Ansiver.— T iiis query brings up two important considerations
in the treatment of bronchial asthma. In the first place the
phrase “she will not submit to skin testing^' is unthinkable
this c/ay and age. There h as been a great improvement m
making and in the interpretation of skin tests. It is not an
ordeal, as Implied. The tests are painless if done cutaneousiy,
and if carried out intracutaneously the pain is slight. No a tte : *
effects should follow skin testing but the testing &n°uw
carried out by one who lias bad experience and who can m
all the necessary tests, both cutaneous and intracutaneous.
a patient who is only 36 the substance or substances wmcli ca
the^ asthmatic attacks should be discovered, especially s
eosinophilia is present. The patient should be persuade
have these tests done. , ..

The relationship of bronchial asthma to njenstruati
pregnancy has received a great deal of consideration a ^
consensus is that there is a definite connection, hut .

has been able to prove that menstruation is the un J j
cause of asthma. One must realize that menstruation is
a predisposing factor in asthma; there is usually an

e . r t x, 1 Ur, Avnnclir f

factor and the attacks are precipitated by exposure
such substance as pollen, molds, house dust, drugs o
food. Every one agrees that many female asthma i P as
are worse just before the flow and feel better • e

menstruation begins. Because of this, many pny& c * a
injections or tablets of ovarian material. Injecti
week of an extract of the whole ovary are probably
monly used, and in many cases excellent results ar ^
the amount of asthma is frequently much lessened DJ j or
X'Ray castration for asthma is not warranted, cP . jj 0 ^
a patient so young. Artificial menopause is someti . fS

by intractable asthma. Epinephrine in oil mtramus
longer relief than 1:1,000 epinephrine subcutaneous ).

to some

PUSTULAR

To the Editor ; — Is there such

PSORIASIS OF HEEL

o condition os "puslulof ,lt

heels?" The patient hos shown no other signs ypeskt'o* 9 ?'!

years ago. There is nr sl

onset of the condition of his heels two years ago. ousiun

with associated pustutofion of the heels in which the r
for several days ond (hen are apparently aosor ThcmPF.IT

resultant exfoliation of the overlying layers of tne • f ur j;a-A
included roentgen ond ultraviolet radiation and on en , jctP> ”

constitutional therapy hos not been neglected. P , s »ett ,

proceed to a certain point and then the conditii , inuc a.
if neglected, or remains stationary, if treatment i ^ Virgi/iio-

Answer. — Pustular psoriasis occurs on the jtatd; 45

and may be associated at times with 0 characterized by c** 0 " 1 .'

elsewhere on the skin. The lesions are - -

tion and insets of intra-cpidermic lakes of ster J 3Cr()! j cr rra-
to be differentiated from eczematotd rtngtvor

It r« c

Volume 113
Number 17

QUERIES AND MINOR NOTES

1SS7

litis perstans of Hallopcau. The relationship to so-called pus-
tular bacterid is much debated. Some dermatologists believe
that pustular psoriasis, acrodermatitis perstans and pustular
bacterid are mere variants of one another clinically and histo-
logically. In its most characteristic form, however, pustular
psoriasis may be differentiated from acrodermatitis perstans of
[he palm by the fact that in the former the lesions originate
an the thenar and hypothenar surfaces, whereas in the latter
they first involve the regions about the nails. In acrodermatitis
there is atrophy, even of the phalanges, while in pustular psoria-
sis there is none. The pustules are sterile in pustular psoriasis,
while they often contain staphylococci in acrodermatitis.

In pustular bacterid, which many believe is identical with
pustular psoriasis, the best therapeutic responses have followed
the eradication of foci of infection. These have been found
most frequently in the tonsils and teeth. Stimulating agents
applied locally often are found to irritate. In pustular psoriasis
also one should on general principles seek foci of infection.
If any are found they should of course be eradicated. Such
general measures as are applicable for other types of psoriasis
may be employed, such as the administration of arsenic. Pus-
tular psoriasis resists ordinary local therapy. A combination of
chrysarobin and ultraviolet radiation has been found useful.
Roentgen therapy may be helpful. These remedies should not
be used too long if they are ineffective, nor should their dosage
go beyond a safe limit.

CHRONIC LETHARGIC ENCEPHALITIS

To the Editor : — A white man about 23 years of age had what he says
was a mild case of scarlet fever and mumps about five years ago. Since
that time he has been drowsy and lethargic, especially late in the day.
He says that the condition is no worse now than it was four years ago,
but he is more conscious of it and worries all the time. His wife states
that he talks more slowly and does not smile as much or take an interest
in his friends and surroundings. He refuses to go out with other people,
as he is afraid they will notice his trouble. The only other complaint
is shortness of breath. Physical examination is essentially negative. He
is well developed. The tonsils are hypertrophic. The facial expression is
rather blank; however, he does appreciate a good joke. The superficial
reflexes are somewhat hyperactive. No pathologic reflexes are present.
I have termed this encephalitis with a slight tendency toward paralysis
agitans. As to treatment, I am using benzedrine sulfate. The questions
in my mind are: Is the benzedrine a curative measure or does it only
give symptomatic relief? In view of the fact that the patient has gone
four years without getting any worse, is there any chance of complete
recovery? Would hospitalization with studies of spinal fluid and x-ray
examination of the skull be of any advantage? I am allowing the
patient to continue his work; would bed rest be better? Is it better
to use stramonium with the benzedrine?

J. F. Hattenbach, M.D., Cleveland.

Answer. — Benzedrine sulfate is used for symptomatic relief
only if the patient has encephalitis. The chronic lethargic
encephalitis due to influenza is usually an incurable affliction.
Occasionally patients are seen whose symptoms are mild and
who under proper medication improve so much that it appears
that the patient has made a recovery. The pathology of encepha-
litis due to influenza, on the one hand, is such as not to permit
recovery. Encephalitis following scarlet fever and mumps, on
the other hand, usually clears up completely. Spinal fluid
examination should be made. It may show evidence of abnor-
malities in the Cell count, globulin content and colloidal gold
reaction. The pressure of the fluid should be determined by a
manometer with testing for subarachnoid block. The patient
should work if possible. It is suggested that he be given 30 drops
of tincture of stramonium three times daily for one week, then
50 drops three times daily for another week and 75 drops three
times daily from then on; 10 mg. of benzedrine sulfate should
be given in the morning and at noon. No benzedrine should be
given after 3 p. m. because of its tendency to produce insomnia.

EXOPHTHALMOS AFTER THYROIDECTOMY

To the Editor : — Can you give me some information on the treatment of
exophthalmos which follows thyroidectomy for acute exophthalmic goiter?
Following the operation there was only a slight protrusion of the eyes,
but approximately six months later the left eye became extremely
prominent and the right eye a little more than at first. This exophthalmos
is severe. The patient has a — 12 basal metabolic rate. I am interested
in knowing whether or not the administration of thyroid or any other
therapeutic agent is of any value in this type of case or whether surgery
offers the only possibility of relief. M.D., N. Y.

Answer. — Sometimes exophthalmos of the type described is
relieved by the administration of iodine. This may cause the
basal metabolic rate to be reduced to a lower level, with symp-
toms of hypothyroidism. It may therefore be necessary to give
both iodine and thyroid. This is the only hope of relieving the
condition medically. Surgical procedures should not be resorted
to unless the exophthalmos is so pronounced that prolapse of
1C e J'cball or corneal ulcers occur.

IMMUNITY TO TETANUS

To the Editor: — Will you please send me any information on record as to
whether or not recovery from a tetanus infection will confer permanent
immunity. Ralph E.- White, M.D., Santa Ana, Calif.

Answer. — The question cannot be answered until such a
patient has been followed over a period of years with tests of
the blood serum for amounts of tetanic antitoxin persisting.
There is every reason to believe however that, if a person has
once had an attack of tetanus and has recovered, response to a
second infection would be more prompt and effective. The
anamnestic antibody response is a well known phenomenon and
has been shown to apply to reinjections of tetanus toxoid. Prac-
tically, however, if the antitoxic content of the serum is not
known, prophylactic injection of tetanic antiserum is the only
safe procedure in any condition in which tetanus is likely to
develop.

POSSIBLE CONGENITAL SYPHILIS

To f he Editor: — A womon aged 28 was treated throughout her pregnancy
intensively with neoorsphenamine and a bismuth compound. At term
her Wassermonn reaction was 4 plus, but she gave birth to an appar-
ently normal child with a negative Wassermann reaction. Should this
child receive antisyphiiitic treatment, and if so at what age and in what
amount? Another case is exactly the same except that the second
child has a positive Wassermann reaction. What treatment would you
advise in this case ond at what age? ^ ew y or R

Answer. — The information given in regard to the first baby
is inadequate. If the blood serologic studies were done within
eight weeks after the baby’s birth, the report is not entirely
reliable as to the presence of syphilis in the child. However,
if subsequent serologic tests have shown the child’s blood to
be negative and if the baby has no clinical evidence of syphilis
there is no need of treatment for syphilis. Each month after
the second month of life that the serologic tests are reported
negative, the greater becomes the probability that the child
does not have syphilis. Accordingly, if the child is now more
than 2 months old and the tests are negative there is no need
of treatment for syphilis. Continued observation and reexam-
ination for syphilis until the child is at least 2 years of age
are, however, advisable.

If the time factors have been given the same consideration
in the second case as in the first, the second child should be
treated for syphilis immediately. If the positive test was taken
when the child was more than 2 months old, treatment is indi-
cated. If, however, the blood was taken from the umbilical
cord or during the first month of life, the test is in reality a
test of the mother and not the child, because the substance
which produces a positive Wassermann reaction may have been
carried over to the child, which would not produce syphilis.
On the other hand, if Spirochaeta pallida as well as the sub-
stance x was transmitted, the child will develop syphilis. In
the interpretation of the serologic tests in the newborn the time
factors are most important, and they were not stated in either
of these cases. If the second child has syphilis, treatment
should be started immediately. The method and manner of
treating a newborn child for syphilis has been outlined in a
recent publication of the Cooperative Clinical Group and may
be obtained from the Venereal Disease Division of the United
States Public Health Service, Washington, D. C.

FLEISCHMANN'S YEAST— ALLERGENS IN RICE

To the Editor : — In the two recipe books for allergic patients which hove
been published recently I find conflicting stotements with regard to
Fleischmann's yeast: One says that the product is mode of topioco and
the other soys that it is made of wheat. Each book claims to quote
the makers. Can you tell me which of these is correct? Can you tell
me whether wild rice contains the some allergen os polished or brown rice?

M.D., Illinois.

Answer. — Both recipe books are partly correct. The label
for Fleiscbmann’s yeast states that the product is fresh yeast
with cereal or tapioca flour, and it is probable that the product
contains either ingredient depending on market conditions.

Wild rice is a species of rice found in Canada, in the United
States and in other parts of the world. Wild rice belongs to
the genus Zizania, while the common brown rice belongs to the
genus Oryza. Although it is a different genus, it belongs with
common or brown rice in the family of Gramincae or grasses
It is difficult to say whether it has the same allergen, but it
undoubtedly behaves as do other members of the Gramincae.
In other words, it is likely to have an antigen common for the
Gramineae in addition to an antigen which is specific for the
genus or species. Generally speaking, the relationship is close
enough so. that it would not be advisable to substitute one for
the other in case of allergy to one of these rices.

15SS

EXAMINATION AND LICENSURE

Jour, A. M. 'A
Oct. 21, 1939

Medical Examinations and Licensure

COMING EXAMINATIONS

STATE AND TERRITORIAL BOARDS

Examinations of state and territorial boards were published in The
Journal, October 14, page 1511.

NATIONAL BOARD OF MEDICAL EXAMINERS

National Board of Medical Examiners: Parts I and II. Medical
centers having five or more candidates desiring to take the examination,
Jr'H- Ex - Sec " Mr. Everett S. Ehvood, 225 S. 15th Street,
Philadelphia.

SPECIAL BOARDS

American Board of Anesthesiology: An Affiliate of the American
Board of Surgery. Written. Part I. Various places throughout the
United States and Canada, Feb. 15. Sec., Dr. Paul M. Wood, 745 Fifth
Ave., New York.

American Board of Dermatology and Sypiiilology: Oral Phila-
delphia, Nov. 3-4. Sec., Dr. C. Guy Lane, 416 Marlboro St., Boston.

American Board of Internal Medicine: Written. Various sec-
tions of the United States, Feb. 19. Formal application must be received
on or before Jan 1. Sec., Dr. William S. Middleton, 1301 University
Ave., Madison, Wis.

American Board of Obstetrics and Gynecology: Written exami-
nation and review of case histories (Part 1) for Group B candidates will
be held in various cities of the United States and Canada, Jan. 6. The
final date for receipt of these applications was Oct . 4, 1939. General
oral and pathologic examinations (Part II) for all candidates (Groups
A and B) will be conducted in Atlantic City, N. J. f June 8-11. Applica-
tions for admission to Group A, Part II c-raimnafioii.r must 6c on file not
later than March 15. Sec., Dr. Paul Titus, 2015 Highland Bldg., Pitts-
burgh (6).

American Board of Ophthalmology: Written . Various cities of
the United States and Canada, March 9. Oral. New York, June 10.
Formal applications must be received before Jan. 1. Sec., Dr. John
Green, 6830 Waterman Ave., St. Louis.

American Board of Orthopaedic Surgery: Boston , Jan. 20-21.
Applications must be filed on or before Nov. 1. Sec., Dr. Fremont A.
Chandler, 6 N. Michigan Ave., Chicago.

American Board of Pathology: Memphis, Nov. 22-23. Sec., Dr.
F. W. Hartman, Henry Ford Hospital, Detroit.

American Board of Pediatrics: New York, April 30 and May i.
Kansas City, Mo., preceding the Region 111 meeting of the American
American Academy of Pediatrics, Seattle, June 2. Sec., Dr. C. A.
Aldrich, 723 Elm St., Winnetka, 111.

American Board of Psychiatry and Neurology: New York,
December. Sec., Dr. Walter Freeman, 1028 Connecticut Ave. N.W.,
Washington, D. C.

American Board of Radiology; Atlanta, Ga., Dec. 9-11. Sec.,
Dr. Byrl R. Kirklin, 102-110 Second Avenue S.W., Rochester, Minnesota.

American Board of Surgery: Part II. Atlanta, Ga., Nov. 15. Will
include candidates living in the South only. Sec., Dr. J. Stewart Rodman,

22 5 S. 15tli St., Philadelphia.

American Board of Urology: Chicago, Feb. 9-11. (The only exami-
nation session to be held in 1940.) Case reports must be submitted not
later than November 9. Sec., Dr. Gilbert J. Thomas, 1009 Nicollet Ave.,
Minneapolis.

Wien .

Medizinische Fakultat der Universitat
(1928) 83.2, (1932) 78.3
Hessische Ludwigs-Universitat Medizinische

Giessen '

Universitat Heidelberg Medizinische Fakultat.

(1912)

Fakultat,

.(1910)

.(1904)

81

W.l

Year

Grad

(1935)

School FAILED

George Washington University School of Medicine...

Medizinische Fakultat der Universitat Wien '. (1913), (1930)

Lhristian-Albrechts-Universitat Medizinische Fakultat, Kiel (1921)

Phdipps-Universitat Medizinische Fakultat, Marburg (1923)

Regia Universita degli Studi di Roma. Facolta di Medicina e

Chirurgia (1516)

Regia Umversita di Napoli Facolta di Medicina e Chirurgia (1933)

Twenty-four physicians were licensed by reciprocity and nine
physicians were licensed by endorsement from January 26
through July 20. The following schools were represented:

School LICENSED BY BECIPBOCITY Year

College of Medical Evangelists... (1918) California

College of Physicians and Surgeons of San Francisco. . (1905) Pfnna.

Georgetown University School of Medicine. . . (1926), (1929)Dist Colum.,
(1932) Minnesota, (1938) New York

Loyola University School of Medicine (1938) Ohio

Northwestern ” * * ■»*•*•« .(1935) New Jcrsrr

Rush Medical ■ (1931) Penna.

Johns Hopkins ' .(1922) New York

Tufts College Medical School (1930)

University of Michigan Medical School (1924)

University of Nebraska College of Medicine (1936)

Cornell University Medical College... (1934)

University of Oregon Medical School (1936)

Jefferson Medical College of Philadelphia.. (1923)

University of Pennsylvania School of Medicine (1932)

Medical College of the State of South Carolina (1938) S. Carolina

University of Vermont College of Medicine (1935) New Yorf.

Medical College of (1936) Virgin?

Univ. of Virginia ' >), (1937) UrflW

University of Manit " ...(1926) Louisiana

Year Endorsement

School LICENSED BY ENDORSEMENT Gra( J, 0 f

College of Medical Evangelists (1939, \\' FV

George Washington University School of Medicine.... (1937)N.h'J{' -

Northwestern University Medical School \r Ft

University of Minnesota Medical School S' if Ft

Cornell University Medical College (1935)N. B. . .

New York University, University and Bellevue Hos- y

University of Pennsylvania School of Medicine S 1 ! ! .lii'ti

Vanderbilt University School of Medicine (I936JN. B.iU- ^

* License withheld pending completion of internship.

New York
Michigan
Nebraska
New York
Oregon
Ohio
Penna.

Maryland June Examination
Dr. John T. O’Mara, secretary, Board of Medical Examiners
of Maryland, reports the written examination held at Baltimore,
June 20 -23, 1939. The examination covered nine subjects and
included ninety questions. An average of 75 per cent was
required to pass. One hundred and fifty-two candidates were
examined, of whom 145 passed and seven failed. The following
schools were represented:

Year

Grad.

Per

Cent

83.3

85.2
90

83.3
88.5
79.2
S3,

PASSED

School

College of Medical Evangelists (1939)

George Washington University School of Medicine (1939)

Georgetown University School of Medicine (1939)

Northwestern University Medical School (1939)

Rush Medical College ; ; 0937)

X.ouisiana State University School of Medicine (1939)

Tohns Hopkins University School of Medicine (1935)

(1936) S9, (1937) S3, (1938) SO, S3.3, 85, (1939)

77 5 7S.3, 79.2, S0.1, SI, 81.1, 82.1, 82.2, 83, 83.2,

S3 3, 84, 84. S4, 84.2, S4.2, 84.4, 85, 85, 85, S5, 85, 85,

85 5, 86, 86.1, S6.2, 86.6, S7, 87, 87, 87, 87, S7.1,

87.2, 87.12, S7.4, SS, 88, 88.5, 90, 90.2,

University of Maryland School of Medicine and College

of Physicians and Surgeons (1937)

(193S) 80, 82.2, 83.4, 84, 85.2, (1939) 7S.1, 78.2,

78 3 79 3 79.3, 79.5, 80.2, 80.2, 80.4, S0.5, 81, SI, SI,

815’ 83, 82, S2.2, S2.3, 82.5, S2.5, S3, 83, S3, 83.3,

S3V 83.3, S4, 84, 84, 84, S4.2, 84.3, S4.3, 84.4, S5,

85 S3, 83, 85.2, S5.3, 85.4, 85.5, 85.6, 86, S6.1, S6.2,

S 6 3 S6.4, S6.5. S6.5, 86.5, 87, 87, 87, S7, 87.1, 87.1,

87 4 SS, SS, SS, 88.3, S9, 89, S9, S9.1, S9.1, S9.2,

89!s! 90.4, 90.5, 90.5, 91, 92

Harvard Medical School.........-...; ,

New York University College of Medicine ( 939) 81, 86.3^

Duke University School of Medicine. (1939) 79..

University of Oregon Medical School noret

Medical College of Virginia uy -'

Louisiana June Report

Dr. Roy B. Harrison, secretary, Louisiana State Board o
Medical Examiners, reports the written examination w
New Orleans, June 1-3, 1939. The examination covered
subjects and included 100 questions. An average of 75 pw c
was required to pass. One hundred and forty-three can 11 *
were examined, all of whom passed. Seven physicians »
licensed by reciprocity. The following' schools were represen

Year JA

School WSSED Grad-

Northwestern University Medical School °

School of Medicine of the Division of the Bio logics M03R)*

Sciences ; /}olQ)t

Louisiana State University School of Medicine ■ '

82.9, 83.1, 83.6, 83.7, 83.7, 84.2, 84.2, 84.2, 84.4,

84.5, 84.7, 84.7, 84.7, 84.8, 84.9, 85, 85.1, 85.2, 85.2,

85.2, 85.4, 85.5, 85.5, S5.5, 85.5, 85.6, 85.6, 85.7,

85. 5, 85.9, 85.9, 85.9, 86, 86.1, 86.1, 86.1, 86.2, 86.2,

86.3, 86.4, 86.4, 86.4, 86.6, 86.7, 86.7, 86.9, 87, 87,

87, 87.5, 87.6, 87.8, 88.1, 88.3, 88.4, 88.7 . . , 1Q

Tulane University of Louisiana School of Medicine... -I

86.6, * (1939) 84.7, t (1939)§ 80.5, 80.5, 80.9, 8 1,

81.4, 81.4, 81.5, 81.5, 81.5, 81.8, 81.9, 82.4, 82.5,

82.5, 82.6, S2.6, 82.7 , 82.7, 82.7 , 83, 83.2, 83. 5, 83./,

83.7, "

84.1,

84.4,

85.2,

86.3,

87.3, S7.8, 87.8, 88.4 . . ,,053)

Johns Hopkins University School of Medicine /iQtfi)

Tufts College Medical School

Creighton University School of Medicine

Year

83.1

823,

85 . 2 ,

School

LICENSED by RECIPROCITY

Grad.

81.3

University of Arkansas School of Medicine.

University of Pennsylvania School of Medicine. (uy>4)

University of Pittsburgh School of Medicine. . • ■ • • • ■ •

University of Tennessee College of Medicine . . 0 936L t

Baylor University College of Medicine (1930), t

•License withheld pending completion of internship. ... rcC eirr * f
f These applicants have received the M.B. " cgrec , no t hern i‘< 5 f'
M.D. degree on completion of internship. Licenses n United S tJ
J License withheld pending completion of internsnip
citizenship. . ...

§ Licenses withheld pending completion of intern J •

843
SJ?
80 S

trifh

ArU? 1 ?

Fcr.rJ-

T

&

Volume 113
Number 17

BOOK NOTICES

1589

Book Notices

Now and Nonofllclal Romodlcs, 039. Containing Descriptions of tho
Articles Which Stand Accepted by tho Council on Pharmacy and Chom-
Istry of the Amorlcan Medical Association on January I, 1939. Cloth.
Trice, $1.50. Tp. 017. Chicago: American Medical Association, 1939.

New and Nonofficial Remedies is of interest and value to many
classes of persons who are concerned with the use of medicinal
preparations — physicians, pharmaceutic manufacturers, chemists,
pharmacologists, government officials, teachers, medical students
and ultimately the lay consumer, in whose interest that of all
must be judged.

To the physician the book is a reliable source of therapeutic
and posologic information on the newer materia medica. To the
pharmaceutic manufacturer it represents a record of the best
achievement in his field and a goal toward which he may bend
his efforts in improving bis own ends. To the chemist it is a
book of standards. To the pharmacologist it represents a com-
pendium of knowledge of the newer drugs. To the government
official it represents a book of standards for preparations which
have not become official and a yardstick on permissible thera-
peutic claims made for new products of proved or promised
therapeutic value. To the teacher it is such a text on progressive
modern materia medica as is nowhere else available. To the
medical student it is a valuable source of training in rational
therapeutics, a vade mecum for his subsequent professional
career. To the lay consumer it is a valuable protection that
operates indirectly through his physician. Criticisms of the
form and manner of presentation of data in this book have been
made with justification from the points of view of the various
classes enumerated. The fact remains, however, that each can
find in it what he looks for if he will take the trouble to use the
paraphernalia provided.

New and Nonofficial Remedies 1939 conforms to the general
pattern of the thirty-two annual volumes which have preceded it.
Some new drugs have been added, a great many new dosage
forms of already accepted drugs have been added, some drugs
have been omitted either for conflict with the rules or because
they have been taken off the market. Most noteworthy among
the newly accepted drugs are the crystallized estrogenic prepa-
rations Estrone (theelin) and Estriol (theelol). In line also
with the modern trend toward the use of crystalline principles
instead of extractive preparations are the new crystalline vita-
min principles Thiamin Chloride (crystalline vitamin Bi hydro-
chloride), Nicotinic Acid (vitamin B.) and Nicotinic Acid
Amide. Other newly included drugs are Benzedrine Sulfate,
Prostigmine (as the bromide and methylsulfate) and Immune
Globulin (Human).

Noteworthy omissions are those of serobacterins, because of
failure to live up to their promise of therapeutic value, and “Sup-
positories Salyrgan”, found to be the cause of undesirable irri-
tation.

The chapter formerly called Organs of Animals has been
dispersed and the various endocrine preparations formerly
included in this chapter appear alphabetically under their indi-
vidual names : Ovary, Pancreas, Parathyroid, Pituitary and
Thyroid. Drastic revision of the monograph Ovary was made
necessary by the addition of new crystalline principles.

The chapter Vitamins and Vitamin Preparations has been
revised to use the newer chemical nomenclature to present the
Allowable Claims” up to date. Other revisions are found in
the articles Anesthetics Local, Bismuth Compounds and Fibrin
Ferments and Thromboplastic Substances.

Dissociation of Tubercle Bacilli: Investigations on the Mammalian Types
including BCG. By J. Frlmodt-Moller. Acta tuberculosea Scandlnavlca,
Supplementum II. Paper. Pp, 256, with 49 illustrations. Copenhagen :
Elnar Munksgaard, 1939.

This extensive monograph in English on the dissociation of
tubercle bacilli, presented to the University of Copenhagen in
fulfilment of the requirements for the degree of doctor of medi-
cine, also appears in the Acta tuberculosea Scandinavica. It
is a laudable volume from the standpoint of reviewing ably a
subject which has been controversial from its explosive incep-
tion about a decade ago. The author reports on part of exten-
sive investigations (reported in 1932 and 1935) carried out in
the tuberculosis department of the State Serum Institute at

Copenhagen on matters relating to the types of tubercle bacilli.
Tbe purpose at hand was to study the variations of bovine and
human strains isolated from tuberculous material from human
beings and cultivated on artificial nutrient mediums and to
examine any possible changes of their virulence. It was beyond
the scope of tbe work to describe strains which displayed varia-
tions solely as a result of animal passages. These investigations
having proved to be closely related to studies on variations in
the growth of tubercle bacilli carried out by other workers,
it was natural to include tests of their results and methods and
to supplement them with dissociation experiments on the BCG
strain. A possible justified criticism might be offered that this
is not an original investigation but a repetition or verification
study in which no newly devised methods are used with a view
to advancing the horizon of knowledge on this subject. Thus
also the conclusions give little new information for so exten-
sively recorded an investigation. However, many will welcome
this book for its rounded presentation of the previous investi-
gations on dissociation (chapter n) and further attempts to
dissociate BCG (chapter in). Besides dissociation, generally
understood to mean variation in the structure of bacterial
colonies, which variation may be associated with a change in
virulence (a term first employed by Petroff in 1927), the author
utilizes the Royal British Commission on Tuberculosis terminol-
ogy of 1907 in which a convenient term for the greater or
lesser facility with which a tubercle bacillus grows on artificial
nutrient mediums was introduced, the words dysgonic and
eugonic meaning respectively a sparse and a vigorous growth.

The chief impression gained by the author when looking back
on the investigations reviewed is the great multiplicity of
observations, which however in only few cases will bear close
examination. Thus it seems justifiable to report a series of
experiments in which it has been possible, according to the
author, with a simple techpic to reproduce dissociations with
strains of both human and bovine types. In addition, experi-
ments on the dissociation of the BCG strain are included.
Chapters vi to xn are taken up with a consideration of the
author’s investigations, and an appraisal and summary are
included in chapters xiii and xv, with an appendix of experi-
mental records. The points made in the summary are that pure
cultures of both the dysgonic and the eugonic colonies of human
tubercle bacilli could be preserved for an unlimited period
through any number of transplantations or animal passages, and
the two variants had the same virulence for guinea pigs and
rabbits as the standard human type, with no mutual differences.
The bovine dissociants were in many cases mutually different
in their growth, tbe dysgonic colonies being smooth, dome shaped
and bright and the eugonic colonies irregular, finely wrinkled
and dry. Rough eugonic Petroff medium colonies contained
fewer viable bacilli than dysgonic colonies, a fact which must
be considered when appraising virulence. An acid Lowenstein
medium stimulates the formation of eugonic secondary colonies
(R forms), as stated by previous investigators. The factor
inciting this was not determined. It cannot be said that it is
merely caused by adaptation to glycerin or by increased resis-
tance acquired through lysis. The dissociations always took
place in the direction from dysgonic to eugonic forms (S,
smooth, to R, rough). The bearing of dissociation on the rela-
tionship between the human and the bovine type is debated, but
so far no transformation in vitro of a bovine to a human type
has been demonstrated. Repetition of Petroff’s experiment on
forced dissociation of BCG by means of cultivation on Sauton
with rabbit immune serum proved to be negative, no change
being found in the mode of growth or the virulence of the BCG
strain. Reservation is being taken in respect to Petroff’s claim
of having demonstrated virulent forms of BCG cultures; never-
theless, though practically minimal, the possibility is entertained
theoretically since BCG-like variants were found to arise from
typical dysgonic bovine strains, and avirulent eugonic variants
actually regained their virulence by animal passages. Tbe disso-
ciation of H 37 was substantiated, however, only on the assump-
tion that H 37 was originally bovine and not of human type
(which is contrary to all the published data on H 37).

The monograph is well worth reading, especially for its
rounding out of a subject which still requires further solution
and possibly to be attacked by more exacting and conclusive
methods. • It may possibly resolve itself when dissociation as a

1590

BOOK NOTICES

whole is more fully understood. This has happened before in
tuberculosis with the acquisition of additional knowledge, after
which a few well planned experiments have been able to settle
a problem. However, since the specialist and investigator must
be aware of the problems involved in the present interpretation
of tuberculosis, this volume should be accepted heartily by those
wishing to be conversant with the subject of the dissociation
of tubercle bacilli and how this affects the status of BCG today.
It is presented in good form and in a clear, well written English.
The cost is nominal.

Medical Jurisprudence and Toxicology. Ily William D. McNally, A.B.,
M.D., Assistant Professor of Medicine and Lecturer In Toxlcolopy, Rush
Medical College, University of Chicago, Chicago. Cloth. Trice, $3.75.
Pp. 386, with 23 Illustrations. Philadelphia & London: W. B. Saunders
Company, 1939.

The purpose of this book, as stated in the preface, is to pro-
vide medical, pharmaceutic and dental students with a textbook
covering the essentials of toxicology and also to furnish physi-
cians with information concerning medicolegal testimony. Seven
eighths of the book is composed of material on poisoning, blood,
semen and hairs, all of which has been abridged from the
author’s larger work on toxicology published in 1937 ; 263 pages
of this section is devoted to a discussion of poisoning in its
various forms: homicidal, suicidal, accidental and industrial.
Major emphasis is placed on clinical aspects such as methods
of diagnosis and adequate treatment of various poisonings. One
eighth of the book represents newly written chapters on courts,
sudden or violent death, firearms identification and insanity.
The treatment of these phases is rather superficial.

Although modestly concealed by the author, drama stalks
throughout the pages of the book. Drawing on his wide court
experience as expert toxicologist in causes cclcbrcs of the past
quarter century, the author regales his reader with accounts of
mass murder by arsenic for the purpose of collecting insurance
(p. 169), the application of geometry as well as chemistry in
exposing a “framed” cyanide murder (Orpet case, p. 267), the
attempted murder of an archbishop, his friends and associates
by putting poison in the soup served at a banquet in the prelate’s
honor (p. 171), and even the detection of hydrocyanic acid in
the blood of one of the victims of the Cleveland Clinic disaster

(p. 266).

Apparently the process of condensing from the older and more
voluminous text was conducted largely by the “scissors and
paste-pot” method. Paragraphs and pages were lifted from
the older book with the result that in this volume transitions
are oftentimes abrupt, owing to the elimination of intervening
material. Unfortunately this material was largely copied
verbatim, including mistakes and typographic errors, so that a
student who attempts to follow up the author’s references will
be required to do some careful detective work. The literature
of toxicology has become so extensive that it is impossible to
cover the entire field in any moderate sized volume. For this
reason the author may be pardoned for the many omissions.
While this book is a fairly satisfactory elementary textbook, it
is unfortunate that the author and publisher did not use greater
care in providing a more accurate and reliable work for student
and reference use.

Traits d’ophtalmoloflie. Puhlte sous les auspices de la Soclete fran-
caise d'ophtalmologle. Par MM. P. BaUliart, Ch. Coutela, K. Redslob,
E Velter. Rend Onfray: Secretaire general. Tome II: Physlologie,
teclmtQues d'examen. Par MM. P. BallUart et al. Cloth. Pp. 1,144,
with illustrations. Paris : Masson & Cle, 1939.

This is the second volume of the new eight volume encyclo-
pedia of ophthalmology that is being produced under the
auspices of the French Society of Ophthalmology. It is divided
into two parts, physiology and technic, with the following sub-
' divisions : the protective apparatus of the eye, by Magitot and
Rossano of Paris; sensibility • of the eyeball, by Cense and
Thurel of Paris; nutrition and circulation of the eye, by Bailhart
of Paris; conjunctival circulation, by Rollin of Paris; endocular
■ fluids and nutrition, by Magitot of Paris ; ocular tension by
•Magitot; physiology of extrinsic ocular motility, by Nordman
of Strasbourg; intrinsic musculature, by Magitot; theoretical
and applied optics, by Haas of ■ Paris ; physiologic optics, by
Joseph of Paris; biologic optics, by Leplat of Liege; entopic
phenomena by Viallefont of Montpellier; changes an the retina
under the influence of Sight, by Magitot; physiology of vision,

Jobs. A. J!. A
Oct. 21, mi

by Pieron of the College de France, and binocular and spatial
vision, by Opin of Toulon. The chapters on the technic d
examination are shorter and divided in the following manner:
methods of examination of the living eye, by Lemoine and Valois
of Never; optotypes, by Lemoine and Valois; trial cases, by
Joseph of Paris; instruments for the measurement of refraction,
by Haas of Paris; skiascopy, by Joseph of Paris; perimetry,
by Dubois-Poulsen of Paris; tonometry, by Dubar of Paris;
ophthalmodynamometry, by Rollin of Paris; methods of pho-
tography of the eye, by Maivas of Paris; radioscopy and
radiography, by Hartmann of Paris ; methods of localization tf
intra-ocular foreign bodies, by Dollfus of Paris, and electromag-
nets and sideroscopes, by Veil of Paris. The chapters are net
of as uniform caliber as are those of the first volume. Some,
particularly those of Magitot and Bailliart, are brilliant bet
tend slightly toward the expression of personal opinion, whereas
others are somewhat skimpy', especially the one on biomicros-
copy. Isn’t it interesting to see that term, coined by our dm
E dward Jackson, coming into such universal use? Striking is
the lack of chauvinistic attitude throughout the chapters, for the
bibliographies are international in character and full credit is
given, regardless of differences in international politics. Tbs
is refreshing in contrast to the regimentadve attitude that pre-
vails elsewhere on the continent. The mechanical aspect of fa
volume is good and the majority of the illustrations are excellent
Particularly' good are some of the color plates. After the second
volume has been digested, the feeling still remains that this is
a “must have” work.

A Textbook of Obstetrics with Special Reference to Nursing Care. $f
Charles B. Reed, M.D.. F.A.C.S., Associate Professor of Obstetrics, bora-
western University Medical School, Chicago, and Bess I. Cooley, •
Supervisor and Instructor, Department of Obstetrics, Wesley 5jw»
Hospital. Chicago. Cloth. Price, $3. Pp. 47G, with 209 illustraw--
St. Louis : C. V. Mosby Company, 1939.

The authors are a physician of many years’ experience and a
competent supervisor of nurses at an excellent hospital, i er
lias been a tendency for textbooks on nursing gradual;
broaden their subject matter until the content pertains more
the practice of medicine than to that of nursing. This j
goes further in that direction than most. It contains sew
excellent chapters, particularly on anatomy and phjs° Sk
There is a good chapter on anesthesia and analgesia, an
good chapter on normal labor. . a.

The arrangement is not always orderly; lor examp t, ^
chapter on antepartum care digresses to give a descrip 1 ^
aseptic technic to be observed during the birth of the cm ■
is undesirable and entirely out of place. There are a n
of statistical facts, for example those of multiple preplan ^

those on intra-uterine mensuration of the fetus, w™ c ’ c ^
facts and formulas that could not be of value to the nU * n "o«
paragraph concerning the thyroid gland states t a,
series, 60 per cent of pregnant women were abor e ^
of glandular hypertrophy.” No reference is given nor ,
any references in the book. This statement on ^ ^

gland would tend to give the student nurse an entire 1 nc y.
conception concerning thyroid disease complicating P ^
The chapter on toxemias might lead the nurse o
certain methods of treatment are mandatory rather ec ] 3ffi p;a
available to the physician. There is a statement a o ^ j;
but no discussion of preeclamptic toxemia, j ,e concC ni-
poorly arranged. There is also the following sta ™ !0 by

ing the treatment of eclampsia, which is not su ^ ; 5 fi
most obstetricians at the present time: It e D0 $jib!e ty
labor, the process should be hurried as , ,|, e uterfa

forceps or by version and extraction. If not in a > j n
activity can be induced by the bag, bougie, °t P
emergency by cesarean section under gas _ani es 1

In one chapter there is given a list of eign > should Im®' 1 ’
ectopic pregnancy which, it is said, the 0 b s tdricV-

about. This might be confusing even to the t (,y pfh~ :

Two of these types of pain could be ebet e -

examination. . , E

The authors write easily about the s, gns <} u ring P'£
ciency and the value of vitamin E for . n the pt cvcPil ‘,i

nancy. While vitamin E appears to be of ' connc ction vX--'
of spontaneous abortion, its description m
be confusing to the student nurse.

Volume 113
Number 17

BOOK NOTICES

1591

- The book contains descriptions of several methods which
: appear to be entirely obsolete and some of which are considered
•to be dangerous; for example, resuscitation of the asphyxiated
■baby by means of Byrd's method of manipulation.

In connection with the advice concerning intravenous trans-
fusion, a description of the technic for cutting down on, and
-ligation of, the vein is given. This is a procedure which is
almost obsolete, and yet there is nothing in the description to
indicate that this is so. A description of the Walcher position
is interposed between paragraphs on curettage for incomplete
abortion and paragraphs on artificial interruption of pregnancy.
A statement is made concerning artificial rupture of the mem-
•branes at term for placenta praevia centralis. Surely the authors
must have had in mind placenta praevia partialis or marginalis.
There is a description of the induction of labor by four doses of
from S to 10 grains of quinine sulfate. It is suggested that the
patients may be given a drachm of 1 : SO dilution of chemically
pure sulfuric acid in a glass of water for each 5 grains of
quinine. Treatment which is rarely employed is out of place
in a book on obstetrics for nurses. A description is given of
the use of laminaria tents for the interruption of pregnancy.
This method of induction of labor is not surely aseptic and
there is no reason to include this in a textbook on obstetrics or

• on nursing. There are a number of excellent outlines for the
setup of the operating rooms for various obstetric procedures
•which should be of considerable value to the graduate nurse,
and particularly to one who is instructing nurses in obstetric

• procedures.

This book would have been of greater value if it had been
■ published in condensed form as a handbook of the nursing technic
of obstetric procedures.

Psychlscher Befund und psychiatrische Diagnose. Von Professor
Kurt Schneider, Director des Kllnlsclien Instltuts der Deutschcn For-
schunesanstalt fur Psychiatric (Kaiser Wllhelm-Institut) In Miinclien.
Paper. Price, 1.40 marks. Pp. 27. Leipzig: Georg Thlcme, 1039.

This is devoted to a discussion of symptoms and their evalua-
tion in psychiatric diagnosis. It is intended primarily for prac-
titioners. The subject is introduced with a suggestion that
disturbances in the individual functions be sought for and inter-
preted and, from these symptoms, a diagnosis be built. The
more frequent psychoses, schizophrenia and cyclothymia, and
the demarcation of these psychoses from neuroses, psychopathic
personality and toxic and organic cerebral conditions are
-stressed. Disorders of perception, of thought and mood and of
will and instincts are considered. Symptoms are then grouped
into those which are significant for a diagnosis of schizophrenia
and those which are more general and can be utilized as diag-
nostic aids only against the background of the total clinical

• picture. Interspersed are warnings against pitfalls in the inter-
pretation of symptoms and cautions as to common sources of
errors. This all too brief monograph is a concentrate of an

• extensive psychiatric experience. A study of its pages will
. reward the prepared reader, yet one questions its usefulness for
■ the general practitioner. The average physician, allergic to
. psychiatric phraseology, may find this condensed presentation,
, the delicate distinctions of ideas and categories and the terminol-
. ogy too formidable for ready usage.

Lungenabszess und Lungenabszodierunccn im Kindesalter. Von Dr. mcd.
Sotirlos Roufogalls. Mit einem Geleltwort von Prof. Dr. med. F. Goebel,
Dlrektor der Klnderkllntk der Medtzln. Akademle, Diisseldorf. Paper.
Price, 16.50 marks. Pp. 160, with 37 Illustrations. Leipzig: Johann
Ambroslus Barth, 1939.

Pulmonary abscess in the opinion of Professor Goebel, who
writes the introduction, has received little attention in the
pediatric literature (German), which he notes is in marked
contrast to the extensive consideration given the subject in the
literature of surgery and internal medicine, and this literature

is concerned largely with the disease as seen in the adult. The
generally accepted causes of pulmonary abscess are considered
impartially; in fact all through the monograph the author pre-
sents data and elaborates their bearings on the problems, with
no attempt at empasizing his own point of view, which is that
of a pediatrician. Tonsillectomy is noted as a rather frequent
cause of pulmonary abscess, though at one time it was thought
to be a rare or; in Germany, a nonexistent etiologic factor in
this disease. Diagnosis is chiefly by the x-rays, though the
Physical signs are clearly and- carefully stated. In treatment

the author is conservative as to radical operation. He states
that, whereas formerly preference was given to surgical inter-
vention, today operation is seldom advised unless empyema is
present. (The monograph concerns children only.) Though
strongly conservative on the question of surgical intervention,
the author feels that there are cases in which external operation
should not be postponed, especially in older children. He
regards it as extremely difficult to lay down rules as to the time
to operate as well as to determine the right time in any par-
ticular case. In most cases the best results have come from
general treatment by the pediatrician. He speaks well of bron-
choscopic aspiration, but he has had limited opportunity for
observing its effect in his own cases. The younger the child
the worse the prognosis of pulmonary abscess, according to his
experience. The illustrations are all reproductions of roentgeno-
grams; they are well chosen and show clearly what they are
intended to show. The statements are well documented by
references and case reports. The general excellence of the
book and the wealth of detail would justify a good index for
ready reference. In common with similar monographs, this
one has only a table of contents.

Tho Licensing of Professions in West Virginia. By Frances Priscilla
De I.ancy, Instructor in Polilical Science, West Virginia University, Mor-
gantown, West Virginia. A Dissertation Submitted in Partial Fulfilment
of tho Requirements for the Degree of Doctor of Philosophy in the
Graduate School of Arts and Sciences of Duke University. Cloth. Price,
$2.25. Pp. 197. Chicago, Illinois : Foundation Press, Inc., 1938.

Much has been said concerning the defects of our various
systems of professional licensure, but little has been written
about the fundamental principles or social theories on which
such regulation must rest. In her doctoral thesis Miss De Lancy
has analyzed the professional laws of West Virginia and sum-
marized their history. For the purpose of her study she has
formulated a definition of the term profession both interesting
and unique, namely “that organized vocation in which individuals
are licensed by the state after a period of formal academic
education and training in an approved professional school.” So
restricted, the term excludes such long recognized professions
as the ministry, journalism, teaching and the stage because
they are not licensed by the state. It also ignores such newer
aspirants to professional recognition as plumbers, realtors and
barbers on the ground that for them no formal education is
deemed necessary. In her discussion of the administration of
licenses the author has shown unusual discrimination in the
appraisal of the functions of professional associations. Unfor-
tunately it is erroneously stated that Negro physicians are not
admitted to membership in the American Medical Association.
Altogether the book is stimulating and informative. An excel-
lent bibliography enhances its value.

Schilddrusc, Jod und Kropf: Kliniscbc und experimentelle Unter-
suchungen. Von Jinx Saegesser. Helvetica medlca acta, Supplcmentum
IV, 1939. Paper. Price, 10 Swiss francs. Pp. 163, with 20 illustra-
tions. Basel: Benno Schwabe & Co., 1939.

According to the conclusion on page 162, the purpose of this
book is goiter prophylaxis. With two exceptions (and two
translations) only German literature is quoted. On page 94
the analyses on one sample of blood are given, in micrograms
per hundred cubic centimeters ( 7 %), as from 8.2 to 69.2. With
750 per cent error it is rather difficult to understand how small
differences in the results of iodine analysis can be used for
theoretical work. Furthermore, there is a peculiar method of
using the analyses. The micrograms per hundred grams ( 7 %)
in thyroid, heart, lung, liver, kidney, muscle, brain, spleen and
skin of a rat are added together and the total is found to be
from 1,677 to 8,894 micrograms in the different experiments,
and yet in one case the thyroid is said to contain only 721
micrograms. Just what these figures mean it is impossible from
reading the entire book to determine, since the weight of no
organs is given, and yet on the basis of these experiments the
exact rates of iodine anabolism and catabolism are estimated.
The alcohol-insoluble iodine in the blood is stated to be almost
entirely in the corpuscles and it is concluded that this iodine
in the corpuscles is what passes out in the urine, although in
another place it is stated that the process of iodine catabolism
has to be gone through with in order to make this iodine alcohol
soluble. On page 101 it is stated that simply raying the skin
with ultraviolet causes an increase in the iodine content of the

1592

BOOK NOTICES

rat and that the additional iodine must have been absorbed
through the skin and lungs (presumably from ordinary air),
but the values which yon Fellenberg has given for the iodine
content of air would make the increases noted impossible dur-
ing the time of the experiment ; i, e. the rate increased from
4,718-4,767 to 8,774-8,894 micrograms in four days. Wheat
grains were raised in one hour of ultraviolet irradiation from
7 to 16 micrograms, and the author says this is in harmony
with von Fellenberg’s observation that the flora has more
iodine in the summer! On page 145 are given data on five
cretins in whom thyroids had been implanted. To use this
procedure seems a pity, since it is well known that thyroid
administered by mouth or subcutaneously can be very much
better controlled than thyroid grafts, which will not grow.

Symptoms and Signs in Clinical Medicino: An Introduction to Medical
Diagnosis. By E. Noble Chamberlain, M.J)., M.Sc., F.R.C.P., Physician
to Out-Patients, Royal Liverpool United Hospital, Royal Infirmary
Branch, Liverpool. With a chapter on The Examination of Sick Children.
By Norman B. Capon, M.D., F.R.C.P., Lecturer In Diseases of Children,
University of Liverpool, Liverpool. Second edition. Cloth. Price, $ 8 .
Pp. 435, with 318 illustrations. Baltimore: William Wood & Company,
1938.

This edition is essentially the same as the first, and it must
be remembered that physical diagnosis is a static rather than a
dynamic science. There is, however, a change which adds to
the satisfactory arrangement of the book, namely the collection
into two chapters of all the laboratory data which had been
scattered throughout the volume. There has also been added
a table of biochemical standards. The book consists of thirteen
chapters. The first two are more or less general and include
the history taking, the physical examination and the external
characteristics of disease. The next seven are devoted to impor-
tant body systems, with two chapters on the nervous system.
Succeeding these is a chapter on fever, another on examination
of sick children and the two on laboratory data. As far as
physical diagnosis is concerned, the chief objection to the book
is the slight space devoted to important procedures in physical
examination. Thus, percussion of the lungs is dealt with in
what is equivalent to about two pages when four illustrations
are deleted; incidentally, two of these, figures 77 and 78, are
excellent, whereas figures 79 and 80 seem to be redundant.
About the same amount of space is devoted to percussion of
the heart. Auscultation is likewise dealt with rather briefly,
as are other methods of physical examination which require the
use of the four senses. To one of the senses is allowed a con-
siderable amount of space; not only are a good many words
written about the division of physical diagnosis which has to
do with inspection, but also there are innumerable and excellent
illustrations to explain the written contents. In addition to
many photographs there are several colored plates and a few
diagrams. The book can be recommended for the beginner in
medicine. It is reasonably complete and deals largely with
elementary essentials in the diagnosis of disease.

fiber die integrative Nator der normaien Harnbildung. Von Costa
Ekeliorn, D : R med. Telle I, II und III. Paper. Pp. GIG ; GI9-1137 ;
1I39-I43I. Helsingfors: Mercators Tryekeri, 1038.

This wordy treatise is written by a native of Sweden in
German and published in Finland; the first sentence of the
preface states that it is a continuation of the author’s previous
book “Principles of Renal Function,” which was published in
English. The author first assumes that the glomerular filtrate
is an ultrafiltrate of the blood and that the kidney tubules are
impermeable to creatinine and only slightly permeable to urea.
He calls them “schlackenstoff” to distinguish them from
"schwellenstoffe,” or threshold substances, including salts and
water. Later, however, he spends much space disproving the
impermeability of the tubule for creatinine. .He states that the
glomerular capillary blood pressure may be so high as to equal
half the normal systolic arterial pressure, and therefore the
glomerular filtrate volume averages about one fourth the renal
blood volume. On the assumption of impermeability to creati-
nine', he quotes tables from Rehberg’s 1926 publication to show
the amount of ultrafiltrate and the amount of absorption of salt,
water and urea back into the blood. The author states that
wheh the reabsorption of water decreases during diuresis the
reabsorption of urea decreases and that therefore there is more
water and urea in the urine. The glomerular filtrate, he.sajs,

Jou*. A, 51. i.
Oct. !l, W)

is about 125 times the volume of the urine. Therefore 111
volumes are reabsorbed. He accepts the opinion that the
increase in the nonfiltrabie constituent of the blood as it passes
through the glomeruli controls the amount of reabsorption of
salt in the convoluted tubules of the first order. The bool:
might be said to end with the pointing out of many unsolved
problems in kidney physiology and of analogies between these
problems and problems connected with the secretion of gastric
juice.

Nursing Mental Diseases. By Harriet Bailey, R.N. Fourth edition.
Fabrikoid. Frlce, $2.50. Pp. 2G4. New York : Macmillan Company, 11%

This is a concise, practical, informative and interesting text-
book for the instruction of nurses fn the understanding and
management of psychiatric patients. The early chapters deal
with the history of the care of the mentally sick and with legal
aspects of mental disorders, followed by a genera! discussion
of personality development, causes and classification of menu!
disorders, symptoms and special nursing measures required in
the care of psychotic patients. Especially commendable is (be
chapter detailing such nursing procedures as the administration
of food, relief of insomnia, prevention and treatment of bd
sores, attention to evacuation of the bowels and bladder, tk
management of excited patients and precautions against suicide,
which are so important and sometimes so difficult in the care
of the mentally ill. Chapters vnr to xxr describe specific menial
disorders and, in brief, the special nursing procedures requisite
to each. Later chapters deal with methods of treatment such
as occupational, recreational and physical therapy', which m
hospitals are usually under the supervision of specially trained
workers • but which the nurse may be called on, especially m
private practice, to direct. In conclusion there is a valuable
discussion of measures for the prevention of mental illness and
the promotion of mental health, and finally an excellent bibliog-
raphy of suggested supplementary reading, including not on)
didactic but also popular writings on the subject of w™ 3
illness such, for example, as Shakespeare's King Lear an
Timon of Athens.

Ker's Manual of Fevers. Revised by Frank L. Her, B.A., M-B-. 9^,

Senior Assistant and Deputy Medical Superintendent, UUte W®
Hospital, Birmingham, England. Fourth edition. Cloth, v,, ' r <llj
Tp. 354, with 15 illustrations. New York & loDdon: Oxford
Press, 1939.

In the preface of this edition the son of the original aud' 0 ^
has expressed his desire to adhere to the aims of _h>s j
As a consequence revisions iti the text consist chiefly o ° .

changes or additions made necessary because of .advance. '
edge, particularly with respect to treatment., including c
therapy. To any one familiar with the subjects discuss *
contents of the book should be refreshing. It is readily apP
that the clear and complete descriptions of the various con
diseases as presented by Claude B. Ker are the resu 0 ^

observation, careful thought and extensive experience. ^
are few technicalities but much information that is 50U -j.

practical. The volume is likely to receive its greatest a PI> ^
tion from those who have had training in contagious
hospitals. To the medical student the chapters on , 5 . jg,
and typhoid should be of special interest. The SIX ... (t3 .
though not in color, are all good, particularly the ones i ^
tive of smallpox. A fable of infectious diseases at t e
the volume will be valued by the student.

Bericht uber den VIII. Internationale!! K o n g r e s s f b e M n I a ! I ^ . petrr
Berufskrankbelten Frankfurt a. M. 26. bis 30. SrMjJ-

der Scbirmherrschaft dea Hcrrn Reichsarbeitsmln s . 3 j 5 .lL-.

Bouden I und II. Paper. Price, 50 marks per set. IP- "
with 145 illuslrations. Leipzig: Georg Thleme, J-MJ- .

of the

This report contains the proceedings and papers t i on3 j

International Congress for Industrial Medicine an 1
Diseases, held in Frankfort on the Main m ^ the

number of papers presented by European vor ter s . ( ’ wl0

American reader an excellent opportunity to gai p, rS

their practices and experiences. Although 53105 0 nc5 art
are in German, French or Italian, many of the S ^
provided with excellent English summaries. re55 of P rc "

a joint discussion, by the two. sections of the co S / ^

disposition and wear and tear in their rela io

Volume 113
Number 17

BOOK NOTICES

1593

accidents and occupational diseases. Such subjects as the
relation of the condition of the body to the effect of injuries,
cutaneous conditions as a factor in occupational injuries and
neurologic and genetic aspects indicate the extent to which
this topic is discussed. In one paper special attention is given
to the problem in the so-called mass production industries.
Volume it, the larger of the volumes, contains the papers of
the section on industrial surgery and those of the section on
occupational diseases. The industrial surgeons confined their
discussions to two topics: (1) injury to the peripheral nerves
with the exception of the sympathetic system and (2) injuries
to the foot. The cause, nature and modes o f treatment of these
injuries arc discussed thoroughly and at length by many world
authorities. The section on occupational diseases provides papers
on scores of topics, including hydrocarbon solvents, manganese
pneumonia, occupational cancer, silicosis, asbestosis, carbon
bisulfide and chlorinated hydrocarbons, chiefly trichlorethylenc.
It appears from the proceedings of this international body that
the problems relative to occupational diseases are at this time
essentially the same for all the industrial countries of the world.

Gynaecology. By Herbert II. Schllnk, Lecturer and Examiner In
Gynaecology, University of Sydney, Sydney. Cloth. Price, 32s. Gd. Pp.
557, with 181 Illustrations. Sydney & London: Angus & Robertson,
Limited, 1039.

This was designed as a textbook for students at the University
of Sydney and as such is an admirably prepared volume. Par-
ticularly well done are the chapters on anatomy and physiology
and the chapters dealing with prolapse and displacement of the
female generative organs. The chapters on history taking and
methods of examination are at the end of the book, subjects
which it appears should be taken up at the outset in a study of
any specialty. The chapters on operative gynecology, postopera-
tive complications and treatment and the descriptions and desig-
nations accompanying the illustrations are incomplete and even
confusing at times, while the author is much too dogmatic in
expressions relative to the choice of operation, particularly with
regard to the treatment of retroversion by round ligament
shortening. This may, as stated previously, be an excellent
textbook for use by Schlink's students at Sydney. In view of
the already published and most excellent textbooks of gynecol-
ogy available, this book adds nothing of value for the American
practitioner or student.

Problems in Prison Psychiatry. By J. G. Wilson, M.D., Director, Divi-
sion oi Hospitals and Mental Hygiene, Department of Welfare of the
State of Kentucky, and M. .T. Pescor, M.D., Clinical Director, United
States Public Health Service Hospital, Fort Wortti, Texas. Cloth. Price,
J3. Pp. 275. Caldwell, Idaho : Caxton Printers, Ltd., 1939.

This is an extremely interesting pioneer work directed toward
understanding the mental problems of criminals. The authors
have worked with many prisoners and attempt an understanding
of the cause, therapy and prevention of neurotic and psychiatric
crirhes. The work should be studied by prison administrators
as well as physicians having to do with prisons. It is a sound
psychiatric study and is the best of its kind so far attempted.

Radiologic Clinique du cceur ct des gros vaisseaux. Par Cli. Laubry,
P. Cottenot, D. Routicr et II. Ilcim de Balsac. Fascicules I ct II. Cloth.
Price, 430 francs. Pp. 1G3; 164-340, with 1,049 Illustrations. Paris:
Masson & Cie, 1939.

There are three parts to the monograph. The first is con-
cerned with the utility of x-ray examination of the cardio-
vascular system and the various technics by which this method
may be applied to such examination. The second part is con-
cerned with the appearance of the normal heart in all its varia-
tions and the factors at work in the production of such normal
differences. The third part is concerned with organic heart
disease and considers rheumatic, congenital, syphilitic, chronic
myocarditic, hypertensive and pulmonary heart disease in the
order named. Then the pericardial involvements and the pic-
ture produced by heart failure follows. The appearance
produced by extracardiac mediastinal masses is finally consid-
ered. The bibliography is extensive. This two volume work on
cardiovascular roentgenology is highly recommended. It is
beautifully and completely illustrated and the terse discussion is
quite adequate. The x-ray delineation of the right and left sides
uf the heart separately in the cadaver by means of barium sul-

ate injections is illuminating.

Regeneration: Ihre Anwendung in der Chirurgle. Mit Elnem Anhang:
Operationslehre. Von Dr. Johann v. Ertl. Paper. Price, 24 marks.
Pp. 246, with 388 illustrations. Leipzig: Joliann Ambrosius Barth, 1939.

This book reports the principles used and the results obtained
in tiie care of about 60,000 patients with war injuries. It is
purposely written twenty years later in order to give the late
results. It is a general treatise on the theory behind the work
done rather than a statistical survey. The- late results are
shown by numerous reproductions of photographs and x-ray
plates. There is a short incomplete historical sketch, followed
by a general discussion of the regeneration and transplantation
of the various tissues, but little of which is the author’s original
work. The principle of repair of tissue defects in layers is
stressed repeatedly, as are the biologic conditions of successful
transplantation of tissues in general. These are well accepted
concepts. The author makes frequent use of thin flexible bone
grafts, so-called osteogenic grafts, and reports excellent results.
A small number of small bone chips are removed attached to
the periosteum in preparing this type of graft. It is used as
an onlay graft or doubled back on itself in replacing bone defects,
as in the lower jaw. The book could be more detailed in
describing technical procedures. The illustrations and sketches
cannot be compared as to quality with those of older German
writings.

The Mechanism of Thought, Imagery and Hallucination. By Joshua
Itosett, Professor of Neurology in Columbia University, New York. Cloth.
Brice, $3. Pp. 289, with 12 illustrations. New York, Morningsido
Heights : Columbia University Press, 1939.

A tremendous amount of effort has been put into this great
tome in an effort to explain the mechanisms of mental processes
on a strictly organic basis. Biologic data and the experiments
with diseases affecting man are utilized in deducing the mecha-
nisms of thought. Each chapter outlines a phase of the subject
and is followed by a detailed summary and bibliography.
Thought, imagery and hallucination are discussed and described,
but the explanations are not satisfactory even though based on
physiology. We still appreciate Sherrington’s statement that
understanding the physiology of the brain leads us but little
closer to understanding mental processes.

Troubles du myecardc dans )es anomies: Etude Clinique, experimental
et pathogenique de I’insuffisance nutritive d’originc sanguine. Par lc
Docteur Charles Range. Paper. Pp. 124, with 9 illustrations. Paris:
Librairlc E. Le Francois, 1939.

This monograph, based on analysis of six case reports and
seventeen animal experiments correlated with a thorough review
of the literature, deals with the effect of acute hemorrhagic
anemia and chronic progressive anemia on the heart. The
author properly points out that the effect of anemia on the
heart constitutes an important part of the clinical picture. As
a result of his analyses the author states that gallop rhythm,
an increase in the magnitude of the heart activity fluoroscopi-
cally, the presence of heart murmurs and low voltage and low
T waves constitute the elements in chronic anemia. Occasion-
ally, coronary electrocardiographic changes are present. This
is more prevalent in the acute form. The circulatory changes
are due as much to the changes in circulatory blood volume
and composition of the plasma in the acute form as to the loss
of hemoglobin. Transfusion is considered the most important
method of treatment. The monograph will repay the cardiolo-
gist for perusing it. Perhaps the assembly of data dealing with
this subject will inspire further investigation of this all impor-
tant subject.

How to Psychoanalyze the Bible. By H. F. Haas. Cloth. Price, $1.
Pp. 116, Orangeburg, S. C. : Haas Publication Committee, Publishers,

1939.

The author of this book, apparently a layman who bears the
same name as the publishers, attempts to expound a rationalistic
attitude toward Christianity and the Bible. He exhorts the
reader to adopt the methods of reason and science and to free
himself from the influence of the superstitions and fears which
have been distorting the true meaning and value of Christ’s
teaching. Much use is made of such terms as “psychoanalysis,"
“unconscious” and “repression,” but in such a way as to make
obvious that the author has no knowledge of their true meaning.
The book can in no way be recommended as a serious psycho-
logic study of the Bible. '

1594

BUREAU OF LEGAL MEDICINE AND LEGISLATION

Jour. A. Ji.
Oct. 21, 193 )

Bureau of Legal Medicine
and Legislation

MEDICOLEGAL ABSTRACTS

Workmen’s Compensation Acts: Appendicitis Allegedly
Resulting from Trauma.— ICeahey fell in the course of his
employment, Dec. 5, 1932, injuring his back and hip, and was
paid compensation under the Texas workmen’s compensation
act. On March 21, 1933, he underwent an appendectomy. July 3,
1935, more than two years iater, lie underwent an operation
for the relief of intestinal strangulation caused by adhesions
which had developed following the appendectomy. He died the
following day. His widow and children claimed compensation
under the Texas compensation act, attributing death to the
original industrial accident, but the industrial accident board
rejected their claim. They then instituted proceedings before
foe district court, Wheeler County, Texas, which rendered
judgment on a verdict of the jury in their favor, and the
employer’s insurer appealed to the court of civil appeals, Texas,
Amarillo.

The workmen’s compensation act, said the court of appeals,
provides compensation for injuries arising out of and in the
course of employment. The term “injury” is limited by the act
to mean "damage or harm to the physical structure of the
body and such diseases or infection as naturally result there-
from.” It follows, then, that injury or death resulting from
intervening, independent agencies is not compensable. Thus, if
by reason of an industrial injury a workman’s resistance against
diseases and infections coming from other sources is reduced
and he contracts and dies from those diseases and infections,
his death is not compensable. Texas Employers’ his. Ass’n v.
Burnett, 105 S. W. (2d) 200.

To prove that the intestinal adhesions and the surgical opera-
tion performed on the workman July 3, 1935, to remove them
were the ultimate result of the industrial injury of Dec. 5, 1932,
the claimants called Dr. York, who had treated the workman
in March 1935 shortly before the last operation but had not
seen the workman prior to that time. Dr. York first testified
that he thought the injury contributed to the disease condition
of the appendix. Later he stated that in his opinion the injury
caused the appendicitis but said he “couldn’t just qualify on
that.” Still later he testified that in his belief the injury caused
the appendicitis. On cross-examination he stated that he could
not say “just exactly that the injury was the sole cause, but
it was a highly contributing cause,” because he believed that
inflammation resulted from the industrial accident and, by a

process of contiguity, progressed through the muscles, organs
and tissues of the body from the locus of the injuries through
the psoas and other muscles in the lumbar region and through
the peritoneum and finally reached and involved the appendix,
necessitating the appendectomy on March 21, 1933.

The value- of Dr. York’s testimony, said the court, depends
on-whether or not there was present in the region of the appen-
dix or in the appendix itself, when the appendectomy was per-
formed in March 1933, inflammation or infection which had
originated at the locus of the injuries to the workman’s back
three and a half months prior thereto and whether or not such
inflammation or infection caused the appendicitis. The testi-
mony of the physician who had performed the appendectomy in
question and the nurse who had assisted him was quite clear
that at the time that the appendectomy- was performed there
was no inflammation of the tissues surrounding the appendix
or bowels or any part of the abdominal cavity except the appen-
dix itself, nor was there any black, blue or bruised spot on
the patient’s back or elsewhere on the body and that the work-
man “was- suffering from an ordinary case of appendicitis.
That physician further stated that the conditions which, m t le
opinion of Dr. York, existed in the region of the appendix and
brought about its disease condition ami neccsBWaWd t w appen-
dectomy did not exist. This physician further testified that he
had never known or heard of a case of ^P^dicitis resulting
-from a bruised back . or hip and. that he had ne^r read any
medical authority which reported such a case. He stated that,

if the appendix had been affected by inflammation proceeding
from the injuries in the patient’s back, the organs -and few
m the region of the appendix and between the appendix and
the locus of the injuries would have' shown an inflamed or
infected condition, but that he found no evidence of any inflam-
mation or infection of any organs or tissues except the appendix.
He stated that if such inflammation or infection could be so
communicated it would have to go through the heavy lumbar
muscles which form the back side of the body wall and then
through the psoas muscle, both of which are very thick, and
then it would have «to proceed through the bony pelvis or ilium
and the back bone and then the kidneys and other tissues in
that region, and that inflammation from a bruise could not
proceed through such tissues, muscles and portions oi the body
so. as to cause appendicitis. If such a thing were possible, he
said, the injury would have to be so tremendous that the patient
would be dead before the results could be transmitted through
such heavy structures as intervene between the back and the
appendix. In his opinion there could be no possible connection
between a back injury and the development of appendicitis, espe-
cially alter so long an interval.

In the opinion of the court, Dr. York’s testimony merely
raised a surmise or suspicion that the attack of appendicitis may
have been the result of the injuries to which the workman ms
subjected three and one-half months prior to the attack of
appendicitis and did not warrant the trial court submitting the
case to the jury. If, said the court, there was any connection
between the original injury and the appendicitis, there must
have been present, in the region of the appendix at the time that
operation was performed, inflammation or infection that had its
origin in the injury to foe workman's back, and the existence
of this condition is the very basis of Dr. York’s opinion. The
testimony of the operating physician and his nurse, houWb
leaves no room for doubt that the appendical region at the tlItK
the appendectomy was performed was, as a matter of fad, w*
from any such infection or inflammation and thus destroys tie
theory and opinion of Dr. York. The trial court should M
instructed a verdict in favor of the insurance company
The court of civil appeals accordingly reversed the judgnw
in favor of the widow and the children .— T raders & Genera >■ ■
Co. v. Kcahcy (Texas), 119 S. IV. (2d) 618.

Malpractice: Trench Mouth Diagnosed as ■

The plaintiff consulted the physician defendant, Jw *
relative to sore mouth, throat and gums, informing '
she had had “trench mouth” about two years “ e ore '. , ^
physician, without resorting to a Wassermann test, w ^
told her was unnecessary, from a superficial examma ^
the mouth and gums made a diagnosis of syphilis in an a
stage and instituted a course of bismuth and arsenic rea ^
In about two weeks her eyes became inflamed and wa ’ w
in about three weeks her feet, ankles, arms and legs ,
swell. The treatments, however, were continued unit “
ber 13. She was hospitalized September 17, at « i ^
she was semiconscious and had pimples all. over er
which pus and water exuded. She remained in ' nt
jnder die defendant’s care for thirteen days wit 1 1 L B ;tal and
mprovement and was then removed to another i ^
placed under the care of Dr. Turner, who roa e .
if exfoliative dermatitis (arsenical), ' mcent s » s };ed
ityalism or salivation. Eventually her hair fell ' - riV ” to
ler finger and toe nails and she was affected wi' an( j v -js
he extent that she could open her mouth but s ig . ( $ j
mable to masticate her food. She brought sui | ;Cf

lefendant physician, who defended by conten i S
njuries, if any, were due to an idiosyncrasy. not the

At the trial medical experts testified that > a(tw pt
ccepted, standard or proper practice for a P 51 w icro-

diagnosis of syphilis without a Wassermann r _ r ; c tt
copic test or a blood smear. With respect bismuth

f the defendant’s continuing to administer. a ^f e ” t j, c s \ve!!‘
i the presence of inflammation of the patiem 5 , * ’ there
tig of her limbs and her entire body and t ,e - c poboriy
,-as medical evidence that when, symptoms o . - st ; on , v'-
re present in a patient undergoing the therap) tJD(n t a. -
roper course is immediately to discontinue

Volume 113
Number- 17

BUREAU OF LEGAL MEDICINE AND LEGISLATION

1595

give the patient something to counteract the ill effects of the
treatment. There was further medical testimony that subse-
quent to the defendant-physician’s release from the case other
physicians had made Wasscrmann blood tests of the patient,
that none of these physicians had made a diagnosis of syphilis
and that none of these physicians had treated her with arsenic
or bismuth. At the close of the plaintiff’s case, the trial court
• directed a verdict in favor of the physician-defendant and the
patient appealed to the court of civil appeals of Texas, Amarillo.

The sole question to be determined by the appellate court
concerned the right of the trial court under the testimony to
direct a verdict in favor of the physician. While a physician,
said the court of civil appeals, does not insure results, he is
required to have such reasonable skill as the profession gen-
erally possesses and to exercise such skill with reasonable care
and diligence. The physician here offered no testimony and the
evidence adduced by the patient is undisputed that the physi-
cian informed the patient that he could make or have made a
Wassermann test, that such a test or a microscopic blood test
was in common use in the locality in which the defendant prac-
ticed and generally by the profession and was deemed by them
essential in order to diagnose the disease of syphilis ; and
that die defendant made no such test but relied on the super-
ficial examination of looking into and swabbing the mouth and
throat, which was undependable and not relied on by the medi-
cal profession to determine the existence of such disease. The
evidence raises fact issues as to a negligent diagnosis and as
to whether the patient’s damage resulted from the treatments
of arsenic and bismuth administered by the defendant. The
jury should have been permitted to determine these issues.
The judgment in favor of the defendant-physician was accord-
ingly reversed and the cause was remanded . — Gifford v. Howell
(Texas), 119 S. Iff. SIS.

Taxes: Antivivisection Activities as Charitable Activi-
ties.— For federal estate tax purposes, the Commissioner of
Internal Revenue refused to allow as a deduction from the gross
estate of a testator a legacy left to the New England Anti-
Vivisection Society, and the executor of the will sought a
reversal of the commissioner’s ruling in the United States dis-
trict court, D. Massachusetts.

The federal estate tax law under which this case arose pro-
vided that for the purpose of taxation the value of the net
estate shall be determined by deducting from the value of the
gross estate:

The amount of all bequests, legacies, devices, or transfers ... to
or for the use of any corporation organized and operated exclusively for
religious, charitable, scientific, literary, or educational purposes, including
... the prevention of cruelty to children or animals, no part of the
net earnings of which inures to the benefit of any private stockholder or
■individual . . ,

The executor contended that the New England Anti- Vivisection
Society is an organization organized and operated exclusively
for charitable purposes within the meaning of the federal estate
tax law.

The commonly understood and narrow meaning of the word
“charity,” the court said, is good will to the poor and suffering,
almsgiving and provision for the care or relief of the poor
(Webster’s International Dictionary, ed. 2). In the law, how-
ever, a far broader and more comprehensive significance has
been given to the word. The most generally accepted definition
.of it is found in the extensively cited case of Child v. Washing-
ton Hospital for Foundlings, 95 U. S. 303, 24 L. Ed. 450,
'wherein it was said that “a charitable use, where neither law
nor public policy forbids, may be applied to almost anything
that tends to promote the well-doing and well-being of social
man.” It was clear to the court in the present case that what
is done out of good will and a desire to add to the improvement
of the moral, mental and physical welfare of the public generally
comes within this meaning- of the word “charity.” The charter
of the society provides that it was organized for the purpose
of systematic, scientific research relative to the practice of vivi-
section — its relation to science and its effect on those who
practice it and on society ; exposing and opposing secret or pain-
ful experiments on living animals, lunatics, paupers or criminals';
urging education and legislation in pursuance of these ends, and
issuing posters, pamphlets and other publications. In the opinion

of the court, the aims and purposes of the organization were
for the public good and were charitable within the meaning of
the federal estate tax law.

The evidence disclosed that the society had sponsored several
bills in the Massachusetts legislature asking that dogs be exempt
from the practice of vivisection. The circumstances of the
society favoring the passage of this legislation, the court said,
did not in any way place the society outside the provisions of
the federal estate tax law. This legislation was merely inci-
dental to carrying out the purposes and accomplishing the pur-
poses of the society. The help of the legislature was necessary
to enable it to advance its aims. Such activity was, as expressed
in the case of Sice v. Commissioner of Internal Revenue, 42 F.
(2d) 184, 72 A. L. R. 400, “mediate to the primary purpose,
. . . ancillary to the end in chief.” This incidental activity,
the court concluded, did not militate against the contention that
the society was "exclusively” organized and operated for chari-
table purposes. The ruling of the Commissioner of Internal
Revenue was therefore reversed . — Old Colony Trust Co. v.
Welch, 25 F. Supp. 45.

Workmen’s Compensation Acts: Refusal of Employee
to Accept Medical Treatment Tendered by Employer. —
The workmen’s compensation act of Indiana provides that dur-
ing the first ninety days after an injury the employer “shall
furnish or cause to be furnished, free of charge to the injured
employee, an attending physician, for the treatment of his
injuries, and in addition thereto such surgical, hospital and
nurse’s services and supplies as the attending physician or the
industrial board deem necessary.” The refusal of the employee
to accept such services and supplies, when so provided by the
employer, bars the employee from all compensation during the
period of such refusal.

On Oct. 22, 1937, the claimant, Pipkin, as the result of his
employment with the defendant corporation, sustained a right
inguinal hernia. He consulted two “company doctors,” furnished
by the defendant, who advised against an operation because he
did not have a “complete hernia.” He also consulted two other
physicians of his own choice who diagnosed his condition as a
“complete hernia” and advised that he undergo an operation for
its repair. On November 19 he requested the defendant to
provide such an operation. This request was at first refused
but later the defendant agreed to provide the services of one
of its “company doctors” for such an operation. The claimant,
however, refused to accept such services because he believed
that the company doctor "did not know what was the matter
with him.” Instead, he submitted to an operation by a physi-
cian of his own choice. Later, he filed a claim with the indus-
trial board of Indiana for compensation under the workmen’s
compensation act. The board, however, found that by his refusal
to accept the medical services tendered by his employer he had
forfeited his right to compensation. From an award of the
board denying compensation, the claimant appealed to the appel-
late court of Indiana, in Banc.

The workmen’s compensation act, said the appellate court,
bars any employee from compensation who refuses to accept
such surgical, hospital and nurse’s services as the attending
physician, who is furnished by the employer, or the industrial
board may deem necessary. As was held in Witte v. J. Winkler
Sr Sons, Inc., 98 Ind. App. 466, 190 N. E. 72, the employee’s
refusal to accept such services does not bar his claim for com-
pensation unless his refusal is unreasonable. Whether a refusal
is or is not reasonable will depend on the facts of each par-
ticular case and is a question for the determination of the
industrial board in its sound discretion. In the judgment of
the court, the evidence did not show conclusively that the
claimant’s refusal to accept the company surgeon’s services was
reasonable. The qualification of the company surgeon and his
ability to perform the operation were proved and undisputed.
Lack of confidence in the physician, which was the claimant’s
sole reason for refusing to accept his services, was not a suf-
ficient reason. If it were held to be so, it would in effect be
holding that the employer must furnish a surgeon satisfactory
to the employee, whereas the workmen’s compensation act docs
not give the employee the privilege of choosing his own physi-
cian.. Accordingly, the appellate court affirmed the award of
the industrial board denying compensation.

■1596

SOCIETY PROCEEDINGS

Jouk. A. M. A.
Oct. 21, 193)

Judge Laymon, in a special dissenting opinion, disagreed with
the opinion of the majority of the court. In his opinion, the
mere fact that an employee desires to submit to the services of
a physician of his own choosing, and, by reason of that fact
alone, all other facts being equal, refuses the same services
proffered by his employer, does not of itself make such a refusal
unreasonable, ft would indeed be a harsh rule that bound an
employee to submit to a surgical operation, where life and death
are at stake, and to accept the services of a physician who
advised against the operation, after diagnosing the case and
consulting the patient, simply because the physician is being
furnished by the employer. The dissenting justice relied for
his opinion on the case of U'itte v. J. Winkler & Sons, Inc.,
supra, in which the court said:

The question of whether an employee is justified in refusing; to submit
to a surgical operation proffered by his employer is one that has to do
largely with the personal element. It is the employee upon whom the
operation lias to be performed, and his rights and interests should be
seriously considered.

— Pipkin v. Continental Steel Corporation (hid.), 16 N. E. (2d)
9S4. ....

Foods: Liability of Packer and Retailer for Trichi-
nosis. — One of the defendants, a packer of meats, sold smoked
pork infested with parasites known as trichinae to another
defendant, a retailer of meats. The defendant retailer ground
or chopped up the pork and without cooking it made it into
a sausage, which he smoked for about a week The plaintiff
purchased some of the sausage from the defendant retailer and
subsequent to eating it developed trichinosis. He attributed the
disease to the sausage and brought suit against both the packer
and the retailer in the court of common pleas, alleging that
the smoked pork and the sausage were unwholesome, adulter-
ated, diseased and infected. From a judgment of the court of
appeals, Lucas County, affirming the judgment of the court of
common pleas in favor of the plaintiff, the defendants appealed
to the Supreme Court of Ohio.

The defendants contended, among other things, that the
plaintiff was negligent in eating the sausage without cooking
it. They pointed out that there was no practical method of
inspecting pork for the presence of trichinae and that if the
laws of Ohio impose an absolute liability on them for the sale
of pork infested with trichinae such laws violate the constitu-
tions of the United States and of Ohio. But, said the Supreme
Court, a manufacturer or packer of food warrants to the public
generally that the food produced by it is fit for human con-
sumption and it is liable for a breach of that warranty. In
the instant case, the liability of the packer was primary and
that of the retailer was secondary. Their liability was sepa-
rate, not joint, and the packer and retailer should not have
been sued jointly. Because of the misjoinder of the parties
defendant, the Ohio Supreme Court reversed the judgment in
favor of the plaintiff and remanded the cause for action in
accordance with the court’s mandate. — Kniess v. Armour & Co.
(Ohio), 17 N. E. (2d) 734.

Workmen’s Compensation Acts: Hemorrhoids in Rela-
tion to Strain.-— The claimant. Nantron, in the course of bis
employment with the defendant company, slipped while moving
a “terrazzo machine” down a board onto a driveway. He'
claimed that he strained himself in trying to keep the machine
from falling. From five to ten minutes later he felt pain in
the region of the rectum. His condition was diagnosed as
internal and external hemorrhoids with a rectal abscess at the
base of one of the external ones. He was advised by a
Dr. Webb to undergo an operation to eradicate his hemor-
rhoids. He disregarded this advice, . however, and instead
obtained treatment from another physician, who advertised the
cure of piles “without a knife.” An ischiorectal abcess developed
which eventually resulted in the formation of a fistula. Because
of his condition, he lost about three and one-half weeks of work,
and after resuming work he apparently was no longer able to do
heavy work. He filed a claim with the workmen’s compensa-
tion commission of Missouri for compensation under the work-
men’s compensation act of Missouri, claiming that his hemor-
rhoids and subsequent complications had been caused by strain
in the course of his employment. The commission found that
his condition had not been caused by the accident and denied

compensation. From a judgment of the circuit court affirmiw
that award, the claimant appealed to the St. Louis court rf
appeals, Missouri.

Dr. Webb, one of the' physicians who treated the claimant
and the only witness other than the claimant to testify, in
answer to a hypothetical question incorporating all the essta-
tia! facts of the case and asking whether the accident had any-
thing to do with the production of the hemorrhoids, testified:

I cannot see how a mere slipping of any kind would product
hemorrhoids unless it would cause the whole rectum to turn
out and he would have immediate pain with the thing; k
would suffer immediately without a lapse of any time." In Mi
opinion, if the hemorrhoids had been due to the accident there
would not have been a lapse of from five to ten minutes between
the injury and the pain. In the judgment of the court of
appeals, Dr. Webb’s testimony furnished competent and sub-
stantial evidence to support the award of the workmen’s com-
pensation commission denying compensation. Accordingly, the
judgment of the circuit court upholding the commission’s award
was affirmed. — Nantron v. General Tile & Marble Co. (Mo),
121 S. IV. (2d) 246.

Health Insurance: “Medical or Surgical Attention"
Defined. — In an action on a policy of accident and health
insurance the court of appeals of Georgia, division 2, agreed with
the decision in Federal Life Ins. Co. v. Summcrinll, 45 Gs.
App. 829, 166 S. E. 54, that the term “medical or surgical
attention” as used in an application for health insurance mews
“medical or surgical attention for some illness or disease of
substantia! importance or of a serious nature and not consulta-
tion, treatment, or attendance concerning some trivia! or tem-
porary indisposition or feeling which has passed away without
affecting the general health.” In the judgment of the court, the
policy of insurance was not rendered void by the denial of
insured, who later became ill with tuberculosis, in her applica-
tion for insurance that she had received “medical or sttrP®
attention” during the two years preceding her application, w *
in fact during that period of time she had consulted t re
physicians because of her spitting of blood but bad been
by them that they could find nothing the matter with
North American Acc. Ins. Co. v. Gilbert (Ga.J, 199 S. n. t

Society Proceedings

COMING MEETINGS

American Academy of Pediatrics, Cincinnati, wove® ceerctary* ,
Clifford G. Grulee, 636 Church Street, Evanston, ^ %

American Society of Anesthetists, Los Angeles, Dec. 1 •

Wood, 745 Fifth Ave., New York. Secretary. 2 1*24. pr ‘

American Society of Tropical Medicine, Memphis, Tenn.,

E. Harold Hinman, Wilson Dam, Ala., Secretary.

Association of American Medical Colleges, Cincinnati, * -
Fred C. Zapffe, 5 South Wabash Ave., Chicago, Secretary ^ y
Central Association of Obstetricians and Gynecologists, A j 0 v.-a C*W>
Nov. 2-4. Dr. W. F. Mengert, University Hospitals,
Secretary. , . . . Pr. t- 11

Central Society for Clinical Research, Chicago, Nov,

Thompson, 4 932 Maryland Ave,, St. Louis, Secrets y. Clyde t.
Gulf Coast Clinical Society, Mobile, Ala., Oct. 26-4/.

Rouse, 56 St. Joseph St., Mobile, Ala.,. Svcretap. . C y 0 p.

Inter-State Postgraduate Medical Association of North ft p rrt! crt.
Oct. 30. Nov. 3. Dr. W. B. Peck, 27 East Stephenson o
Iff., Managing Director. York, Oct.

National Society for the Prevention of Blindness, N /> ncr aJ
Mr. Lewis H. Cams, SO. West . SOtb J3t„ Nctv Y«fc A *

New York State Association of Public Health , ^ e All 2 "'
Nov. 3. Miss Mary B. Kirkbride, New Scotland
Secretary-. B f -

Omaha Mid-West Clinical Society, Omaha, Oct. as-/

McCarthy, 107 S. 17th St., Omaha, Secretary. Portland, O ’t

Pacific Coast Society of Obstetrics and Gyn«olog>, ^

Nov. 8-11. Dr. T. Floyd Bell, 400 29th St., Oakland, ua. n .,j. Ik-
Radiological Society of North America, Atlanta, ■' v y„ S*****S
Donald S. Childs, 607 Medical Arts Bldg., Syracuse.

Society for the Study of Asthma and Allied C j. S rt rcUU-

Dec. 9. Dr. W. C. Spain, 116 East 53d St., New • Mt , C. r-
Southern Medical Association. .Memphis, Tenm, Aov. -

Loranr, Empire Bldg., Birmingham, Ala., Sccreiary- g. A-

Southern Surgical Association, Augusta, Ga- u - . • . p

Ochsner, 1430 Tulane Ave., New PfJ c:m5 v r S<r T 9-11. h\n.

Southwestern Medical Association, El Tc p, ’pa W ,' Teas.

. Spearman,. 1001 First National Bank Bldg.. DP A rtansas,

Volume 113
Number 17

CURRENT MEDICAL LITERATURE

15 97

Current Medical Literature

AMERICAN

The Association library lends periodicals to members of the Association
and to individual subscribers in continental United States and Canada
for a period of three days. Three journals may be borrowed at a time.
Periodicals are available from 1929 to date. Requests for issues of
earlier date cannot be filled. Requests should be accompanied by
stamps to cover postage (6 cents if one and 18 cents if three periodicals
are requested). Periodicals published by the American Medical Asso-
ciation are not available for lending but may be supplied on purchase
order. Reprints as a rule are the property of authors and can be
obtained for permanent possession only from them.

Titles marked with an asterisk (*) are abstracted below.

American Heart Journal, St. Louis

IS: 133-260 (Aug.) 1939

Electrocardiographic Picture of Experimental Localized Pericarditis.
H. B. Burchell, A. R. Barnes and F. C. Mann, Rochester, Minn. —
p. 133.

•Prognosis of Intraventricular Block. L. G. Kaplan and L. N. Katz,
Chicago. — p. 145.

•Effect of Oxygen on Exercise Tolerance of Patients with Angina Pec-
toris. J. E. F. Riseman and M. G. Brown, Boston. — p. 150.

Cardiac Neurosis Associated with Organic Heart Disease. S. Schnur,
Brooklyn. — p. 153.

Acute Endocarditis in Wild Animals, with Especial Reference to Opos-
sum. H. Fox, Philadelphia. — p. 166.

Effects of Whole Bile and Bile Salts on Perfused Heart. K. G. Wakim,
H. E. Essex and F. C. Mann, Rochester, Minn. — p. 171.

Congenital Heart Disease: Report of Case of Dextroposition, Persis-
tence of Early Stage of Embryonic Development of Heart, Persistent
Truncus Arteriosus, Abnormal Systemic and Pulmonic Veins and Sub-
diaphragmatic Situs Inversus. D. W. Goltman and N. S. Stern,
Memphis, Tenn. — p. 176.

Medionecrosis Aortae Idiopathica Cystica: Report of Case, with
"Healed” Dissecting Aneurysm. J. T. Roberts, Cleveland. — p. 188.
Effects of Diphtheria Toxin on Heart. R. W. Boyle, C. H. McDonald
and A. F. DeGroat, Little Rock, Ark. — p. 201.

Effect of Carbon Dioxide Inhalation on Peripheral Blood Flow in Normal
and in Sympathectomized Patient. I. E. Steck and E. Gellhorn,
Chicago. — p. 206.

Value of Special Radiologic Procedures in Detecting Cardiac Enlarge-
ment in Children with Rheumatic Heart Disease. Ann G. Kuttner
and Gertrude Reyersbach, Irvington-on-Hudson, N. Y. — p. 213.
Measurement of Circulation Time with Calcium Gluconate in Patients
Receiving Digitalis, with Electrocardiographic Studies. H. C. Wall,
New Orleans. — p. 228.

Prognosis of Intraventricular Block. — Kaplan and Katz
collected data from the hospital and clinical records of 126
patients whose electrocardiograms conformed to the criteria for
the various varieties of intraventricular block, all showing a
QRS duration of 0.11 second or more. They find that the
character of the underlying disease, rather than the presence
or absence of intraventricular block, determines the prognosis,
although the presence of intraventricular block carries with it
a high mortality rate in the first year (particularly in the first
three months). The fatality rate within a year of the discovery
of the conduction lesion was 80 per cent. Patients surviving
this period have a materially better life expectancy, as another
10 per cent died within the second year and some of the
remaining 10 per cent survived up to the seventh year. Appar-
ently, a relatively benign type of intraventricular block occurs.
Therefore the configuration of the electrocardiogram or the
duration of the QRS deflection is of no prognostic significance.

Oxygen, Exercise Tolerance and Angina Pectoris. —
Riseman and Brown describe the effect of breathing high con-
centrations of oxygen on the amount of work which seventeen
patients with angina pectoris could do before pain developed.
Breathing room air from the Douglas bags did not increase and
in several instances actually caused a decrease in the amount
"’Ork which could be done before pain developed. Breath-
m S oxygen from the Douglas bags enabled eleven of the seven-
teen patients to do considerably more work ; four exercised
until forced to stop because of fatigue without developing pain.
Nine of these eleven patients were from 39 to S3 years of age.
Two were 57 and 58 years old. Seven patients found that it
required more than thirty-five trips (mount and descend a two
step staircase) to induce pain while breathing room air; the
other four patients felt pain on less than thirty-five trips. The
remaining six of the seventeen patients were not able to do
more work while breathing oxygen. Only one of these
patients was less than 53 years of age, and only two could
perform more than thirty-five trips before angina developed.

le data are consistent with the anoxemia theorv of angina
pectoris.

American Journal of Diseases of Children, Chicago

58 : 457-690 (Sept.) 1939

•Obesity in Childhood: I. Physical Growth and Development of Obese
Children. Hilde Bruch, New York. — p. 457.

Enterogenous Intramural Cysts of Intestines. D. J. Pachman, Chicago.
— p. 485.

New Creatinine Standard for Basal Metabolism and Its Clinical Applica-
tion. N. B. Talbot, Jane Worcester and Ann Stewart, Boston. —
p. 506.

•Prevention of Diphtheria. H. P. G. Seckel, Chicago. — p. 512.

Old Tuberculin and Purified Protein Derivative in Tuberculin Patch
Test: Comparative Study. H. Vollmer, New York, and Esther W.
Goldberger, Staten Island, N. Y. — p. 527.

•Influence of Fluid and of Evaporated Milk on Mineral and Nitrogen
Metabolism of Growing Children. Helen J. Souders, Helen A.
Hunscher, Frances C. Hummel and Icie G. Macy, with assistance of
Mary F. Bates, Marion L. Shepherd, Priscilla Bonner, J. Horton, A.
Theresa Johnston and Louise Emerson, Detroit. — p. 529.
Hyperparathyroidism in Children: Report of Two Cases. W. E.

Anspach and W. M. Clifton, Chicago. — p. 540.

Importance of Sensitization Mechanism in Clinical Phenomenon of
Allergy: Possible Cause and Prevention. E. B. Shaw and H. E.
Thelander, San Francisco. — p. 581.

Causes of Prematurity: I. Review of Literature. Nina A. Anderson
and R. A. Lyon, Cincinnati. — p. 586.

Development of Obese Children. — Bruch studied the
growth and development of 102 children from 2 to 13 years of
age whose obesity was the principal clinical symptom and she
compared her observations with results obtained in normal
children. One aim of the study was to establish an objective
basis for the diagnosis of the underlying endocrine disorder,
if any, through an analysis of the progress in growth. She finds
that in obese children growth in stature is in excess of the
average normal but in harmony with the height development of
children who mature early. Skeletal maturation is normal or
advanced, certainly not delayed. The menarche in obese girls
occurs early, ill several instances before the age of 10 years.
More than 50 per cent of the boys between 11 and 14 years
old show signs of approaching or attained puberal development.
The high weight of the obese child is considered as an exag-
geration of a normal trend. The observations of intensive
growth and early maturation are not consistent with theories
which attempt to explain obesity on the basis of hypothyroidism
and hypopituitarism ; they agree with observations of the growth-
promoting effect of abundant nutrition.

Prevention of Diphtheria. — Seckel discusses three factors
relating to the prevention of diphtheria. 1. The best statistical
method of checking the efficiency of active immunization against
diphtheria is the so-called control series method. Diphtheria
morbidity in immunized children is only one third to one eighth
or even less than that of nonimmunized children. The statis-
tical method of comparing the diphtheria morbidity in a given
area before and after the introduction of immunization should
not be used for scientific purposes except against the background
of the secular waves of diphtheria morbidity. 2. In general, the
“severity” of diphtheria in immunized children is less than in
nonimmunized controls. If the clinical typology of diphtheria
in immunized children is analyzed statistically (according to
Escherich’s types), there is found an overwhelming majority of
cases of localized pharyngeal diphtheria, an almost complete
disappearance of diphtheritic croup and about the same per-
centage of cases of toxic diphtheria as for nonimmunized chil-
dren. The last two types of severe diphtheria are clinically less
alarming in immunized children than they are in the control
groups. 3. While antitoxin therapy reaches the natural limits
of its preventive efficiency in cases of progressive toxic and
malignant diphtheria, its limits may be in part overcome by
nonspecific preventive treatment: parenteral protein tiierapy and
intravenous dextrose therapy. The two types of nonspecific
treatment are combined in a routine way with the injection of
medium doses of diphtheria antitoxin and may, in cases of malig-
nant diphtheria, be combined with each other.

Type of Milk and Mineral and Nitrogen Metabolism.—
Souders and her collaborators determined the relative efficiency
of plain fluid and of evaporated milk in meeting the mineral
and nitrogen demands of the growing child. The nitrogen and
acid-base mineral balance study was conducted on three healthy
growing children (from to 6 years old) who received a basal
diet of inexpensive foods, always available, which conformed
with accepted nutritive standards. Each child received 400 Gm.
of plain fluid milk daily for from twenty-five to forty days;
during the following twenty to twenty-five days the same

Volume 113
Number 17

CURRENT MEDICAL LITERATURE

1599

mg. per hundred cubic centimeters. The therapeutic value of
sulfanilamide is known for infections caused by certain micro-
organisms elsewhere in the body, and therefore because of its
rapid diffusion in tbe ocular fluids it should be considered
equally valuable for the treatment of infections of the eye
caused by these same organisms.

Archives of Pathology, Chicago

2S:2S3-426 (Sept.) 1939

Carcinoma Cells in Thoracic and in Abdominal Fluids. M. J. Scliles-
inger, Boston. — p. 283.

Cerebral Lesions in Hypoglycemia: III. Experimental Investigations.
A. B. Baker, Minneapolis. — p. 29S.

New Formation of Elastic Tissue in Adhesions Between Serous Mem-
branes and in Myocardial Scars, C. H. Bunting, Madison, Wis. —
p. 306.

Histologic Study of Reparation of Experimentally Produced Defects in
Calvariums of Rats. C. J. Sutro and S. A. Jacobson, New York. —
p. 313.

Chemotropism of Human Eosinophilic Polymorphonuclear Leukocytes.

E. S. Ingraham and \V. B. Wart man, Cleveland. — p. 3 IS.

Genesis of Infarction. L. LocfHcr, Decatur, III. — p. 323.

•Incidence and Significance of Healed Miliary Tubercles in Liver, Spleen
and Kidneys. II. S. Keichlc and J. L. Work, Cleveland. — p. 331.

Action of Estrogen on Skeletal Tissues of Immature Guinea Pigs. M.

Silherberg and Ruth Silberberg, St. Louis. — p. 340.

Anitschkow “Myocyte/* J. C. Ehrlich and B, Lapan, New York. —
p. 361.

Changes in Prostate Caused by High Frequency Current. L. A. Maslow,
Chicago, and E. Martos, Budapest, Hungary. — p. 371.

Medial Degeneration of Aorta: Study of 210 Routine Autopsy Speci-
mens by Serial Block Method. A. Rottino, New York. — p. 377.

Healed Miliary Tubercles : n Viscera. — Because of a
tentative hypothesis that the small calcified bodies occurring in
tlie liver, spleen and other parenchymatous viscera are miliary
tubercles, Reichle and Work conducted a systematic study on
material obtained at necropsy in 500 consecutive cases. In the
search for these lesions, particular care was taken to examine
the organs for manifestations of active, latent or healed tuber-
culosis. Approximately two thirds of the lungs were injected
with solution of formaldehyde U. S. P. (diluted 1 to 10) and
sectioned. The remaining material was examined in the fresli
state. Partial necropsies and necropsies on stillborn infants,
premature infants and infants who died before discharge from
the hospital were excluded. There were forty-eight sucli cases ;
452 cases remain. Nodules were found in one or several of
the parenchymatous organs in ninety-one, an incidence of 20.1
per cent. This is a high incidence, since few conditions other
than parenchymatous degeneration, hyperemia, edema, primary
tuberculosis and' arteriosclerosis occur in more than one fifth
of the bodies coming to necropsy in the Cleveland City Hos-
pital. The nodules were not phleboliths but true miliary tuber-
cles. They are microscopically indistinguishable from small
primary tubercles. Animal inoculation demonstrated the pres-
ence of tubercle bacilli. Their distribution points to hema-
togenous dissemination and their morphology to some association
in point of time with the primary complex. The high correla-
tion between apparent resistance to progressive tuberculosis and
the incidence of these lesions leads to the suggestion that this
dissemination acts as an autovaccination, conferring a relatively
high resistance to reinfection. The spleen was most commonly
affected, in seventy-three of the ninety-one cases, the liver in
forty-seven and the kidneys in two. In the liver they were
usually situated just beneath but not within the capsule and
were only occasionally found in the deeper parenchyma. In the
spleen they were commonly encountered deep in the pulp and
infrequently beneath the capsule. The nodules bore no neces-
sary relation to the structure of the organ in which they occurred
or to its blood vessels. They could be easily extracted from
the parenchyma but could never be shelled out of a casing such
as is consistently found about a phlebolith. The number of
lesions varied widely. In a few cases only one or two nodules
were found while in otiiers they numbered several hundred.

Bulletin New York Academy of Medicine, New York

15: 577-636 (Sept.) 1939

So , m ' Difficulties in Use of Insulins in Dinbctic Practice. IV. R. Camp-
Mi, Toronto— p. 579.

reatment of Postabortal and Postpartum Sepsis, with Special Considera-
tion Sulfanilamide and Allied Drugs. E. G. Waters, Jersey City,
v u J* — 597 *

^oogenesis and Present Da 3 ' -Treatment of Urinary Infections. M. F.
• Lam Poen, New York. — p. 609. -

Journal of Bacteriology, Baltimore

38: 121-248 (Aug.) 1939

Virus of Psittacosis: I. Propagation and Developmental Cycle in Egg
Membrane, Purification and Concentration. A. S. Lazarus and K. F.
Meyer, San Francisco. — p. 121.

Id.: II. Centrifugation, Filtration and Measurement of Particle Size.

A. S. Lazarus and K. F. Meyer, San Francisco. — p. 153.

Id.: III. Serologic Investigations. A. S. Lazarus and K. F. Meyer,
San Francisco. — p. 171.

Comparison of Hydrogen Production from Sugars and Formic Acid by
Normal and Variant Strains of Escherichia Coli. E. J. Ordal and
H. O. Halvorson, Minneapolis. — p. 199.

Inhibition of Proteinases of Certain Clostridia by Serum. L. D. Smith
and C. H. Lindsley, Philadelphia. — p. 221.

Journal of Clinical Investigation, New York

18: 497-616 (Sept.) 1939

Magnesium Content of Erythrocytes in Pernicious and Some Other
Anemias. O. Bang, Copenhagen, Denmark, and S. L. 0rskov, Aarhus,
Denmark. — p. 497.

Rate of Attainment of Diffusion Equilibrium for Thiocj'anate Between
Plasma and Transudates Following Intravenous Injection of Sodium
Thiocyanate in Patients with Edema. ■ D. R. Gilligan and M. D.
Altschule, Boston. — p. 501.

•Formation of Methentoglobin and Sulfhenioglobin During Sulfanilamide
Therapy. J. S. Harris and H. O. Michel, Durham, N. C. — p. 507.
The In Vitro Formation of an Oxidizing Agent by Surviving Tissues
and Sulfanilamide. J. S. Harris, Durham. N. C. — p. 521.

•Clinical Studies of Blood Volume: VII. Changes in Blood Volume in
Bright’s Disease With or Without Edema, Rena! Insufficiency, or Con-
gestive Heart Failure, and in Hypertension. A. W. Harris and J. G.
Gibson 2d, Boston. — p. 527.

Inability to Demonstrate a Platelet Reducing Substance in an Acetone
Extract of’ Spleen from Patients with Idiopathic Thrombocytopenic
Purpura. F. J. Pohle and O. O. Meyer, Madison, Wis. — p. 537.
Studies in Iron Transportation and Metabolism: III. Normal Fluctua-
tions of Serum and “Easily Split-Off” Blood Iron in Individual Sub-
jects. C. V. Moore, Virginia Minnich and Jo Welch, Columbus, Ohio.
— p. 543.

Id. : IV. Observations on Absorption of Iron from Gastrointestinal
Tract. C. V. Moore, W. R. Arrowsmitli, Jo Welch and Virginia
Minnich, Columbus, Ohio. — p. 553.

Treatment of Acute Alcoholism with Glucose and Insulin. W. Goldfarb,
K. M. Bowman and S. Parker, with technical assistance of B. Kraut-
man, New York. — p. 581.

Blood V-Factor (Coenzyme) Level in Normal and Pathologic Subjects.
H. I. Kohn and F. Bernheim, with technical assistance of A. V.
Felsovanyi, Durham, N. C. — p. 585.

Treatment of Gas Gangrene Infections in Guinea Pigs with Neoprontosil,
Sulfanilamide and Sulfapyridine: Experimental Study. D. B.
Kendrick Jr., Rochester, Minn. — p. 593.

Ultrafiltrable Magnesium in Hyperthyroidism. L. J. Softer, D. A.
Dantes, E. B. Grossman, H. Sobotka and Mildred D. Jacobs, New
York. — p. 597.

Coagulation Defect in Hemophilia: . Clot Promoting Activity in Hemo-
philia of Berkefelded Normal Human Plasma Free from Fibrinogen and
Prothrombin. E. L. Lozner, R. Kark and F. H. L. Taylor, Boston. —
p. 603.

•Occurrence of Abnormal Dark Adaptation and Its Relation to Vitamin A
Metabolism in Patients with Cirrhosis of Liver. A. J. Patek Jr. and
C. Haig, New York. — p. 609.

Methemoglobin, Sulfhemoglobin and Sulfanilamide. —
Harris and Michel assayed quantitatively the effect of sulfanil-
amide on the formation of abnormal heme pigments. There
were 960 blood examinations made on 476 patients. Methemo-
globin, in quantities demonstrable by the hand spectroscope, was
found in the erythrocytes of 277, or 58 per cent, of the patients
at some time during the administration of sulfanilamide. The
percentage of patients developing methemoglobinemia is roughly
equal in the sexes but is higher in the young. Since the extent
of methemoglobinemia did not increase markedly with the dura-
tion of dosage, it is not a cumulative effect of the drug and
does not depend on the total dose of sulfanilamide. It is possible
that the development of methemoglobinemia is favored by the
presence of larger concentrations of circulating hemoglobin.
To analyze this factor, 647 determinations on patients who
showed methemoglobinemia at some time during their course
of therapy were arranged in accordance with the hemoglobin
content and the level of blood sulfanilamide. It was found that
the percentage of bloods positive for methemoglobin in each
sulfanilamide level group did not vary with the hemoglobin
content. However, the average methemoglobin concentration
showed a tendency to vary in direct relation to the amount of
hemoglobin present, so that the average methcmoglobin/total
hemoglobin ratio remained rather constant at each blood sulf-
anilamide level. The blood hemoglobin levels were rather evenly
distributed and unaltered by the age, sex and sulfanilamide con-
centration of patients. Sulfhemoglobincmia was more frequent
after long courses of sulfanilamide but did not bear any rela-
tionship to age, sex or the concentration of sulfanilamide or

1600

CURRENT MEDICAL LITERATURE

lorn. A. .V. 3
Oct. 21, 1939

methemoglobin in the blood. On the basis of these observations,
it is postulated that an active substance is normally produced
in the course of sulfanilamide metabolism which causes the
production of methemoglobin and sulfhemoglobin. The data
presented are found to agree with the concept that methemo-
globinemia depends on the balance of the formation of the active
agent, oxidation of hemoglobin under the influence of the active
agent and reduction of methemoglobin by the body.

Blood Volume in Nephritis. — Harris and Gibson observed
the course of the plasma and total blood volume in nephritis.
Three factors appear to be concerned in the regulation of the
plasma volume: serum albumin concentration, nonprotcin nitro-
gen concentration and the degree of anemia. Regardless of the
stage of the disease, whether acute, subacute or chronic, with
or without edema or renal insufficiency, the level of the plasma
volume reflects the interrelationship of these three factors. The
relationship of the changes in plasma and circulating erythro-
cyte volume is such that the total blood volume always remains
below normal. With development of congestive heart failure,
regardless of the degree of anemia present, an additional factor
appears to be introduced resulting in an increased circulating
erythrocyte volume and hence increased total blood volume. In
the edematous stage hypoproteinemia tends to diminish, and, if
present, anemia tends to augment the plasma volume. During
diuresis there is a tendency for the plasma volume to increase
chiefly in relation to the increase in the albumin fraction of the
serum protein. Circulation time in the group of cases exhibit-
ing subacute glomerular nephritis with edema (nephrosis syn-
drome) was slower than in the group with chronic nephritis
without edema. The lowered metabolism characteristic of the
former group may explain this paradoxical observation.

Dark Adaptation, Vitamin A Metabolism and Cir-
rhosis. — Whether vitamin A deficiency occurs in patients with
hepatic disease whose intake of the vitamin is adequate and who
are not jaundiced was determined by Patek and Haig by studies
on vitamin A metabolism in twenty-four cases of cirrhosis of
the liver. The studies show that patients with cirrhosis of the
liver may be deficient in vitamin A. The deficiency is not
attributable to an inadequate intake of the vitamin in their food.
Although the selected cases were free of jaundice, it is possible
that malabsorption contributed to the deficiency. The patients’
resistance to oral therapy might be so interpreted. Abnormal
dark adaptation was observed in nineteen of the twenty-four
cases. In certain cases both elevation of the final rod and cone
thresholds and delay of rod dark adaptation occurred. In most
instances only the latter change took place. These changes
were unrelated to jaundice. They tended to persist in the
presence of a nutritious diet, rich in vitamin A. The oral and
parenteral administration of vitamin A concentrates was fol-
lowed by extensive improvement. Cone and rod thresholds were
lowered and speed of adaptation was increased. This improve-
ment was only partially maintained after treatment was discon-
tinued. These data suggest that abnormal dark adaptation in
patients with cirrhosis of the liver is due chiefly to altered
intermediary metabolism of vitamin A.

Journal of Experimental Medicine, New York

70: 223-332 (Sept.) 1939

Production ot Kidney Antibodies by Injection of Homologous Kidney Plus
Bacterial Toxins. F. F. Schtventkcr and F. C. Comploier, Baltimore. —
p. 223.

Culture Flask for Circulation of Large Quantity of Fluid Medium. C. A.
Lindbergh, New York. — p. 231. _. T _ r

Immunologic Relationship of Capsular Polysaccharide of Type XIV Pneu-
mococcus to Blood Group A Specific Substance., P. B. Beeson and
IV. F. Goebel, New York.— p. 239. TTT

Studies on Bactericidal Agent Extracted from Soil Bacillus: III. Frepa-
ration and Activity of Protein-Free Fraction- R* J. Dubos and C.
Cattaneo, New York. — p. 249. . _ r .

Manner of Growth of Froff Carcinoma, Studied by Direct Microscopic
Examination of Living Intra-Ocular Transplants. B. Lucke and H.
Schlumberger, Philadelphia. — p. 257. _ . ..

Characteristics of Frog Carcinoma in Tissue Culture. B. Lucke, I nila-
delphia.- — p. 269. . . _ .

Passage of Proteins from Vascular System into Joints and Certain Utner
Body Cavities. G. A. Bennett and M. F. Shaffer, Boston. — p. 277.

Passage of Type III Rabbit Virulent Pneumococci from Vascular System
‘into Joints and Certain Other Body Cavities. M. 'F. Shaffer and
G. A. Bennett, Boston.— p. 293. T c

Encephalopathy Following Injections of Bone Marrow Extract. L. b.

Further ContriluU.’on 'to’ Vitairdn' C Therapy in Experimental Poliomye-
litis. C. \Y. Jungeblut, New York.— p. 315.

Journal of Pediatrics, St. Louis

15: 157-316 (Aug.) 1939

Immunologic Relationships Between Cow’s Milk and Goat's Milk. L V
■Hill, Boston. — p. 157.

Acute Coccidioidomycosis with Erythema Nodosum in Children. H. K.

Faber, C. E. Smith and E. C. Dickson, San Francisco.— p. 163.
Relation of Dysentery to Acute Diarrhea of Infants and Children. M. L'
Cooper, M. L. Furcolow, A. G. Mitchell and G. E. Cullen, with asa<-
tance of Helen M. Keller, Barbara Johnson, Janet P. Milliken, II. F.
Marsh, F. J. Grabill and G. W. Thomas, Cincinnati. — p. 172.

\ itamm A Absorption in Celiac Disease. B. B. Breese Jr. and Augusta
B. McCoord, Rochester, N. Y«- — p. 183.

Test for Determination of Vitamin C Storage: Vitamin C Index, L.

# Kajdi, J. Light and Charlotte Kaj'di, Baltimore. — p. 197.

* Comparison of VoJImer Tuberculin Patch Test with Purified Protein

Derivative: Results of Tests on 880 Rural School Children ia St.
Alary’s County, Maryland. E. C. Peck and M. E. Wegman, Baltimore.
— p. 219.

*Study of 1,852 Chest Roentgenograms of Tuberculous Contacts Umltf
Age of 5 Years. H. A. Rosenberg and M. I. Levine, New York—
p. 224.

Value of Roentgenographic Examination in Diagnosis of Syphilis in New
born Infants. A. U. Christie, San Francisco. — p. 230.

Treatment of Scarlet Fever with Specific Antitoxins of Low Protein Con*
tent. J. A. Toomey and E. R. Kimball Jr., Cleveland.— p. 23$.
Control of Common Contagious Diseases in Pediatric Wards of a Gen-
eral Hospital. C. C. Fischer and C. S. Raue, . Philadelphia.— p. 2b-
Multiple Cystic Tuberculosis of Bones: Report of Case. D. W. Martin,
Durham, N. C.— p. 254.

Comparison of Tuberculin Tests. — Over a period of two
months Peck and Wegman performed tuberculin tests on 8S0
school children. Their ages varied from 5 to 21. Tire first
and second purified protein derivative doses were injected mtra-
dermally and the VoIImer patch test was applied to the skin.
The first purified protein derivative dose was injected and tic
patch test applied on the same day and both were read two
days later. Those children who were negative to the w:
purified protein derivative test were tested with the secon
purified protein derivative dose and this was read two ajs
later. In all cases in which the patch test was positive, it u3 '
found that it was as definite on the second day as it was oi
the first day, or even stronger, indicating that one na) rc
the test forty-eight hours after removal of the adhesive ap
just as well as after twenty-four. At least one of ,IC . '
tests used was positive in 319, or 36.2 per cent, of the c > ■

The patch test was far inferior to purified protein denv ^
in detecting tuberculin reactors. It was not even as goo
the first strength of purified protein derivative, even tnoug i
patch test did pick up some reactors who were negative o ^
first strength of purified protein derivative. The patch «
pick up eighteen, or 9.6 per cent, of the 188 in whic >
dose of purified protein derivative was negative. I y ^
however, the first dose of purified protein derivative
fifty-five, or 24.4 per cent, of the 225 in which t le pa
negative. It seems to be clear that the patch a j of

replace purified protein derivative either as a diagnos
the individual patient or as a case-finding proce ure ^

health work. Because of the obvious convenience o
test, a possible field of usefulness suggests itsc • nur ;flcd
employ the patch for the primary test in place l
protein derivative, recognizing that if the tes 1 ,, rotor.

must be followed by the second strength of pu i

derivative before a definite opinion can be given. tacts.

Chest Roentgenograms of Tuberculous ([lC

Rosenberg and Levine studied 1,85- roen gen g , r! _

chests of 584 infants, varying in age from 1 jfgntoux
from tuberculous homes. Among 3/9 cases m i shadows

tests were negative, the incidence of tra f c ,e0 , Tffla l shadows

alone was 6.8 per cent and the incidence o p< . jijuiouv

was also 6.8 per cent. Among 205 cases i ^ sta dows
tests were positive, the incidence of trac i wa s 40 P« r

was 9.2 per cent and that of parenchymal shadov ^ ^
cent. Increased tracheobronchial shadows per t |, e

than three months in 26.6 per cent of e ccnt jhe

Mantoux tests were negative, as against / . i p. ircnc |nT.uI
cases in which the tuberculin test three nw” 1 ''"’

shadows persisted on subsequent exami cases 3"<!

or more in eight of sixteen of the negative In[
in sixty-one of the sixty-six positive ^Wito ^-nat
dying of tuberculosis generally stow d tubcrcu !osis

shadows on a roentgenogram Since tmtay &f h tie
the most frequent cause of death in e.xanu" 311 '-'

diagnosis of lethal forms of tuberculosis by x raj

Volume 113
NUMBER 17

CURRENT MEDICAL LITERATURE

1601

was readily made. Increased tracheobronchial shadows in
infancy may not be accepted as pathognomonic of tuberculosis,
even in the presence of a positive Mantoux test. However, a
majority of the parenchymal lesions in tuberculin positive infants
are probably tuberculous in nature.

New England Journal of Medicine, Boston

281:291-328 (Aug. 24) 1939

Transient, Recurrent Bundle Branch Block. H. Miller and F. T, Fulton.

Providence, R. I. — p. 291.

•Phenolphthalein Test in Diagnosis of Gastrointestinal Disease. B. M.

Banks and L. E. Barron, Boston. — p. 296.

* Clinical Experience with 95 to 98 per Cent Oxygen in Treatment of

Abdominal Distention and Other Conditions. P. Congdon and A. M.

Burgess, Providence, R. I. — p. 299.

Perianal Cryptic Tabs. E. T. Whitney and J. F. Keane, Boston. — p. 303.
Pediatrics. R. C. Eley, Boston. — p. 306.

Phenolphthalein Test in Gastrointestinal Disease.— In
order to determine the rationale of the phenolphthalein test in
the diagnosis of gastrointestinal disease, as suggested by Wold-
man, 203 patients were submitted to the test by Banks and
Barron. Of these, fifty-two bad intrinsic lesions of the gastro-
intestinal tract. The remaining 1S1 had a variety of condi-
tions other than those of the gastrointestinal tract or no
demonstrable pathologic lesion and served as controls. Only
thirty-six positive tests were obtained in the group of fifty-two
patients. Carcinoma of the stomach and intestine gave the
highest proportion of positive results, whereas negative tests
were found in two cases of esophageal carcinoma, possibly
owing to the brief period of contact between the drug and the
diseased area. Ulcers of the mouth and pharynx gave uni-
formly positive tests. Of twenty-two patients with gastric or
duodenal ulcer, approximately one third yielded negative results.
More detailed analysis of these failures revealed that gastric
stasis or pyloric obstruction with fluid retention and possible
precipitation of the drug might account for several, and one
patient had an' ulcer high in the cardia. No explanation was
apparent in the remainder. There were three failures in four
cases of chronic ulcerative colitis or amebic dysentery charac-
terized by frequent liquid stools daily. Here again insufficient
contact due to the hypermotility of the intestine may have been
a factor. In the control subjects 'the test yielded 127 negative
and twenty-four positive tests. The test was consistently nega-
tive in cases of hysteria, unexplained syncope, anorexia nervosa,
diabetes and osseous disease. Positive tests were found espe-
cially in serious and advanced heart disease with pulmonary
edema, paroxysmal nocturnal dyspnea, coronary occlusion, acute
toxemia, infection and malignant metastasis. One must assume
either that breaks in the mucous membrane of the alimentary
canal frequently exist under such conditions or that the vitality
of the cells is so impaired that the enteric membrane no longer
acts as an efficient barrier to the drug. Several asthmatic
patients also excreted significant amounts of free phenol-
phthalein in the urine. It is the authors’ impression that the
test may find its greatest field of usefulness among ambulatory
patients, in whom the chance of obtaining false positive tests
because of severe toxemia or far advanced systemic disease
would be largely eliminated. In view of the rapid absorption
from oral lesions which might obscure a more serious condi-
tion lower down, the patient should drink the test fluid through
a straw, rinsing the mouth immediately and thoroughly with
water without swallowing further. Excessive salivation should
be noted and prevented from interfering with the test. In
cases of suspected gastric disease, the test is best done after
gastric lavage or gastric analysis in order to obviate retention
and consequent excessive dilution of the test liquid. At times
catheterization to obtain the urine specimens may be indicated,
as in prostatic cases in watery diarrhea.

Oxygen for Abdominal Distention and Emphysema. —
Congdon and Burgess used 95 to 98 per cent oxygen in the
treatment of forty cases of abdominal distention and three
vases of subcutaneous emphysema treated. Twenty-five of the
patients with abdominal distention were strikingly benefited,
the benefit in five was questionable and ten were uninfluenced.
Of those with emphysema, all had satisfactory results. Fol-
lowing encephalography the routine use of the method has
appeared to prevent severe headaches. It is in severe abdom-
inal distention, such as that which is seen in certain infec-

tious diseases, notably pneumonia, typhoid and peritonitis after
abdominal operations, that the method is most useful and at
times life saving. It should be considered an emergency mea-
sure when simpler means have failed.

New Jersey Medical Society Journal, Trenton

30: 473-522 (Aug.) 1939

Factors Determining Localization of Organ Tuberculosis. S. Berg.
Newark, — p. 479.

Primary Bronchopulmonary Aspergillosis. A. J. Stolon*, Glen Gardner.
— p, 484.

Neurosurgical Aspects of Cranial Neuralgias: Trigeminal Neuralgia,
Glossopharyngeal Neuralgia and Meniere’s Syndrome. W. Ehrlich,
Newark. — p. 486.

Perineal Repair: Choice of Operation. D. N. Barrows, New York. — -
p. 492.

Management of the Rheumatic Patient. J. G. Kaufman, Newark. —
p. 496.

Toxemias of Pregnancy. A. J. Walscheid, Union Cit 3 ’. — p. 500.

Clinical Manifestations and Management of Early Syphilis. G. D.
Astrachan, New York. — p. 508.

Maternal Mortality Statistics 1938. A. W. Bingham, East Orange. —
p. 510.

Pennsylvania Medical Journal, Harrisburg

42: 1297-1424 (Aug.) 'l939

Gastrointestinal Manifestations of Urinary Disease and Urinary Mani-
festations of Gastrointestinal Disease. P. W. Brown and E. G. Wake-
field, Rochester, Minn. — p. 1309.

Rationale of Cholecystectomy in Noncalculous Gallbladders. L. D.
O’Donnell, Pittsburgh. — p. 1315.

Cancer. S. P. Reimann, Philadelphia. — p. 1319.

Treatment of Fractures of Hip. L. F. Bush, Danville. — p. 1325.

Physical Therapy in Otolaryngology. W. H. Schmidt, Philadelphia. —
p. 1330.

Management of the Gallbladder Patient. M. E. Rehfuss, Philadelphia. —
p. 1335.

•Vaccination During Pregnancy as Prophylaxis Against Puerperal Infec-
tions. J. B. Bernstine and G. W. Bland, Philadelphia. — p, 1340.

Vaccination for Puerperal Infections. — A second series
of 177 pregnant women vaccinated against puerperal infections
are the subject of the report by Bernstine and Bland. The
article dealing with the first series of fifty-one pregnant women
so vaccinated was abstracted in The Jourxal, March 21, 1936,
page 1037. The vaccine consists of five strains of Streptococ-
cus haemolyticus, eight of Streptococcus viridans, two of
Staphylococcus aureus, two of Bacillus coli communis, four of
Streptococcus nonhaemolyticus and ten of Staphylococcus albus.
The respective percentages of these strains in the vaccine are
35, 15, 15, 15, 10 and 10. The patients (228) in both series
were delivered with no fatalities. The puerperal morbidity was
5.4 per cent as compared to the morbidity of the nonvaccinatcd
women, which was 19.2 per cent. Ninety male and eightv-
two female children were born to the 177 vaccinated patients.
There were three abortions and two stillbirths. In the entire
group there were three abnormalities— hemangioma of the
maxilla, supernumerary digits and left clubfoot. The vaccine
was administered to pregnant women with various complica-
tions in addition to their pregnant state. These complications
varied in type and severity, and yet not a single case was
observed that presented an aggravation of the preexisting con-
dition. The patients were not hand picked but represent a
cross section of the average obstetric practice with its asso-
ciated complications.

Public Health Reports, Washington, D. C.

5 4: 1509-1546 (Aug. IS) 1939

•Treatment of Induced Malaria in Negro Paretics with Mapharsen and
Tryparsamide. M. D. Young and S. B. McLendon.— p. 1509.

Pulmonary Tumors in Mice: Parts VI, VII, VIII and IX. H. B.
Andervont. — p. 1512.

Induced Malaria in Negroes with Dementia Paralytica.
— According to Young and McLendon during the last year, at
the South Carolina State Hospital, ten Negro dementia para-
lytica patients who had been infected for therapeutic purposes
with quartan malaria were given mapharsen. Each patient
received 0.04 Gm. of mapharsen intravenously weekly for a
period of ten weeks. At the same time 0.02 Gm. of thiobismol
was given. Subsequently, two of the ten patients received a
course of tryparsamide. Twenty-two weeks after the comple-
tion of the mapharsen treatment, blood smears from all ten
patients still showed parasites (Plasmodium malariae) although
the patients showed no symptoms of the disease. To test the
viability of the parasites, submoculations were made from two
of the mapltarsen-treated persons to two uninfected subjects.

1602

JI. .1
Orr. 21, 19!'

CL'RREXT MEDICAL LITERATURE

r >l)ical symptomatic and parasitic infectious with quartan
maiaria developed in both, which showed that the mapharsen
had not affected the viability of the malaria parasites. Exami-
nations were made of three quartan malaria patients who had
received tryparsamide in antisyphilitic treatment. One year
after the completion of the tryparsamide treatment two patients
still harbored Plasmodium malariae in the blood stream.
Another patient still had parasites nine months after treat-
ment. Another group of eight patients was started on trvp-
arsamide. Four patients completed the treatment and the
malaria parasites were continually present. Treatment of the
other four was interrupted after the fifth week, and all had
shown malaria parasites continually. Subinoculation from one
ot this group resulted in a typical symptomatic and parasitic
course of malaria, showing that the parasites were still viable.
As these drugs relieved the symptoms without eradicating the
infection, their use might inadvertently result in quartan
malaria carriers being released and thus establish foci of infec-
tions of a type of malaria now rare in the United States.

5-4: 1547-1586 (Auk. 25) 1939

x.-unral Infection of Triatoma Gerstakeri with Trypanosoma Crnzi in
Texas. A. Pnckchanian. — p. 1547.

Disabling Morbidity Amonc Industrial Workers, First Quarter of 1939.
tV. M. Gafafer. — p. 1554.

'•Outbreak of Botulism in Tennessee Due to Type II Clostridium Botu-
linum. C. 33. Tucker and II. Swanson.— p. 1556.

Botulism in Tennessee.— -Tucker and Swanson report two
cases of botulism, which are of particular interest because for
the first time Clostridium botulinum toxin was demonstrated
to be present in home-canned vegetables in Tennessee. More-
over, for the first time in Tennessee Clostridium botulinum,
type B, was actually recovered. Twenty cases of botulism in
Tennessee which occurred prior to 1939 are reviewed. Home-
canned okra and possibly home-canned beans were the foods
icsponsible for the two cases reported.

Wisconsin Medical Journal, Madison

OS : 605*703 (Aug.) 1939

Use and Importance of Electrocardiography in Prognosis and Treatment
of Diseases of Heart by the General Practitioner. \V, Adams,
Chicago. — p. 623.

Low Grade Occult Inflammatory and Neoplastic Diseases of Orbit
W. L. Benedict, Rochester, HI inn. — p. 628.

The Asphyxiated Infant. II. A. Cunningham and A. B. Schwartz,
Milwaukee. — p. 032.

‘‘Evaluation of Therapy in Trigeminal Neuralgia: Results of Treatment
with Typhoid Vaccine in Eighteen Cases. E. R. Schmidt. Madison, and
J. M. Sullivan, Milwaukee. — p. 635.

Convalescent Serum in Contagious Diseases. J. A. Conner, Chicago. —
p. 638.

Aberrant Gastric Mucosa in Rectum with Ulceration and Hemorrhage.

G. H. Ewell and R. H. Jackson Sr., Madison. — p. 641.

Treatment of Prostatic Obstruction: Analysis of 300 Cases. \V. G.
Sexton, Marshfield. — p. 644.

Trigeminal Neuralgia. — In evaluating the results of hyper-
pyrexia treatments in trigeminal neuralgia, Schmidt and Sulli-
van chose typhoid vaccine because of its ease of administration
and handling, treating eighteen patients. Injections at about
biweekly intervals, starting with a dose of 10,000,000 killed
organisms, were given intravenously, and the doses were stepped
up by ten or twenty million each time until a good thermal
reaction was obtained. Early in their series they learned that
results could be obtained as readily with a mild fever response
as with a high thermal reaction. The majority of their patients
were hospitalized for their treatments, but several ambulatory
patients were treated and no ill effects have been encountered.
Of five patients more than 80 per cent relief was obtained and
they were satisfied to control their residual tic with mild anal-
gesics or Christian fortitude rattier than submit to further
therapy. Of five other patients, relief was complete and con-
tinuous. Four patients experienced complete relief for from
two to four months and failed to respond to a second course
of vaccine therapy, so that alcohol injections were necessary
for the further control of the tics. Three patients obtained 50
per cent relief or less and needed alcohol injections to complete
their treatment. Only one patient in the series failed to show
some amelioration of ’symptoms following vaccine therapy; the
sensory root of the trigeminal nerve was resected and complete
relief ensued. Women showed a slightly better response than
men to this form of treatment. Snake venom m a trial group
proved unsuccessful in relieving pain of this type.

FOREIGN

C- , 1 ’ lletore n tl,,e “"licates lb. 1 t the article i< a|,.t«ttel
below. Single case reports ami trials o£ new drugs are ,«!»)), S

Australian and New Zealand J. Surgery, Sydney

0:1-110 (July) 1939

~, r kcneliu Dtgby and His “Choice Receipts.” K, F. Russell.— p. I

1 A A fi $ r n ?S°? , Syme Oration: Surgery in England in ‘if

.Making, A. Wcbb-Johnson. — p. }Q.

Early Symptomatology and Conservative Treatment of Blari&c X«
Obstructions. R. J. Silverton.— p. 31.

Some Points in Treatment of Retinal Detachment. J. R, Androct

Sinusitis. G. C. Scantlehury. — p. 46.

Mechanical Principles in Causation and Treatment of Disease: lecture 1
Fay Mnclurc. — p. 66.

British Journal of Medical Psychology, London

18: 105-284 (July) 3939 ■

Psychologic Observations on Hematemesis. A. T. M. Wilson.— p. Ill
Symbolic Significance of Glass and Its Relation to Diseases ef Kjc
W. S. Inman. — p. 122,

Case of a Middle-Aged Embezzler. D. Forsyth. — p. 141.
Conception of Dread of Strength of Instincts. X. J. Symons.— p. 131
Is Aggression an Irreducible Factor? W. R. D. Fairbairn.— p. R3.
Aggression. _ A. \V. Wolters.— p, 17L
Aggression in Early Childhood. Karin Stephen. — p. 1?8.

Sin, Sex and Sickness in Saulteaux Belief. A. I. Hallowell.— p. 151.
Analytic Observations on Scala Perfection^ of Mystics. P. Hcphr*.
— i>. 198.

Some Interpretations of painting Called “Abstraction.” R. W. Pickford.

— p. 219. ...

Studies on Psychopathology of Compulsive Wandering: Prelimmary
Report. E. Stengel. — p. 250.

British Journal of Surgery, Bristol

27: 1-308 (July) 1939

‘Increased and Decreased Density of Bone, with Special Reference t-
Fibrosis of Marrow'. II. A. T. Fairbank.— p. 3.^

Improved Spinal Analgesia. G. Macpherson.— p. 34.

Treatment of Empyema Thoracis by High Negative-Pressure Drai :

E. R. Trethewie. — p. 58, . , . . nn . n ,

Veritol: Blood Pressure Stimulant for Use During and Auer vfr
tions. II. Dodd and G. Merton.— p. 78. T . _ riW ri

Spontaneous Rupture of Gallbladder with Massive Intrape
Hemorrhage. R. Mailer, — p. 91. . 4 Rfo:

"Vascular Anomalies of Upper Limbs Associated with Lerv
Report of Case and Review of Literature. B. M. P** \i
Vascular Complications of Cervical Ribs and First Thoracic R '
malities. K. C. Eden. — p. Ill,

H. Bailey.— p. 140. # ^ f. }l

U

Coiiins. — p. J44.

Due to Dysenteric Ulceration.

y- : ,Vcw k Abduction Splint. W- A* Coctontc-P- | 5 J

... ■■■ • ■ -. of Cut Pancreatic Duct into Duodena®.

Harries. — p. 354.

Congenital Absence of Right Femur. K. Manonar. P> * .o
Congenital Defect of Shaft of Femur. H. H. EJJS
"Gallstones and Cancer: Problem of Etiology, with Special

Role of Irritation. H, Burrows. — p. 166. , , ,

Density of Bone and Fibrosis of Marrow.--
lists the principal conditions in which more or , a;
generalized osteoporosis, or want of density of ,c .
a whole, is found: osteogenesis imperfecta, osteog » r ;ekelf.
fecta cystica, infantile scurvy, rickets, osteomalacia, ,
idiopathic steatorrhea in adults, renal rickets, ren
in adults, hyperparathyroidism, osseous dysp a . OS } CO poro-
icterus neonatorum, thyrotoxic osteoporosis m a u > rJ |.
sis due to pituitary basophilism, senile ostcoporosi
ized osteoporosis from prolonged recumbenc) dj t ccti- l ‘:
Alterations in the density of the bones (li . n c j a ji:e:

there

either of osteoporosis or of osteopetrosis.

These two

may be present in a single case, even in a 8 ^ t ,

being a tendency in many cases for an mlfl L s t s th !

be replaced by increased density. The a known i\

marble bones with a limited distribution, ge fibrosis <’•

melorheostosis, is really a particular type 0 netrc-is

bone. Some evidence is presented that genera O co5i- r '

or Albers-Schonherg’s disease, may be simt ar. n3 ture.

association of cutaneous lesions, usually ° ,j, e ctiol-y
with multiple bone changes is commented on. ., ara thyrc-'
of the more obscure disorders it is possible diverse c "f

may be responsible, partly or entirely, !or bI1 nC for V

Vascular Anomalies of Upper
libs.— Hill cites a case of hi
onlv bv vasomotor disturbance:

ditions as renal rickets and marble bones, as
fibrocvstic osseous changes of hyperparati , • Cerv ica 5

Limbs and
,-ical ribs acconiP--,

Ribs.— Hill cites a case of bilateral c . erv VT nf ,j, c acrMT*
cs of the hands ot me

Vo LI' SI E 113
Xl'MBER 1 7

CURRENT MEDICAL LITERATURE

1603

type in which removal of a rib and the fibrontuscular band
relieved pain, diminished swelling and improved the color of
the hand on the corresponding side. Other anatomic variations
are worthy of consideration in cases of vascular disorders of the
upper extremities and, with rational indications, exploratory
operation on this region would be warranted.

Gallstones and Cancer. — In order to prove further that
chronic irritation is not the cause of cancer, Burrows placed
gallstones and other foreign bodies in the gallbladders of fifty
guinea pigs, which subsequently lived for periods varying from
nine to 359 weeks. In no instance did cancer of the gallbladder
develop. These results are regarded as supporting the view
that experimentally chronic irritation alone is not the cause of
cancer.

British Medical Journal, London

2 : 265-320 (Aug. 5) 1939

Present Position of Chemotherapy tty Drugs of Sulfanilamide Group:

BacterioloKtc amt Experimental Aspect. C. IT. Browning. — p. 265.
Pharmacology of Sulfanilamide Group of Drugs. G. A. If. Buttle. —
p. 269.

Achlorhydric Hypochromic Anemia Associated with Peripheral Neuritis:

Report of Two Cases. C. Worster-Drought and .T. Shafar. — p. 273.
"Rheumatism and Climate. J.. Ilill. — p. 276.

'Hepatic Insufficiency in Scarlet Fever. R. \V. Carslarv. — p. 27S.

Rheumatism and Climate. — The literature contains many
speculations about the influence on rheumatism of cold and
damp, cyclonic disturbances, the electrical state of the atmos-
phere and the like but Hill states that the evidence shows that
it is conditions produced by dirty, artificially heated and poorly
ventilated bouses and density of population which cause decay
of teeth, catarrhal infections and rheumatic troubles. The ill
effects of these conditions arc intensified by a diet in which the
protective foods arc deficient. Women suffer from rheumatic
troubles more than men, because the latter by going to work
change to better conditions. The fear of cold intensifies the ill
effects of the indoor environment.

Hepatic Insufficiency in Scarlet Fever. — Carslaw studied
219 cases of scarlet fever in the hope of detecting some warning-
in those cases in which nephritis developed later. He noticed
that there was a general fall itt the urea factor throughout the
first three weeks of the illness and that the figure was at its
lowest at the critical period — that is, at the period when nephritis
most commonly occurs ; at the end of the third week. The urea
factor was found to be lower in the nephritic than in the non-
nephritic cases. Therefore the author proposes the determina-
tion of the specific gravity of the urine and the percentage of
urinary urea as a clinical test of hepatic function. The urea
factor can be of value in the prognosis of scarlet fever.

2: 321-382 (Aug. 12) 1939

Medical Treatment of Peptic Ulcer anti Its Complications. E Mt-uleu-
gracht. — p. 321.

Food Conservation in Relation to National Food Supply. J. Bancroft. —
1>. 324.

Commoner T 3 F pes of Supersensitiveness and Their Management. J. G.
, .Graham and J. D. O. Kerr.— p. 327.

Nicotinic Acid in Treatment of Delirium Tremens. F. Mainzer and M.
Krause. — p. 331.

"Hematemesis and Helena: Observations on Salt and Water Require-
ments. ' F. A. Jones. — p. 332.

Series of 200 Cases of E«ophagoscopy for Foreign Bodies. F. G.
Wrigtey.— p. 334.

Nicotinic Acid for Delirium Tremens— Mainzer and
Krause state that in a chronic whisky addict an attack of
delirium tremens (recurrence) associated with severe gastro-
intestinal manifestations and acute stomatitis was made to dis-
appear within twelve hours by the administration of 0.6 Gm, of
nicotinic acid. Previous to this, thiamin chloride had been given
in large doses without any perceptible result. The prompt
response to nicotinic acid favors the assumption that lack of this
vitamin is an important factor in the development of delirium
tremens.

Salt and Water Requirements in Hematemesis and
Melena. — Jones examined the postmortem records of seven
eases of hematemesis and melcna that have ended fatally after
hemorrhage had ceased, that is delayed death. An analysis indi-
cates ‘that severe dehydration Was the common factor in these
eases and that symptoms were masked by the liberal adminis-
tration of opiates. The dehydration was due partly to insufficient
5 trnl intake and partly to a forced diuresis. The latter was

probably the result of a much increased excretion of urea, pre-
sumably derived from the digestion of blood in the intestine.
Such patients should receive enough fluid to meet the normal
requirements of the kidneys, skin and lungs, and to replace any
abnormal fluid loss. In addition, it is recommended that they
should be given 10 Gm. of sodium chloride daily during the
first few days after the hemorrhage.

Journal Obst. & Gynaec. of Brit. Empire, Manchester

46: 645-812 (Aug.) 1939

‘Maternal Age and Parity in Tlacenta Praevia. L. S. Penrose. — p. 645.
Studies in Vaginal Fluid. N. Lissimore and D. \V. Currie. — p. 673.
"Pathology of Hyperemesis and Vomiting of Late Pregnancy. H. L.
Sheehan. — p. 6S5.

'Some Problems Concerning Etiology and Treatment of Hyperemesis
Gravidarum. E. Bandstrup.- — p. 70 0.

Vaginal Implantations in Uterine Carcinoma. G. T. Strachan. — p. 711.
Glycogen Content of Fallopian Tubes During Menstrual Cycle and
During Pregnancy. K. Joel. — p. 721.

Lipoid Content of Fallopian Tubes During Menstrual Cycle and During
Pregnancy. K. Joel. — p. 731.

Further Investigations on Induction of Uterine Hemorrhage by Means
of Progesterone: Second Report. B. Zondek and S. Rozin. — p. 736.
Effects of Emotional Stress on Contractions of Human Uterus: Pre-
liminary Report. E. M. Robertson. — p. 741.

Pregnancy in Uterus Containing Multiple Eibromyomas : Case. H. E.
Murray. — p. 748.

Radium Treatment of Menopausal Hemorrhage, Followed by Carcinoma
of Body of Uterus Three Tears Later. S. G. Luker. — p. 753.

Two Unusual Cases of Ectopic Pregnancy. D, F, Anderson. — p 756.

Maternal Age and Parity in Placenta Praevia. — Penrose
studied the maternal histories of seventy-two cases of placenta
praevia. The material collected, together with some additional
data, has been analyzed in such a manner as to obtain informa-
tion about the etiologic importance of maternal age and multi-
paritv. The data suggest that increasing maternal age is a
significant factor in producing the central type, though multi-
parity can be the chief cause in some marginal and lateral cases
of placenta praevia. The expected mean maternal age at normal
births is seen to be 29.1 years; the observed mean maternal
age in all the cases of placenta praevia is 31.86 years. The
difference between these two means is of highly significant
value in the statistical sense : it is nearly four times the standard
error, which is ± 0.71 years. With regard to multiparity the
mean birth rank for placenta praevia was 3.55. This value was
higher than that of expected normal births, 2.58. The difference
of almost one rank between observed and expected values is
statistically significant and is nearly as significant as the mater-
nal age difference?

Pathology of Hyperemesis of Late Pregnancy. — In the
course of routine work it became evident to Sheehan that the
textbook descriptions of the pathologic lesions of hyperentesis
or late vomiting were somewhat misleading. A study was
made of the thirty-two patients who died and were examined
post mortem within the last ten years, adequate histologic
material having been preserved. The thirty-two patients died
as a direct result of hyperemesis or of vomiting of late preg-
nancy, either before or within twenty-four hours after delivery.
The author points out that the pathologic lesions found in these
cases resulted from vomiting and an inadequate diet. There is
evidence of loss of weight, but the body is usually not greatly
emaciated. The heart is atrophied; the severity of this change
is proportionate to the duration of the vomiting. The kidneys
frequently show fat in the mitochondrial zone of the first con-
voluted tubules; this is dependent on acidosis during the last
few days before death and is not present if adequate amounts
of dextrose are administered during this time. The liver some-
times shows a fatty infiltration which may be centrilobular or,
less commonly, periportal. This appears to be due to mobiliza-
tion of body fat consequent on starvation. The brain, in patients
who develop the terminal cerebral syndrome, shows the lesions
of Wernicke's encephalopathy. Patients who die as a result
of vomiting of late pregnancy do not have atrophy of the heart
but otherwise show the same changes as in hyperentesis. In
addition, evidence of the etiologic factor, such as pyelitis or
hypertensive toxemia, is usually present. Patients who die in
the early puerperium after these .conditions may continue to
show the same lesions that are found’ in the course of the disease.
However, there may be additional changes due to the anesthetic
or to puerperal sepsis. Front the present investigation and
from a study of the literature, it seems probable to the author

1604

CURRENT MEDICAL LITERATURE

Joes. A. 31. A.
Oct. 21, 1919

that all the cases of hyperemesis or late vomiting that have
been reported as showing centrilobular necrosis of the liver
were really cases of delayed chloroform poisoning. Certain of
the other changes reported in the literature, such as necrosis
of renal tubules, are only artefacts produced by postmortem
autolysis. That the liver or kidneys may show any grade of
the development of degeneration or necrosis out of the fatty
change does not rest on any satisfactory foundation.

Etiology and Treatment of Hyperemesis Gravidarum.
—In discussing the pathogenesis of hyperemesis, Bandstrup
sums up present knowledge by stating that, owing to some
unknown cause, the woman begins to vomit. The further course
of the illness may depend to a large extent on psychic factors.
A state of inanition develops, of which want of glycogen in the
liver is probably the most serious feature even though the want
of salt, water and vitamins, together with the development of
acidosis, is an important factor. A specific toxin of hyperemesis
has never been demonstrated as a cause of the necrotic changes
in the liver and other organs, and it is not inconceivable that
these changes may develop as a result of the inanition under
the special endocrine conditions present in pregnancy. In keep-
ing with his view of the pathogenesis of this disease, his treat-
ment consists of psychic, sedative and restorative therapy; if
this is found inadequate pregnancy has to be interrupted. The
psychic therapy consists of a firm suggestive management on
the part of the physician and admission to a hospital, possibly
with isolation of the patient. Sedatives, such as bromides and
barbituric acid, have a calming effect on the mind of the patient
and lower the irritability of the center for vomiting. The
restorative therapy consists in the administration of dextrose,
insulin, sodium chloride, water and vitamins. The future will
show whether adrenal cortex extract is to be established as an
effective remedy in the restorative therapy. If conservative
treatment on these principles fails to lead to recovery, it may
be necessary to induce abortion. Seven symptoms are con-
sidered as indications for interruption of pregnancy in hvper-
emesis. These symptoms include elevation of the temperature
above 100.fi F. or persistent subfebrile temperature, persistent
increase in the pulse rate over 100 a minute, jaundice, albu-
minuria, polyneuritis, ocular symptoms and psychotic changes.
From a study of forty fatal cases of hyperemesis, twenty-five
presented only one or more of the foregoing serious symptoms
for more than one week prior to interruption of pregnancy or
death. So the mere presence of one serious symptom has to
be taken as a warning. All the patients were admitted to the
hospital, even though a few of them did not enter the hospital
till immediately before death. The treatment, as a rule, con-
sisted of restorative and sedative treatment, besides therapeutic
abortion in thirty of the forty cases.

Journal of Physiology, London

90:109-232 (July) 1939. Partial Index
Effect of Forced Breathing - on Motor Chronaxia. B. Dijkstya and
M. X. J. Dirken. — p. 309.

Effect of Clotting and of Addition of Histamine on Its Distribution in
Blood. G. V. An rep, G. S. Barsoum, M. Talaat and E. Wieninger.
— p. 130.

Release of Histamine by Isolated Smooth Muscles. N. Ambache and
G. S. Barsoum. — p. 139.

Rotatory Movements of Apex of Exposed Mammalian Heart. K. J.

Franklin. — p. 164, .

Changes in Elasticity of Mammalian Muscle Undergoing Rigor Mortis.

E. C. B. Smith. — p. 176. . * -a v *

Nerve Excitation by High Frequency Alternating Current. B. Katz.

—p. 202.

Lancet, London

2:297-352 (Aug. 5) 1939

Visceral Neuroses. J. A. Ryle. p. 29/, , .. .. T TI

‘Encephalomyelitis Following Administration of SulfainJaimde. J. H.

Fisher, with note on histologic findings by J. R- Gilmour.-— p. 301.
‘Local Tissue Anoxia and Its Treatment, with Special Reference to
Rheumatic Myocarditis. E. P. Poulton.— p. 305.

Tests for Athletic Efficiency. A. Abrahams.--p. 309.

■RMntric Effects of Svnthetic Estrogen Hexestrol 4: -1 Dihjdroxy-yr. 5-
nXmdm Hexane. ' X. R. Campbell, E. C. Dodds, IV. Lawson and
R. L. Noble. — p. 312.

Encephalomyelitis After Sulfanilamide.-Fisher cites two
cases in which symptoms of encephalomyelitis appeared after
the administration of small quantities of sulfanilamide. The
total dose" taken were small (14 and IS Gm, respectively) and
if the drug was responsible the patients must have been more

than ordinarily susceptible to it. There is evidence in patients
suffering from certain illnesses— including acute rheumatic fever .
and lupus erythematosus— in which toxic manifestations after
taking sulfanilamide are especially likely to develop. Vascular
changes are seen in some cases of encephalomyelitis and their
relation to the demyelmatmg lesions is discussed.

Tissue Anoxia and Its Treatment— Poulton calls atten-
tion to the fact that the importance of local tissue anoxia and
its treatment with oxygen has not been recognized heretofore,
except that success lias been claimed for oxygen therapy in
varicose ulcer with local edema, poisoning with alcohol and
coronary thrombosis. The inhalation of a high percentage ol
oxygen may have a wide application in treatment; its use in
cerebral hemorrhage, thrombosis and embolism is suggested
The evidence that there is, local anoxia in rheumatic myocarditis
is a changed lactic acid metabolism and clinical improvement
on treating patients with oxygen, resulting in a fall of tem-
perature and pulse rate, alteration of murmurs, diminution in
the size of the heart and electrocardiographic changes. Oxygen
treatment in early cases appears to be of permanent benefit, tot
further observations arc required. In seventeen of twenty-six
rheumatic patients (fifteen in their first attack), treated with

better ; they were more active and ate more and cyanosis &•
appeared ; one could “breathe better.” The improvement wu
most obvious of extremely ill patients, such as one with pen-
carditis, nephritis and purpura, who was so ill that oxygen te
probably saved his life, another who bad made but little recover)
from a pericarditis and one with pneumonia and pericardii)-'-
All these were children. Improvement was noticed whether tie
acute rheumatism was a first attack or accompanied by _ an ,°.
standing cardiac lesion. Adult patients also felt better. In ctg
cases there was no clear subjective improvement. ApaW
who bad an enlarged cardiac shadow which indicated pencar •
did well in the tent, but the value of prolonged treatmen w
not realized as he was taken out of it after two days,
and a half months later he was put in the tent for tmr >
days; there was massive edema, scanty urine and an cn
liver; lie died soon after being taken out of the tent. <-
oxygen should not be left till the last stages of rlicuma ic
disease. A control series of sixteen cases observed ?' c, (
same period tells a different story. In two cases m " 1C
were systolic murmurs the cardiac condition cleared up v ^
than a month in one and in eleven weeks in the other. -
patient began with nodal rhythm, ventricular escape, an a
systolic and systolic murmurs; after two months i)crc ^
systolic murmur and good first sound, and the pulmonary
sound reduplicated on inspiration. These three resu s a ^
The results in the remaining thirteen are poor: in t " oc , ' ; fl e
systolic murmurs appeared and have persisted *° r J 1 *® . () jllD
months in one and more than two months in the o i i ^
there were loud systolic murmurs and weak first *°? n! ’ ( j ief c
middiastolic murmurs or their equivalents remained, m j a chv-
remained aortic diastolic murmurs and in two there "
cardia, with a late blowing systolic in one.

2: 353-406 (Aug. 12) t939

Visceral Neuroses. J. A. Ryle- — p. 353. . jj for '

Response of Nutritional Macrocytic Anemia to Analieiu ■ {

Athena Komli.- — p. 360. r n a ilcr art I- ‘

Treatment of Epilepsy with Epanutin. D. Biatr, . :

McGregor.— p. 363. _ _ _ ... „ 357. ,

Epanutin in Epilepsy. J. P. Steel and E. S. jilood

Idiosyncrasy to Acriflavine: Failure to Transm > ,

and Reactions to Allied Drugs. \\. A. 370.

Acute Pancreatitis Caused by Barleycorn, i'. /■ ,

Anahemin for Nutritional Macrocytic , ccrl ja

nd Kondi find that the nutritional macrocy ic purif^

Jacedonia responds as readily to anahemm as (rcS |cd

ver extracts. This response is in contrast o j roffl tlffli-
i India and suggests that the Macedonian ® scs ct ; on is ^< { -
a India, in which a high indirect van den Derg prc paration-
lossitis is common and the highly Purine _, ir }fie<l ex trsCl j
re inactive. Such responses to these hig 1 ) P jyjgar s! !.'
take it appear unlikely that the filtrate . - , a i macrocF"
lacrae is the active one in the cure of n t he Fdtra) c '

nemia in Macedonia. Further, work done j. jnsrtm

ictor concentrate shows that this, adm.msteml alon ,

Volume 113
Number 17

CURRENT MEDICAL LITERATURE

1605

even when given in large doses. It is not impossible that the
response to anahemin is quantitative and related to the liver
content. It is active in 2 cc. doses and will probably be found
active in smaller doses. Although the quantitative aspect is
important, it is probable that the qualitative aspect also enters
into the picture, for work now in progress seems to show that
large amounts of filtrate combined with small amounts of
anahemin are extremely active. This work suggests that the
conclusions drawn by Wills and Evans (1938) and Napier (1939)
do not apply to the nutritional macrocytic anemia of Macedonia
as typical responses to anahemin were obtained. Further, the
suggestion that there is some active principle present in the
filtrate factor is not borne out by work with filtrate-factor con-
centrates, which do not produce any effect on the anemias in
Macedonia. Such observations appear to bring back the position
to that originally postulated by Castle.

Sodium Diphenyl Hydantoinate for Epilepsy. — Blair and
his colleagues used sodium diphenyl hydantoinate in the treat-
ment of fifty-three male and twenty-two female epileptic patients
having grand mal attacks. Fifty-eight of the patients have been
treated continuously for from two to six months, in eleven it
was necessary to terminate treatment and six recently admitted
patients have not yet received two months of treatment. The
authors’ results confirm those of Merritt and Putnam, that the
drug is a strong anticonvulsant, its action sometimes being
dramatic, but a weak depressant. Apart from the reduction in
the number of fits, the drug was beneficial to the mental con-
dition of many patients. In patients having chronic psychotic
epilepsy there was little room for intellectual improvement, but
a beneficial modification of the typical epileptic temperament
was often observed. Most of the patients improved mentally,
being more cheerful and congenial, less quarrelsome and com-
plaining and more easily managed and occupied. In some cases
the effect has been remarkable. Detrimental changes may, how-
ever, develop in association with toxic effects, and whenever
a patient’s mental condition appears worse, chronic poisoning
should be suspected. Many patients exhibited toxic nervous
symptoms, but a rash developed in only one. These toxic symp-
toms often developed after an increase in the dose.

2 : 407-462 (Aug. 19) 1939
Visceral Neuroses. J, A. Ryle. — p. 407.

Transplantation of Ureters into Rectum by Mirotvortzeff’s Method. S. P.

Shilovtzeff. — p. 412.

Analysis, of Normal P Wave. A. Hill.— p. 415.

Malnutrition and Debility in Puerperal Psychoses. Norah A. Haworth.

— p. 417.

^After-Effects of Exposure of Men to Carbon Dioxide. W. Alexander, P.

Duff, J. li. S. Haldane, G. Ives and D. Renton. — p. 419.
Antitumorigcnic Action of Progesterone. A. Lipschutz, R. Murillo and

L. Vargas. — p. 420.

Amyloidosis Complicating Still’s Disease. A. II. Imrie and Anne C.

Aitkcnliead. — p. 421.

Antipellagric Properties of Quinolinic Acid. R. W. Vilter and T. D.

Spies.— p. 423.

Ayerza’s Syndrome: Case. J. A. Brocklebanfc.* — p. 42.3.

Malnutrition and Debility in Puerperal Psychoses. —
It is generally accepted that there is no specific form of mental
disorder associated with childbirth and that when mental illness
begins during pregnancy, the puerperium or lactation, childbirth
may act as a precipitating factor. However, Haworth asserts
that during childbirth there are certain points worthy of con-
sideration. First the mental illness of pregnancy .is often asso-
ciated with some other contributory' cause. Many of these
women have already had one or more confinements and many
of them pass normally through later confinements. This sug-
gests that some other factor of a temporary nature is involved.
Hie most important thing in the study of these contributory
causes is the recognition of those which might be eliminated.
Some,, such as hereditary predisposition and lifelong nervous
instability, cannot be removed, but a knowledge of their presence
m tlie early days of pregnancy should suggest a special effort
to build up the general powers of resistance and to eliminate
additional preventable factors. Of the preventable contributory
causes the author suggests that the two most important are
(1) malnutrition and general debility and (2) stress and anxiety,
emotional or environmental. The admittance of 117 cases of
mental illness arising in connection with childbirth to Severalls
-Mental Hospital over a period of fifteen years shows how com-
mon these factors are. All but six patients were admitted dur-

ing the late months of pregnancy, during the puerperium or
during lactation. In every case this was the first occasion on
which the patient had been admitted to a mental hospital ;
seventy-two of the patients recovered, sixty had already' had
one or more normal confinements and twelve have had one or
more confinements since their discharge from the hospital with-
out developing any mental symptoms. Fifty-four of the sixty-
eight women weighed on admission were below normal weight,
twenty-eight being more than 14 pounds (6.4 Kg.) underweight.
In every' case except one, recovery was associated with an
increase in weight. Only twenty-eight of the 117 patients were
found to be in satisfactory' general health when admitted to the
hospital, none of these showing any sign of physical disorder.
The majority were suffering from minor physical ailments,
eighty had dirty, furred tongues and were and had been suffer-
ing from constipation, sixty had carious teeth or pyorrhea or
both, thirty-two were suffering from anemia and, as has been
shown, many were poorly nourished and underweight. A history
taken in the early days of pregnancy' would have shown that
thirty-six of these patients belonged to families in which a near
relative had suffered from insanity, epilepsy or alcoholism,
twenty-nine had at some period in their life already shown signs
of nervous instability, while twenty-two had undergone long and
severe stress. Therefore it seems that many instances of puer-
peral psychosis could probably be prevented by attention to j
nutrition, general health and environmental conditions early in
pregnancy.

After-Effects of Exposure to Carbon Dioxide. — Accord-
ing to Alexander and his co-workers, after breathing air with
a partial pressure of more than 6 per cent of carbon dioxide
for an hour or longer, five of six men experienced headache on
breathing oxygen and two of them vomited. The bearing of this
observation on escape from submarines is discussed and it is
suggested that in such circumstances men should breathe air or
oxygen for thirty minutes or more before attempting to use
the escape apparatus, because under these circumstances vomit-
ing would prove fatal and calmness and some physical exertion
are required.

Medical Journal of Australia, Sydney

2: 193-234 (Aug. 5) 1939

* Study of Heterologous Antibodies in Serum of Poliomyelitis Patients.

F. M. Burnet, Mavis Freeman, A. V. Jackson and Dora Lush. — p. 198. .

Some Common Problems in Everyday Prescribing. B. L. Stanton. — j

p. 206. 1

Note on Occurrence of Cimex Hemiptcra in Nauru, Central Pacific. •

L. A. Windsor-McLean. — p. 211.

2: 235*266 (Aug. 12) 1939

Chemical Estimation of Vitamin C, with Analyses Made on Some Queens-
land Products. E. L. Leggett and Kathleen \V. Robinson. — p. 241.

Public Health: Plealth Work in Country Centers. C. T. Piper. — p. 244.

Heterologous Antibodies in Poliomyelitis Serum. —
Burnet and his associates postulated that poliomyelitis in human
beings is strictly confined to the central nervous system and that
extremely little antigen reaches any part of the antibody-produc-
ing mechanism. If this is so, poliomyelitis antibody must be
either the response to another antigen having determinant groups
in common with poliomyelitis virus or a change in the serum
globulin content, associated with increasing age or increasing
experience, or both, of a variety of antigenic stimuli. To come
to a decision between these alternatives, they investigated a series
of samples of serum from seventy patients with poliomyelitis
for their content of four antibodies in addition to poliomyelitis
antibody : diphtheria antitoxin, herpes simplex virus, swine influ-
enza antibody, which was included because of its curious
behavior in relation to age (it appears only in individuals more
than 10 years of age), and staphylococcus a antitoxin. The
results have been analyzed according to age and social environ-
ment and compared with those from control groups. There is
no different proportion of any of the beterologus antibodies in
these specimens of serum than would be found in a comparable
group of normal serum specimens. Herpes simplex antibody
and diphtheria antitoxin are both much more frequently found
in children from crowded industrial suburbs than in those from
better class areas'. In the industrial areas herpes infection is
contracted before the age of 2 years, while diphtheria antitoxin
appears as a rule only after the child has begun to attend school.

1606

CURRENT MEDICAL LITERATURE

Join. X JJ. .)
Oct. 21, PP

There is no association between the frequency of swine influ-
enza antibody or staphylococcus antitoxin in serum and the
nature of the social environment. There is a significant corre-
lation between the presence of poliomyelitis antibody and diph-
theria antitoxin in young children from industrial suburbs ; this
suggests that the two antibodies are acquired at about the same
age and under similar environmental conditions.

Practitioner, London

143:129-236 (Aug.) 1939

Venereal Diseases anil the General Practitioner. L. \V Harrison — u
129.

Treatment of Early Syphilis. K. Lees.— p. 134.

Treatment of Late Syphilis. T. Amvyl-Davies. — p. 146,

Treatment of Gonorrhea in the Female and of Vulvovaginitis in Little
Girls. Gladys M, Sandes. — p. 157.

Treatment of Gonorrhea and Chancroid in the Male. If. M. Hanschcll
— p. 165.

Treatment of Lymphopathia Venereum. II. S. Stamms. — p. 172.
Medicolegal Aspects of Venereal Disease. D. II. Kitchin. — p. 177.
Sterility in the Female. H. Taylor. — p. 185.

The General Practitioner am) Psychoanalysis. J. Rickman. — p. 192.
Abdominal Pain in Young Children. V. Smallpeicc.— p. 199.

Use and Abuse of Local Applications in Treatment of Skin Disease
E. W. P. Thomas.— p. 209.

Modern Therapeutics: II. Therapeutics of Iron. J. C. Hatvksley.— p.

South African Medical Journal, Cape Town

13 : 535-5S6 (Aug. 12) 1939
History of Medicine. T. P. Oates. — p. 543.

Psychologic Factor in Disease: I. The Physician. C. D. Brink. — p. 550.
Id.: II. The Surgeon. J. A. Douglas.— p. 559.

Id.: III. The Psychiatrist’s Point of View. \V. Russell.— p. 562.

Id.: TV. The General Practitioner's Point of View, It. Walker -
p. 566.

Tubercle, London

20: 445-484 (July) 1939

Tuberculosis of Chest Walt. N. R. Barrett. — p. 445.

Apical Origin of Phthisis. S. Puder. — p. 460.

Observation on Healing of Tuberculous Cavities: Case Report and
Comparison. G. A. M. Hall.— p. 468.

Tohoku Journal of Experimental Medicine, Sendai

30: 103-298 (July) 1939. Partial Index
Elimination of Sodium Chloride by Isolated Kidney (Normal or Dis-
eased) in Perfusion with Hypotonic Solution of Sodium Chloride.
M. Izumida. — p. 203.

Action of Rerberine on Circulation. S. Suzuki. — p. 134.

Action of Arginase of Digestive Juices and of Pancreas. M. Kaiju. —
p. 153.

Formation of Glycogen from Fats, Particularly Fatty Acids, Under
Action of Epinephrine. K. Sanzyo, — p. 159.

Action of Vitamin C and of Related Substances on Glycogen Content.
K. Terada. — p. 180.

* Acetone Content of Urine in Pulmonary Tuberculosis. K. Yamazaki.

Bruxelles-Medical, Brussels

1»: 3235-1265 (Aug. 6) 1939

’Management of Labor and Prognosis for Child in Breed:
m Old Primiparas. J. Snoeek and R. Canon.— p. 1235 .

19: 1266-1296 (Aug. 13) 1939
Cutaneous Immunizations in Eczema. Gougerot.— p. 1266.
’.Management of Labor and Prognosis for Child in Brcccli PrcsfflMa h
old Primiparas. J. Snoeek and R. Canon.— p. 1272.

Breech Presentation in Old Primiparas.— Snoeek aid
Canon show that the opinions regarding the prognosis of breech
presentation in old primiparas and regarding the management
of such cases differ greatly. They reexamined this problem w
the basis of observations made in the years 1927 to 1933 at the
maternity clinic of the University of Brussels. They present
two scries of eleven cases each. In one group of eleven case.-
the so-called classic methods were employed and the results
for the fetuses were disastrous, the fetal mortality being sever.
In the second series of eleven cases of breech presentation in
old primiparas, the method of treatment was the low cesarean
operation. In all these cases mother and child were entirely
well when they were discharged from the clinic. On the basis
of the comparison of the results obtained in these tiro series w
cases, the authors conclude that the low cesarean operation i>
indicated in “dystocic" breech presentation of primiparas over
30 years of age. They list the conditions which signify “dys-
tocic” breech presentation in an old primipara and which indi-
cate cesarean operation as follows: (1) all breech presentations
combined with narrow pelvis in which the true conjugate diam-
eter measures less than 10.3 cm. so far as the presentation
remains mobile within the limits of time specified later; (-) 3
breech presentations, whatever the true conjugate diameter ma)
measure, which do not become engaged during the first ten «
fifteen hours of labor, and this without taking account ot t
time of rupture of the bag of waters ; (3) ah breech
tions which are engaged before this lapse of time and in " >
the progression is slow or null in spite of two or three wo -
of good uterine contractions ; (4) all breech presentations "'
anomalies of the uterine contractility or of the dilatation o
cervix, when these do not yield rapidly to. energetic
treatment. The authors think that all old primiparas s 10 “
delivered in an obstetric clinic. Regarding the technic ^
treatment, they say that the low cesarean operation - .
entirely segmental and not corporeal or corporeoseg
They think that the transverse section of the muscular . ^
the inferior segment is the only technic which guaran -
integrity of the body of the uterus in case of furt cr
of the surgical incision.

Presse Medicale, Paris

— p. 236.

Acetone of Urine in Pulmonary Tuberculosis. — Yama-
zaki decided to investigate the disturbances in the carbohydrate
and fat metabolism of patients with pulmonary tuberculosis. He
determined the elimination of acetone in the urine and compared
it with that of healthy persons; he also studied the changes in
the acetone content of the urine following tolerance tests with
fat. Tile studies were made on 101 patients with pulmonary
tuberculosis and on six healthy persons. He found that with
healthy persons the urinary elimination of acetone averages
12 mg. daily. In cases of pulmonary tuberculosis it was higher,
the daily average being 16.87 mg. On the whole, tiie acetone
value was the higher, the more severe was the tuberculous
process; that is, there was a parallelism between the type and
stage of the disease and the urinary elimination of acetone. A
comparison of the acetone values in the cases in which a diet
with a high fat content was administered with those in cases
in which such a diet was not given disclosed higher values in
the first "roup. In cases in which glycosuria developed follow-
in" the intake of large quantities of fat the acetone values were
extremely high. Fat tolerance tests of healthy persons increased
the acetone content of the urine on. the average by 12.7 per
cent; fat tolerance tests of patients with pulmonary tuberculosis
and gtveosuria produced an increase of 34.2 per cent. The
author further shows that in cases of pulmonary tuberculosis
the increase in the acetone content goes parallel with the height
oE the temperature and with .the sedimentation speed of the
ervthrocytes.

47:1261-127 6 (Attg. 19) 1939
Amebiasis Xot Recognized in France. 51- Cbiray an

p- 1261. . _ , , ... „ rr ciari"*"

’Covered Perforation of Gastric and Duodenal ulcer.

— p. 1263. . g a

Covered Perforation of Gastric Ulcer.— -FoM® ^

review of the literature on closed perforations o S j
duodenal ulcers, Gjankovic discusses the clinical asp tn-ert
tj-pes of perforations and gives rules regarding ie , 0 jgtr-
In the second part of the paper he describes ms pc -
vations. Among 109 cases of perforated gastrci u
treated by him he encountered thirteen perfora i cortr td
covered (11.92 per cent). All except one o j-Hjcatcs t- 1
perforations concerned duodenal ulcers, "'lnci , , cn3 ; jhi".

covered perforations are much more frequent m , u lcers
in gastric ulcers, even if the higher incidence o
(sixty-nine of the 109) is taken into consideration « ?

thinks that the prognosis of covered perfora i° c£ta b!i:- ; r
favorable but is doubtful until definite cure tre3! tmcr.t i"
Although spontaneous cure is possible, surgira i ., rcCC .-

indicated in all cases. If the perforation is r< : ( ; 0 „ jbr/j

sary to operate immediately, except that the jisease 7'.'

be ruled by the clinical syndrome, the stage 0 . .

the condition of the patient. Of the various - r j or3t p-: i« :
the resection is always indicated in the cou ' ntra indica c: '
gastric and duodenal ulcer if there is no genera (o £■
If on the other hand there is one, it is IICCL J •' i: ca tio:>.
operation, according to the nature oi the cot s b4',m <

suture (if this is practical) with primary sutu

Volume 113
Number 17

CURRENT MEDICAL LITERATURE

1607

wall. Conservative therapy is permitted only in a clinic, where
permanent and competent control is possible. The circum-
scribed secondary abscesses with localized peritonitis should be
opened and drained immediately under strictly aseptic conditions.
Tbe sutures of the covered perforations of tbe stomach and
duodenum as well as anterior or posterior gastro-entero-anasto-
mosis give the best permanent results in 75 per cent of the cases.
The same results can be obtained by resection. The latter has
advantages, because it readily and probably forever excludes
late complications which may develop subsequently with the
conservative operations. Therefore resection is advisable in all
cases of covered perforation except for certain contraindications.

Giornale di Clinica Medica, Parma

30: 1023-1126 (Anp. 10) 1939. Partial Index
^Function of Hone Marrow in Nephritis. B. Nolli. — p. 1023.

Tabes with CHmcohumornl Dissociation: Histopathologic Study of Vase

G. Fattovich. — p. 1050.

Calcification of Nucleus Pul posits: Cases. L. Pinelli. — p. 1073.

Bone Marrow in Nephritis. — Nolli says that early in the
development of nephritis a myelopathy develops which causes
nephritic anemia. The author studied the functions of the bone
marrow in eighteen cases of nephritis of various types and at
different evolutional stages. The observations were made on
medullary blood which was taken by sternal puncture. The
author found that the changes of the myelogram, of the leuko-
erythropoietic ratio in the myelogram and of tiie curves of
maturation of the stein blood cells of both the erythroblastic
and the leukoblastic scries, in renal sclerosis with anemia from
old age, are those which correspond to hypoplasia of the bone
marrow. In acute diffuse glomerulitis as well as in acute
hemorrhagic glomerulitis with anemia the medullary alterations
are of the type of those which are observable in acute and
subacute forms of posthemorrhagic anemia. However, erythro-
cytes in tbe peripheral blood show morphologic alterations which
are characteristic of nephritis. In diffuse chronic renal inflam-
mation the hematopoietic functions (output of stem cells) are
diminished. The leuko-erythropoietic ratio in the myelogram
is disturbed with predominance of either myeloblasts or crythro-
blasts'from uneven formation of the cells, the curves of matura-
tion of the cells are increased, mitosis is diminished and the
medullary threshold for passage of mature ceils to the blood
is increased. Tiie myelopathy causes typical alterations to the
peripheral blood with morphologic changes of the erythrocytes
and diminution of their number. Its evolution parallels that of
the renal disease and it progresses to aplasia of the bone mar-
row. Administration of a combined treatment of arsenicals,
iron and liver extract, early in the development of tbe renal
disease, controls tbe functional disorders of the bone marrow
with consequent control of tbe morphologic changes of the blood
cells. Tbe medullary alterations of nephritic myelopathy arc
different from those which are seen in tbe various forms of
myelopathy in secondary anemia of toxic or infectious origin.
They are also different from those which develop in anemia
from insufficient supply of minerals in the diet and from per-
nicious anemia. In the terminal stages of the renal disease as
well as in true uremia the bone marrow is transformed into a
gelatinous yellow material which does not contain any active
red marrow.

Arch. TJrug. de Med. Cir. y Especialid., Montevideo

, ’ 14: 513-640 (June) 1939. Partial Index

iN eiirolyinphogranulomatous Syndromes. J. C. Pla, A. Perez Sanchez
, t a ™I ■ Pereira Granotich. — p. 513.

Modifications of Elbow and Madelung’s Deformity. R. A. Piaggio

Bianco and F, Garcia Capurro. — p. 532.
ottrgical Treatment of Acute Infections of Fingers and Hands. E.

Andreon. — p. 567.

Neurolymphogranulomatous Syndromes. — Pla and his
collaborators say that malignant lymphogranulomatosis may
cause various types of nervous syndromes from compression of
•be lateral columns of tbe spinal cord, the brain or the nerve
roots by lynipliogranulomatous lymph nodes or their inetastases.
certain nervous syndromes may also be observed ill absence of
nervous compression. Tbe authors report two cases. In tbe
hrst case a syndrome of diffuse memngoradiculoneuritis devel-
oped in the course of tbe disease with paralysis of the sixth
nerve, oculosympathetic paralysis (Horner's syndrome) and
radicular sciatic pain. In the second case, also in the course
>n the disease, a form of progressive bilateral muscular atrophy

of the extremities developed. In both cases the Wassermann
reaction of the blood and cerebrospinal fluid was negative, there
were no symptoms of tumors or tumoral compression at the
brain or the spinal cord, and the cerebrospinal fluid, taken by
spinal puncture, showed the presence of a meningeal reaction of
irritation. In tbe second case paralysis and sensory disturbances
did not exist and the iodized poppyseed oil did not stop after
having been injected by the suboccipital and lumbar routes in
the Trendelenburg position. Tbe authors conclude that in botii
cases tbe nervous symptoms were caused by the lymphogranulo-
matous virus, which was located at the meninges and various
nerve roots in the first case and at the lateral columns of the
spinal cord in the second case. The development of nervous
syndromes in malignant lymphogranuloma in the absence of
nervous compression prove, according to the authors, the exis-
tence of lynipliogranulomatous virus, although it has not yet
been identified.

Klinische Wochenschrift, Berlin

18: 949-980 (July 15) 1939. Partial Index
Regulatory Processes in Organism in Oxygen Deficiency. G. Zaeper. —
p. 949.

"Functional Tests of Liver in Treatment with Sulfanilamide Preparation.
W. Schmidt. — p. 953.

Anaphylactic Shock During Various Degrees of Saturation with Vita-
min C. F. Diehl. — p. 956.

Changes in Blood in Hemophilia. Else Heyl. — p. 960.

Does Human Placenta Contain Cholin Esterase? — p. 963.

Alcapton, Acetone and Carbohydrate Deficiency. C. Jimenez Diaz, H.

Castro Mendoza and J. Sanchez Rodriguez. — p. 965.

Significance of Bile for Resorption and Elimination of Uliron (Sulf-
anilamide). W. Lutz. — p. 967.

Hepatic Function During Sulfanilamide Therapy. —
According to Schmidt, the administration of chemotherapeutic
substances taxes the intermediate metabolism and particularly
tbe liver. He also raises the question as to which toxin is
more likely to cause damage, that of the infection or that of
flic chemotherapeutic substance. In this connection be cites
observers who described cases of gonotoxic icterus and then
describes his own studies on tbe hepatic function of gonorrheal
patients who underwent treatment with sulfanilamide. In
twenty-nine cases he tested tiie hepatic function before, during
and after the administration of sulfanilamide by means of the
galactose tolerance test according to R. Bauer; simultaneously
lie observed the blood sugar curve and examined the urine for
urobilinogen, tyrosine and leucine. He found that tbe functional
examination of the liver of patients with gonorrhea often
revealed pathologic values, before treatment with sulfanilamide
was instituted, and that the administration of sulfanilamide
nearly always exerted a favorable influence on the hepatic
function. In cases in which the hepatic function was normal
before tbe administration of sulfanilamide, no damage was
observed after this medication. Moreover, gonotoxic icterus
rapidly disappeared under the influence of sulfanilamide. A
comparatively large dose of sulfanilamide (63 Gm.) caused no
hepatic impairment in the author himself. In two cases of
severe intoxication with a nitrosulfanilamide body, the test of
the hepatic function disclosed no impairment of the hepatic
parenchyma. Chemotherapy by means of sulfanilamide prepara-
tions never resulted in urobilinogenuria, nor were tyrosine and
leucine ever detected in the urinary sediment during or after
the sulfanilamide treatment. Tiie author concludes that these
results demonstrate tiie indifferent behavior of the examined
sulfanilamide bodies toward tbe hepatic parenchyma.

Zeitschrift fur Orthopadie, Stuttgart

69:3/7-512 (Aus. 4) 1939. Partial Index
’"Surgical Results in Congenital Muscular Torticollis. Koch. — p. 394.

Rare Form of Curvature of Forearm. E. Koptis. — p. 402.

Spontaneous Cure of Congenital Dislocation of Hip Joint. F. Drchmann
— p. 410.

Defective Form of Pelvis in Osteogenesis Imperfecta. E. ItcirUicck

p. 429.

^Surgical Treatment of Severe Static Flatfoot. A. Pavlik. p. 439.

Roentgenogram of Foot. E. Giintz. — p. 445.

Normal Foot and Its Relation to Shoe. Margarctc Schmidt-Schutt —
p. 476.

Surgical Treatment in Congenital Muscular Torticollis.
Koch considers in this report only cases of true congenital
muscular torticollis, disregarding the cases of torticollis result-
ing from primary bone changes and also those mild cases of
torticollis in which exercise and massage counteract the slight
contraction of the sternocleidomastoid muscle. Regarding the

1608

CURRENT MEDICAL LITERATURE

Jol'K. A. M. ,\
On. 21, iS»

surgical technic employed at his clinic, he says that a cutaneous
incision 2 cm. in length (usually longitudinal) is made above
the lower end of the sternocleidomastoid muscle. Then follows
exposure and division of the sternal and clavicular heads of the
muscle and division of the surrounding fascia, also detachment
of all shortened fascial strands. In a few cases from 1 to
1.5 cm. of the muscle is removed. Following arrest of hemor-
rhage and cutaneous suture, Schanz’s absorbent cotton bandage
is applied and the patient's head is fixed in a position which
overcorrects the deformity. The bandage is renewed after eight
and twenty-four days, and after an additional three weeks the
last bandage is removed and then passive exercises and massage
are begun, which are continued for from six to twelve months
or longer. In order to obtain information about the efficacy of
this method, the author made inquiries regarding 117 patients
who received this treatment during the years between 1930 and
1937 inclusive. Information was obtainable from 108 of these
patients. At the time of operation the patients varied in age
between 4 months and 18 years. In 61 per cent of the patients
the operation was performed during the first two years of life.
Summarizing the results, the author says that in eighty-six
cases the results were good, in twenty-one cases were unsatis-
factory and in one case were bad. He emphasizes that the best
results were obtained in those cases in which the operation was
performed during the first two years of life.

Surgical Treatment of Severe Static Flatfoot.— Pavlik
says that the severest forms of flatfoot, which are characterized
by curvature of the leg, especially in the distal portion just above
the ankle joint, and which present subluxation in the talonavic-
ular joint, abduction of the anterior part of the foot, valgus
position of the heel and contracture of the extensors, of the
peroneal muscles and of the achilles tendon, require surgical
treatment because conservative treatment fails to produce the
desired results. The author describes three different types of
surgical treatment which are designed to correct the various
forms of flatfoot. He shows that it is necessary to select that
type of surgical method which, on the one hand, reconstructs
the arch of the foot and, on the other hand, counteracts the
curvature of the lower part of the leg, which is the essential
cause of the collapse of the arch of the foot and of the sub-
luxation in the tarsal joints. If the curvature in the leg is
removed, the crural skeleton becomes shorter and the muscular
contracture, which together with the arthrosis dcformans-likc
changes in the talonavicular joint causes the deformity of the
foot, subsides. The author resects the talonavicular joint by
removing the cartilage and the arthrosis dcformans-like changes
from the head of the talus. By osteotomy of the bones of the
leg he overcomes the curvature and by suitable wedge-shaped
osteotomy of the tibia causes the reposition of the subluxation
in the talonavicular joint to become possible.

Acta Medica Scandinavica, Stockholm

101:1-103 (Aug. 1) 1939

Clinical Investigation in Spring of 1938 of Cases of Sciatica Observed
During Years 1933 and 1934. S. Ekvall. — p. 1.

Exogastric Fibroma with Gastrointestinal Hemorrhages. E. Filo and

Studieswon' Ascorbic Acid by Means of the Photelgrnph. T. Gutlie and

K. K. Nygaard. — p. 40. . ,

Familial and Hereditary Hyposonua and Vitiligo: Importance ol
Pituitary Factor in Cutaneous Dyschromias. M. Cahane and T. Cahane.

— p, 62 ,

* Resistance ami Immunity in Tuberculosis. L. Asclier.— p. 71.

* Iodine Therapy in Hypertension and Arteriosclerosis. N. Ahvall.—p. 83.

Resistance and Immunity in Tuberculosis. — Ascher
directs attention to’ the age law of natural, internal resistance,
which was formulated by him many years ago. According to
this law the general, internal and natural resistance increases
from infancy to school age, reaching its maximum between the
ages of 5 and 15 years, and then it decreases with advancing
age. The author cites statistical reports on tuberculosis from
different countries. He points out that unfavorable nutrition
increases the mortality from tuberculosis, whereas reduction in
industrial activity reduces the mortality rate from tuberculosis.
It has been demonstrated that in times of economic crisis, with
unemployment, the mortality from tuberculosis decreased fur-
ther than it did during times of prosperity and employment.
Moreover this decrease in mortality was limited to the
employed age groups, whereas in children there was a slight

increase in mortality. The author further gives his attention
to immunity and says that in some large cities 100 per cm
of the adults give a positive Pirquet reaction. Approximately
0.5 per cent of these develop tuberculosis annually; that is, 0.5
per cent of the immune persons develop the disease, not 05
per cent of the infected ones. The author emphasizes that the
activity of the tubercle bacillus is limited by the natural inter-
nal resistance of the human organism and by the immunity
produced by tile bacillus itself. However, resistance and
immunity are subject to impairment and consequently ace not
always complete. Factors which play a part in this impair-
ment are nutrition, exertion and exposure. After discussing
these, the author says that the reduction of the tuberculosis
mortality hitherto has been examined only from the point oi
view of medical and social measures. He shows that spon-
taneous, that is, endemically acquired, immunity is the main
factor, at least in regions where and in times when no mea-
sures are taken against tuberculosis, and when its mortality
has been known to decrease more than at times when measures

were taken against it. The comparative freedom of children
of school age from tuberculous manifestations in the presence
of slight individual infection, but of approximately 50 per cent
positive Pirquet reactions, indicates adequate immunity in the
concurrence of highest resistance with small quantities of infec-
tious agent. There is the possibility of improving the immunity
by BCG. Since it is possible that the time may come when
the population will not acquire an adequate immunity in the

spontaneous manner, immunizatory measures, as in the case

smallpox, might have to be employed.

Iodine Therapy in Hypertension and Arteriosclerosis.
— Ahvall points out that iodine is widely recommended m t»
treatment of vascular diseases, particularly arteriosekrost
and hypertension. The generally accepted opinion is that ' 1W
reduces the viscosity of the blood and consequently the rests
tance to the current, thus facilitating the circulation. ■>
opinion was supported by earlier experiments, which ettiti
strated that the viscosity of the whole blood decreases un
the influence of iodine therapy. More recent expenmc : >
demonstrated, however, that the viscosity of the plasma
not the viscosity of the whole blood determines the resis • ' l
to the blood current. For this reason the author reports ^
investigations on the question whether the viscosity 0 ^
plasma is influenced by iodine therapy. He examine
plasma of healthy persons and of persons with hyper
by means of Hess's viscosimeter. He made these tes s
iodine therapy was instituted and after it had been con ^
for shorter or longer periods. The iodine therapy " a ^
to produce no changes in the viscosity of the P asl ® - 0( j; nc
author thinks that this contradicts the old theory ^ ^

therapy reduces the resistance to the bloody current y
the viscosity and thus facilitating the circulation. .y {
gests that there must be another explanation _ or a ^
favorable action of iodine therapy on arteriosc e

hypertension.

Ugeskrift for Lseger, Copenhagen

101:819-842 (July 13) 1939 „ isW ry « !

(itchcraft in Pregnancy and Delivery: Chapter ,

Popular Medicine. J. S. M0»er. P* t f r0Tn j 918

Manifest Hemorrhage Due to Ulcer m Aarhus ,

A. Guldager and F. Heintzelmann p. 826- BIood; prth®-~'-

etliod for Determination of Coagulation inn c

Report. II. Andreassen.— -p. 831. . p rat li. C. >• ’

ortality of Lupus Vulgaris Patients and Cans
Gimdtoft. — p. 832. . r, jiudied

Cause of Death in Lupus Vulgans.-Gui ty .f; v(
: cause of death in 211 cases of lupus ' . , during l l :i
n, 145 women) treated at the Fmsen Inshi A „

t twenty-five years. Only three P»; M

:, died from lupus itself, sixty-one (}" enti ^ an d thR*
men) died from pulmonary tuberculosis, on ^ {frtC .
men died from tuberculous meningitis, n t j l3 n tfco:f

n women died from tuberculous diseases ^ *».

ntioned and about half the patients ( j IU5 reg 3 ^"

nected with tuberculosis. Lupus vulga - . { exaie! a-
a benign disease but one which ca s , otl - procc“"

i as to the possible coexistence ol tune
■where.

The Journal of the
American Medical Association

Published Under the Auspices of the Board of Trustees

Vol. 113, No. 13

Copyright, 1939, by American Medical Association

Chicago, Illinois

October 28, 1939

TI-IE TREATMENT OF RETRODISPLACE-
MENTS OF THE UTERUS

WALTER T. DANNREUTHER, M.D.

NEW YORK

The term retrodisplacement is used clinically to
include both retroversion and retroflexion, although
literally it implies a backward dislocation of the uterus
irrespective of its relation to the vertical plane of the
pelvis. A retroflexion differs from a version only in
the break in alinement at the cervicocorporeal junction,
and a distinction between the two is of only academic
interest. Both alterations in position may be congenital
or acquired ; neither causes symptoms per se, and their
treatment is identical. Retroversioflexions complicated
by prolapse in the axis of the vagina constitute a
separate problem and are not under consideration.

Congenital displacements are identified in most cases
by the foreshortened anterior cervical lip and anterior
vaginal fornix, a general hypoplasia of the internal
pelvic organs, . and the limited mobility of the uterus
despite the absence of restraint from adnexal inflamma-
tory involvements. They are frequently associated with
endocrine derangements and discovered incidentally in
young women who present themselves because of
dysmenorrhea, menstrual irregularities or sterility.
Such patients seldom complain of sacral backache, the
chief symptom attributed to a retrodisplacement. On
the other hand, in cases in which the lesion is acquired
as a sequel of abortion or labor the symptoms commonly
ascribed to the malposition do not appear until after
the lapse of considerable time. Hence it is logical to
assume that uncomplicated retrodisplacements do not
produce symptoms; if they did, there would be a
simultaneous symptomatic onset with the backward dis-
location, and all patients with defects which have
existed since birth would have sacral backache, leukor-
rhea or other local annoyances. The factors responsible
for normal uterine poise and position are the dynamics
of the intra-abdominal pressure exerted against the
posterior surface of the corpus, the tonicity of the
supporting ligaments and the integrity of the perineal
musculature. Impairment of any or all of them may
eventuate in an acquired retrodisplacement. When one
sees patients with displacements that might have been
prevented, ill fitting pessaries inserted upside down or
back to the front or both, operations performed with
failure to relieve symptoms notwithstanding a satis-
factory anatomic end result, and recurrences after.

c , Fr , om tlle Department of Gynecology, New York Post-Graduate Medical
School and Hospital, Columbia University.

. Read before the Section on Obstetrics and Gynecology at the Ninetieth
19V) Scssion of the American Medical Association, St. Louis, May 19,

laparotomy, it is evident that the subject under dis-
cussion has not yet been worn threadbare. It therefore
seems pertinent to emphasize the importance of differ-
ential diagnosis, to clarity the treatment indicated for
various cases, to stress the therapeutic value of the
much abused and often neglected pessary and to con-
sider a few effective surgical procedures for patients in
whom operation is really indicated.

Having recognized a retrodisplacement, it then
becomes important for one to ascertain whether the
malposition is congenital or acquired, whether the
uterus is replaceable or immobilized and whether or not
there is coexisting endocervicitis, parametritis, peri-
uterine fixation, adnexal disease or pelvic tumor. All
of these modifications have a direct bearing on sub-
sequent treatment. Developmental defects require no
corrective therapy. A replaceable uterus may be treated
expectantly, with a pessary or by operation. Immobili-
zation is usually due to associated pathologic conditions
but is occasionally caused by the incarceration of a large
corpus beneath the promontory of the sacrum. If,
despite the absence of adnexal disease or pelvic adhe-
sions, bimanual reposition is impossible with the patient
in the lithotomy position, it can sometimes be accom-
plished by a change to the knee-chest position. Instru-
mental repositors are unnecessary and dangerous. A
freely mobile retrodisplacement is often erroneously
regarded as uncomplicated simply because no grossly
apparent complications can be detected, although there
may be intense concomitant passive congestion. In fact,
it is the insidious onset of circulatory stasis, particularly
in the broad ligament veins, that is responsible for the
delayed and gradual appearance of symptoms in the
majority of cases. With the uterus in normal position,
the uterine and ovarian vessels are widely patent; when
retroversion occurs, lateral torsion on their longitudinal
axis with consequent narrowing of their caliber is
inevitable. As the vascular engorgement increases, the
walls of the veins weaken to such an extent that actual
varicosities may be seen at the operating table. This is
the explanation for the paradoxical initiation of symp-
toms in cases of “uncomplicated,” or easily replaceable,
retrodisplacement.

Of the many complaints credited to retrodisplacement
only three, sacral backache, a sense of pelvic heaviness
and leukorrhea, are apt to be manifestations of the mal-
position itself. There are so many additional causes of
these, as well as of the other pelvic complaints some-
times ascribed to the retroversion, that the mere exis-
tence of a displacement by no means justifies the
assumption of direct cause and ■ effect. In many
instances the. cause will be found elsewhere (table 1).

If a sacral backache can be relieved by such measures
as unloading an obstipated colon, treatment of posterior
parametritis, fitting flat feet with suitable plates, eradi-

1610

UTERINE DISPLACEMENTS— DANNREUTHER

cation of remote foci of infection and orthopedic treat-
ment to remedy abnormalities in the lower part of the
spine even though a displacement persists, the time to
discover this is before a futile laparotomy and not
afterward. In other words, the major problem is not
the recognition of a retrodisplacement but the differ-
ential diagnosis of the true source of the symptoms
attributed to it.

A retrodisplacement may be treated prophylactically,
expectantly, palliatively or surgically. Proper pre-
cautionary measures following abortion, labor and
vaginal operations involving traction on the cervix will
prevent many acquired malpositions. After therapeutic
abortion, packing the uterus with iodoform gauze for
forty-eight hours and administration of 1 cc. of solu-
tion of posterior pituitary twice daily for three days
will hasten involution. After delivery, perineal lacera-
tions should be repaired immediately to restore the
integrity of the perineal musculature. Elevation of the
patient’s shoulders on the second day promotes free
lochiai drainage. Assuming the prone position for five
or ten minutes several times each subsequent day
facilitates forward gravitation of the uterus and exer-
tion of the intra-abdominal pressure on the proper
fundal area. Deep breathing exercises in the knee-
chest position during the third and fourth postpartum
weeks help to prevent diastasis of the abdominal
muscles and also tend to throw the corpus forward.

Table 1. — Symptoms Often Attributed to Rctrodisplaccmcnts
of the Uterus

Symptom

Usual Cause

Sacral backache

Overloaded sigmoid and rectum, posterior para-

metritis, flat feet, focal Infection, sacroiliac
joint, low spinal abnormalities

Menorrhagia

Passive congestion, endometrial alterations,
tumors

Zeukorrbcu

Hndocerv/cJtis, endometrial hyperplasia, tricho-
monas vaginitis

Pain

Inflammatory products in the pelvic structures

Pelvic dragging

Cystocele, rcctocclc, subinvolution

Dyspareunia

Uterine or adnexal fixation, prolapse of ovaries

Repeated abortion

Incarceration, constitutional disease, endocrine
dysfunction

Sterility

Husband, tubal disease, endocrine derangements,
endocervieitis

Regular and continued breast feedings refiexly stimulate
pelvic involution and should be urged for this as well
as other reasons. If all patients are reexamined three,
six and twelve weeks after abortion or parturition,
retrodisplacements will be detected promptly. It is
axiomatic that the farther back the cervix, the farther
forward the corpus. Hence the importance of replacing
the uterus bimanua Uy and holding the cervix back in the
pelvis with a strip gauze vaginal pack, pressed firmly
against the portio, after operations such as curettage
and trachelorrhaphy, which necessitate pulling the
uterus into the vaginal plane.

In addition to congenital displacements which can be
safely ignored, some freely mobile retroversions of long
standing are found to be symptomless and to require no
treatment. Under these circumstances it is wise to
request the patient to return for semiannual examina-
tions. On the other hand, if such a displacement is of
recent origin, one year or less, the uterus should be
held in its normal position for several months with a
pessary and not treated expectantly, because the sup-
porting structures may still be capable of regaining their
tonicity.

Jour. A. JL A.
On. 28 , 1939

Palliative therapy resolves itself into the application
of a pessary in cases of replaceable retrodisplacement,
and the treatment of coexisting parametritis and
adnexal disease when the uterus is thereby immobilized.
The induction of local depletion and hyperemia by such
means as strip gauze and glycerin vaginal packing, hot
saline douches, sitz baths, diathermy and short wave
therapy will ofttimes convert a fixed displacement into
one that is replaceable. When the malposition is dis-
covered early it can be corrected with an excellent
prospect of a nonoperative cure; in other cases relief
is experienced only so long as the pessary is worn.
There are four types of pessary well adapted to the
treatment of retroversion under slightly different con-
ditions : the Hodge, the Albert Smith, the Thomas and
the Findley, of which the Smith is the most popular.
The purpose of a pessary is not to correct a displace-
ment but to maintain proper uterine poise after the
uterus has been replaced. Incidentally, it serves to
demonstrate that permanent anteversion will relieve the
symptoms. Certain prerequisites are essential: The
bladder should be emptied by catheter, the mobile uterus
must be replaced bimanually, there must be no asso-
ciated prolapse or extensive cystocele, and before an
appliance is selected for an individual patient the size
and configuration of the vagina should be estimated.
The length is determined by inserting the fingers high
in the posterior fornix, just as though measuring the
diagonal conjugate diameter of the pelvis. The approx -
imate width is estimated by separating the finger tip
at the midportion of the vagina. It is thus easy to select
a pessary of the size and shape that the patient needs.
Misused, misfitted and misapplied pessaries will cause
distress and local soreness, whereas one that is hue
accurately can be worn with perfect comfort, if it )S
removed, cleaned and replaced every six weeks, h-very
curve in a pessary is designed for a definite reason, an
once the principles of construction are understood t
is no difficulty in making a selection for an indivi
patient. , . .

The uterus having been replaced in its nor
position, the only thing necessary to keep it . e T,
some mechanical contrivance to hold the cervix ■
If two fixed points, the pubic arch and the P°^, e .
vaginal fornix, are kept widely separated by a rtgt
or straight stick, the cervix can move up and
through a small arc but cannot come any
vaginal orifice. If a straight stick were used, o' ’
the posterior tip would push sharply into the or
the end must be bent upward to conform to e
of the fornix and put the uterosacral ligamen s ^
stretch. Provision having been made for the
the vaginal vault, it becomes necessary to ma - e a t j )C
reverse curve in the anterior end, to al ow
upward pressure of the perineal muscuaur. ^
long upward curve permits the pessary o 1 g
of the way in the narrow part of the pu ic a • £

the vagina is a wide canal, it is neces O first
another stick with identical curves parallel 1 w t » ^
and to connect the two anteriorly and p ( ^ rnor ny, the
posterior bar is wider because the fo™ 1 * j,ehind

anterior bar narrower so that it can iie P

the pubic arch. The little transverse notch a ^
ward dip at the anterior end are to prevent
sure on the overlying urethra. . cc< j u tcrus is

Laparotomy for the correction o P , s | 10 u!d

an elective and not an emergent proc >
be advised aniess .be taavds

all palliative measures

Volume 113
Number IS

UTERINE DISPLACEMENTS— DANNRE UTHER

1611

quent pelvic comfort can be anticipated. An operation
which fails to afford symptomatic relief is a failure,
irrespective of the anatomic result.

In a series of 3,400 consecutive office patients, a retro-
displacement was found 429 times, an incidence of
about 12.5 per cent. Of these, forty-two patients failed
to return for treatment and have been disregarded in
this analysis; seventy-two of the remainder bad con-
genital and 315 acquired retroversions or flexions.

Table 2. — Rclrodisplaccmcnts of the Uterus in a Scries of
3,400 Consecutive Office Patients *

Number of Cases Approxl-

, K » mate

Con* Percentage

genital Acquired of Cases

Developmental retroversions 72 .. ID

Symptomless acquired mnlpositions 47 12

Relieved by treatment of complications 50 13

Relieved by pessary 76 20

“Uncomplicated” retrodisplaccmcnts; pa*
tient operated on after wearing: a pessary .. 28 7

Primary corrective operation or operation

after palliative measures failed 87 22

Hysterectomy for tumors (displacement of
secondary importance) 27 7

72 315

* Total 3S7 100

* Exclusive of forty-two who failed to subject themselves to treat-
ment.

Treatment of the malposition itself was unnecessary
in forty-seven cases. In the other 268, palliative
measures sufficed to relieve symptoms in fifty ; bimanual
reposition and a pessary effected a cure in seventy-six ;
twenty-eight patients with “uncomplicated” displace-
ments were operated on after wearing a pessary
temporarily, and eighty-seven had a primary operation
or were operated on after palliative measures failed to
afford symptomatic relief. Hysterectomy for tumor
was performed in twenty-seven cases, the uterine dis-
location being of secondary importance (table 2).

In reviewing this series of cases, certain significant
facts became apparent :

1. Several operations by other surgeons for the cure
of developmental defects were followed by recurrence.

2. Many patients with congenital displacements were
pregnant when first seen or became so after the applica-
tion of negative galvanism to the uterus and the treat-
ment of endocrine derangements. Endowment with a
congenital malposition does not condemn a patient to
sterility.

3. After delivery the uterus may involute in normal
position, even though previously congenitally retro-
displaced.

4. Symptomless acquired retroversions were dis-
covered in patients presenting themselves with conditions
such as Bartholin cyst, pruritus vulvae, trichomonas
infections, cervical polyp, sterility, urinary complaints,
colitis and breast tumor. They were more common in
postmenopausal women.

5. Successful palliative treatment embraced careful
preliminary differential diagnosis as well as the correct
therapy . for hormonal imbalance, endocervicitis, para-
metritis and adnexal disease. In some instances a
Pessary was used after a fixed uterus became mobilized.

6. A high percentage of patients fitted with a pessary
were impregnated while wearing the appliance or soon
thereafter.

The multiplicity of operations devised for the sur-
gical replacement of a retroverted or retroflexed uterus
is not testimony of the uselessness of all of them, as
has occasionally been intimated, but is rather evidence
of appreciation on the part of discriminating gynecolo-
gists that no single technical procedure is universally
applicable. Failures seldom represent lack of skill in
execution ; they more often result from inadequate pre-
operative differential diagnosis, on the one hand, and
overenthusiasm in favor of a particular operation on
the other. In a series of 2,550 personal consecutive
pelvic operations, including ward service cases, I found
that I had utilized some type of intraperitoneal uterine
suspension in 286 (table 3).

In several instances the suspension was reinforced
with a plication of the uterosacral ligaments, and all
laparotomies were supplemented with whatever vaginal
plastic repair was indicated.

The relatively small number of Baldy-Webster sus-
pensions is an index of conservatism in operating for
a replaceable retrodisplacement, since I am prejudiced
in its favor wherever it can be judiciously selected. It
can be done quickly, preserves normal uterine mobility,
elevates prolapsed ovaries and in my experience has
interfered less with subsequent pregnancy and parturi-
tion than any other corrective procedure. It is ideal
for the patient who has worn a pessary with relief of
symptoms, thus demonstrating to both patient and
physician that the annoyances have been due to the
uterine dislocation and nothing else and that maintain-
ing the uterus in its normal position will effect a cure.
Unfortunately its merits have often been responsible
for its misapplication. It has been done when no opera-
tion was imperative, when the round ligaments were
markedly attenuated or when adnexal disease required
salpingo-oophorectomy. The intact utero-ovarian liga-
ment, tube and ovary are the only sturdy structures
capable of exerting counterpressure against the pull of
the transplanted round ligament on the thin leaves of
the broad ligament. It is apparent that if the utero-
ovarian ligament is cut, as it must be when salpingo-
oophorectomy is done, the broad ligament will soon
yield to tension and recurrence is inevitable. Other
causes of failure are using it for the support of a heavy

Table 3. — Surgical Procedures for Retrodisplacement of the
Uterus in 2J>50 Consecutive Pelvic Operations*

Type ol Procedure Number of Cases

Baldy-TYcbstor suspension : SO

Crossen-Gilliam ICO

Ventrlflxation 23

Mann plication of round ligaments 12

Olshausen suspension S

Coffey plication of round and broad ligaments 1

Total 280

* Exclusive of operations for displacements associated pith tumors.

subinvoluted corpus without plicating the uterosacral
ligaments at the same time, and suturing the round
ligaments too low on the posterior surface of the
corpus, so that they serve as a fulcrum instead of as
a support.

The large number of cases in which Crossen’s modi-
fication of the Gilliam operation was done indicates the
high incidence of concomitant adnexal disease in the
patients subjected to surgical intervention for retro-
displacements. This operation also causes little trouble
in event of subsequent gestation and delivery. Some

1612

UTERINE DISPLA CEMENTS— DAN N RE UTHER

patients complain of soreness in the region of the round
ligament attachment during the early months of preg-
nancy, but this is transitory and of little consequence.
In only one of my cases has the operation been respon-
sible for dystocia during labor, and intestinal obstruc-
tion has not followed in any case, so far as I know. The
Crossen-Gilliam operation is not contraindicated by
salpingo-oophorectomy, but the postoperative antero-
posterior excursion of the corpus is somewhat limited
as the bladder and rectum empty and fill.

A ventrifixation of the uterus was performed twenty-
eight times in women past the menopause when the
round ligaments were so short and thick that they could
not be conveniently plicated, when the rapid removal of
adnexal masses after extensive vaginal work was so
easy that hysterectomy did not seem warranted, or when
advantageously combined with a Crossen-Gilliam sus-
pension in cases in which the uterus was prolapsed to
the first degree. This group includes a few ventro-
suspensions, attempted before I learned that the
intended suspension usually terminates in a fixation, or
the artificially created false ligament so stretches that
the displacement eventually recurs.

Mann’s plication of the round ligaments is indicated
when the uterus is small and not to be sacrificed, both
tubes have been removed at a previous operation and
the round ligaments are unusually long but not much
thinned out. Under these conditions it has proved
entirely satisfactory.

Olshausen’s suspension tends to immobilize the
uterine fundus and thus interfere with proper bladder
expansion. It has many strong advocates, but I have
utilized it only five times, when speed was important
after other prolonged operative procedures.

Coffey’s plication of the round and broad ligaments
is especially useful when the tubes have been extirpated
at a previous operation and the round ligaments are so
attenuated that they are almost lost in the reduplicated
folds of the broad ligaments, but such cases are rarely
seen.

SUMMARY AND CONCLUSIONS

Retrodisplacements of the uterus per se do not cause
symptoms.

It is important to ascertain whether a malposition is
congenital or acquired, whether the uterus is replaceable
or immobilized and whether there is coexisting pelvic
pathologic change.

The concealed complication in cases of replaceable
displacement causing symptoms is passive congestion.

The true cause of many symptoms credited to a retro-
displacement will be found elsewhere. Careful differ-
ential diagnosis is of paramount importance.

A retrodisplacement may be treated prophylactically,
expectantly, palliatively or surgically.

Pessaries are used to maintain normal uterine poise
and position, not to correct a displacement. When fitted
accurately they are worn with perfect comfort.

In a series of 3,400 consecutive office patients, a
retrodisplacement was found 429 times, an incidence of
12.5 per cent; 142 of these were subjected to operation.

In a series of 2,550 consecutive personal operations;
some form of intraperitoneal uterine suspension was
done 286 times. -

No single surgical procedure is universally applicable.

An operation which fails to afford symptomatic relief
is a failure.

580 Park Avenue.

Jons. A. M. A.
On. 28, 1919

ABSTRACT OF DISCUSSION
Dr. .Bertha Van.Hoosen, Chicago: Dr. Datmreutkr's
treatment with pessaries I endorse. He makes the statement
that congenital retroversions of the uterus are symptomkss ssi
therefore we shouldn’t think of treating a symptomless condition.
I should like to ask Dr. Dannreuther what he considers the
cause of a congenital retroversion of the uterus. It seems to
me that if the undescended testicle deserves assiduous treatment
we might put a little less assiduous but some more treatment
on the symptomless congenital retroversion. I didn’t gather
whether Dr. Dannreuther made an age limit to the surgical
treatment for retroversion. I make a deadline. If a patient is
over 40 1 feel that she must have had the retroversion lor a
long time and there is apt to be accompanying fibrosis or seed-
ling fibroids, and as the uterus is an organ that is not very
necessary after 40 I invariably do a simple supravaginal hyster-
ectomy. I was disappointed that Dr. Dannreuther never men-
tioned the Alexander operation, which is the pioneer. The
Alexander operation has the advantage that it uses the attenuated
distal portion of the round ligament by which to suspend the
uterus, and I draw that round ligament up so tight that it really
suspends the uterus. I wish the ligaments that support the
uterus, the cardinal ligaments and the uterosacral, to have abso-
lutely nothing dragging on them so that they will recover their
tone at the end of from three to six months. Of course, dur-
ing this three to six months the uterus is pulling on those
adhesions that have been formed around the round ligaments,
and they gradually give way and at the end of six months the
uterus will he in a normal condition with all its mobility. I
feel that mobility is the first requisite, the thing that we should
try hardest to get, and that position of the uterus is secondary-
Dr. R. S. Cron, Milwaukee: Dr. Dannreuther has handled
the problem of retrodisplacements in a masterful fashion. Tno
points that lie has mentioned should be emphasized. The first
is that the postpartum examinations, especially when retrodis-
placement is suspected, should be done at the end of the thin
or the fourth week and again repeated at the sixth or the eign i
week. A tipped uterus, even if congenital, corrected at tto
time and held in place with a properly fitting support, may
permanently corrected. Second, the pessary should be used more
frequently, especially for a therapeutic test in uncompta e
retroversion. There are two statements with which I "'is 1
take issue. The first is the routine packing for forty-eight hours
of all postabortion uteri with iodoform gauze. A few ye 3
ago I reviewed more than 1,000 cases of abortion treate i
various ways and found that those treated most conserva «
and with the least trauma experienced the most satis ac
convalescence. Consequently, I rarely pack. A retroversi
suspected or found at this time is immediately corrector *
a pessary. Second, the choice of operation. A brie stlKi
the last 185 operations performed for retrodisplacement o
uterus also showed a multiplicity of operations
used.

having b eCJ1

It was found necessary or deemed. advisable to jperk^

a hysterectomy in slightly less than one. fourth of t cm. ^
Baldy-Webster technic was used nine times. In SP 1 e
fact that this is the operation advocated by many °‘ . . j

most prominent gynecologists, I am prejudiced a ®^ ln T„ 1 ; na |
know of at least six patients who have develope i —
obstruction following the operation.

In the hands of the average
operator, at least four different openings may be left nce j,
a loop of intestine may become strangulated. , e ^
especially retrocession, are not uncommon. A tec >n ,c jf a ya
many years ago by Reuben Peterson and similar 0 gjdi
operation has in my hands proved to be most satis ac - ' . fC( j
round ligament is drawn through the inguinal ring an f

to the posterior surface of the anterior

sheath of the t
in about 1 0

muscle. This operation was used 120 times, or
cent of the cases. In thirty-eight instances it " a ^ fhere
with the approximation of the sacro-uterine hgamc •
was one recurrence, but no other serious comp lc nre0 tfier

encountered. Finally, it has been noted that r. ^fotrte

has made no mention of the relation of endometri 0 ^^^ fiie

I should like to know whether he - , tr ; u p

regurgitation of the menstrua

through the tubes in congenital or acquired r
an indication for its correction.

retroversion,
possibility of

Volume 113
Number 18

UTERINE DISPLACEMENTS— DANNREUTHER

1613

Dr. Louis E. Phaneuk, Boston : I appreciate Dr. Dann-
reutlier’s lucid presentation of this important subject of retro-
positions of the uterus. I subscribe to the fact that a
retroversion or a rctrodisplaccmeut per sc seldom causes symp-
toms but that it is the concomitant pathologic condition which
is responsible for the symptoms. Obviously a congenital dis-
placement without symptoms requires no treatment. The fre-
quent association of hypoplasia, dysmenorrhea and sterility with
that type of uterus, however, needs our attention. I have found
the atrophied uterus after the menopause in retroposition so
frequently that in my mind the retroposed atrophic uterus is a
fairly normal condition. One of the greatest uses of the pessary
which I have found has been in the puerperal uterus which has
remained large, with lax ligaments, which can be replaced
manually very simply, and which a pessary will hold in position.
The wearing of a pessary for a period of six months will fre-
quently allow the ligaments to take up their tonus and thereby
correct the position. The wearing of a pessary in a replaceable
uterus to determine whether or not the symptoms are caused by
the retroversion in my mind is an excellent procedure. In con-
nection with suspension operations, there are three factors which
govern the proper surgical replacement of the retroposed uterus,
as I see it. The first is to bring the cervix back at right angles
to the vagina, the second to bring the uterus forward, and the
third to obliterate the space on the sides in order to avoid, so
far as it is possible to do so, intestinal obstruction. This is
accomplished by shortening the uterosacral ligaments by doing
a round ligament suspension in such a way that the space on
the sides is obliterated. It is my custom to do some sort of
suspension after having operated for adnexal abnormality, with
the end in view of preventing the formation of an adherent
retroversion.

Dr. O. S. Krebs, St. Louis : I merely want to mention a
phase of prophylaxis of retrodisplacement of the uterus. It
seems that at the end of the second week after delivery the
rule is for the uterus to be forward, that the displacement
occurs between that time and the fourth week, when from 20
to 41 per cent are found displaced posteriorly. Williams says
one out of four or five, and Lynch 41 per cent. In October
1937 I began introducing a collapsible pessary, the Finley pes-
sary of the Smith-Hodge type, in treating all private obstetric
patients delivered by Dr. Royston and myself, just before they
left the hospital. It has also been the custom for these patients
to omit taking any douches for two weeks after getting home,
and to insert into the vagina every other night a large capsule
filled with 80 per cent beta lactose and 20 per cent boric acid,
as suggested by Roblee. In the small series under considera-
tion the results are not entirely tabulated, but the frequency
of retrodisplacement after the puerperium is over is 18 per
cent in primiparas and multiparas combined. There is a high
frequency of congenital displacements . in our cases, about 16
per cent in the aforementioned group, which were considered
in the results, however, and it is noteworthy that among all
the primiparas only those that we felt had congenital displace-
ments ended with retrodisplacements at the end of the puer-
perium, Four of the patients with congenital displacements
during early pregnancy had anteflexed uteri when discharged
from our care. Not considering the lessened incidence of dis-
placement following delivery with the foregoing regimen, which
may be worth while, the improved involution in practically all
cases regardless of the final position of the uterus was very
striking. No douches were given during this postpartal period,
so the effect of heat can be dismissed. Probably the greatest
factor in subinvolution is a local one and that is an abnormality
of circulation which accompanies the displacement, and the
results are obtained by the uterus being maintained in its
normal position when involution is active. In addition to
better involution, the cervix recovered from the effects of
labor at an earlier time and more completely. Since this series
of cases has been under observation it has not been found
necessary to cauterize the puerperal cervix for erosion or
endotrachelitis alone.

Dr._ A. C. Hirshfield, Oklahoma City: Dr. Dannreuther
has rightly emphasized the lack of symptoms in the uncom-
plicated. case and has reemphasized the fact that surgery is
ordinarily not indicated in these cases, but men practicing in

large hospitals and medical centers would be surprised if they
realized the percentage of routine surgery, in the hospitals in
the hinterlands, which consists of operations on tubes and retro-
displacements. Since I recognized the fact that surgery is not
indicated in the ordinary case of salpingitis and retrodisplace-
ment, I have not appeared in the operating room as often as
I used to, and I have no enthusiasm for surgical intervention
in these cases. To get back to the legal aspect of this matter,
I wonder whether phj'sicians realize how many large damage
suit judgments are obtained because women who have been in
minor accidents, particularly in taxicabs, show up afterward
with retrodisplacement. In Oklahoma City the taxicabs com-
pete with the street cars, and one can ride any reasonable
distance for 10 or 15 cents. There are many taxicab acci-
dents, and for years the damage suit lawyers managed to find
physicians who found retrodisplacements in these women and
who qualified as experts and testified more or less convincingly
to the juries that these retrodisplacements were caused by
taxicab accidents. The taxicab attorneys employed one or two
of us who had a more or less scientific view to combat this
wave of damage suit cases in favor of the retroverted uterus.
By means of charts and models and impromptu lectures we
went before these juries and demonstrated that these condi-
tions were either congenital or caused by childbirth or other
more or less natural feminine causes and were not caused by
ordinary taxicab accidents.

Dr. W. H. Vogt, St. Louis : I was glad to see that Dr.
Dannreuther is still so old fashioned as to use the pessary.
There is a definite place for the pessary when used properly
with the proper indications and the proper type of pessary.
There are contraindications to the use of the pessary that
everybody must recognize, and Dr. Dannreuther, I think, has
brought out some of those. In inflammatory conditions of
the pelvis they should not be used; if the uterus cannot be
elevated the pessary should not be used, because it will do
more harm than good. I am not one of those who believe
that the retroversion or retrodisplacement of the uterus which
gives no symptoms should not be treated, There are certain
types of retrodisplacement, that type of congenital retrodis-
placement with a general atrophy of the pelvic organs and
general ill development of the body, that do not need any
treatment ; treatment there is directed in a general way and
not locally. Likewise, those cases of retrodisplacement which
occur in the menopause I don’t believe need any treatment.
In the atrophic uterus of the menopause no treatment is needed,
but in all other cases of retrodisplacement, even though there
are no symptoms, I think treatment is indicated, because I
feel convinced that the uterus acts as a wedge and that the
retrodisplacement is simply a forerunner of a future prolapsus.

Dr. Walter T. Dannreuther, New York: In reply to
Dr. Van Hoosen’s inquiry regarding my opinion concerning
the embryologic factors responsible for a congenital defect. I
confess that I don’t know how they operate. Even if we did
know, it seems unlikely that such knowledge would be of
practical value. To institute any effective therapeutic mea-
sures it would be necessary to make an exact diagnosis, which
would involve the routine examination of all female infants
and children. The Alexander-Adams operation of course was
popular forty years ago, but modern abdominal surgery no
longer carries with it the hazards of forty years ago. One
does not hesitate to open the peritoneal cavity today, whereas
forty years ago there were frequent consultations before such
a serious step was undertaken. The Alexander-Adams opera-
tion requires two incisions instead of one, affords no oppor-
tunity to make an intraperitoneal exploration, is sometimes
attended by technical difficulties when the round ligaments are
thin and hard to find in the inguinal canal, and eventuates in
a certain percentage of unsatisfactory results. Dr. Cron called
attention to a typographic error in my paper which escaped
my notice, namely, the recommendation that the uterus be
packed after abortion ; the qualifying word "therapeutic” should
have been included. No instances of intestinal obstruction fol-
lowing Baldy-Webster operations have come to my attention,
although my patients, both clinic and private, have an excellent
follow-up. On the other hand it is evident that, if sutures
are not placed properly in doing this operation, intestinal

rac men ,n^- hode :

PMEUMOCO w patients ^ sulia pyrid'ne a o ^ ^ 0 \

. -n^nstechtf u ^" nHS . treated^ Ration deals t treated

recovered. c on«num sa \t 4 ® . me nmgito

1938 a"' 1 ‘„„„ comp'« te '> •,„. any »' '“

' PWBUM^- .

a endometn^- ^ sucb^c ^mstan^ more

torted ills *at l ( d''" ^nder th“ ^ primary cts ol

«> stfSi-iw «sT4' 0

r.cr,\aceir' ent ' .,_„tnrnC P r ° . .„,-peting> “

jz*»*

fea-j»Ls5,iV--£«

ar-S^s-sf.'S-jisi

While it is ’ { ^erapy iXl s ? t vrbea «° *?c«ienitigf v
„ nV iovm ot t" , oUt drat m0 coccrc " . ^ c.

S^oSS^v.

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Volume 113
Number 18

PNEUMOCOCCIC MENINGITIS— HODES ET AL.

1615

given every six hours. The full dose of sulfapyridine
was continued by mouth until the patient seemed
entirely well clinically and until several successive cul-
tures of spinal fluid were sterile; the dose was never
reduced before the temperature had been normal for
one week. After this time the dosage was halved
for several ' days and then the drug was discontinued
entirely. On one occasion it was resumed because the
occurrence of a relapse was suspected.

On admission many of the patients in this series
were comatose or delirious and required the adminis-
tration of the drug by nasal tube. This was continued
until the patient was able to swallow.

In the treatment of the last eleven patients in this
series the sodium salt of sulfapyridine was employed
in addition to the oral administration of sulfapyridine.
As Marshall 4 has shown, the sodium salt, unlike sulfa-
pyridine itself, is freely soluble. It is most conveniently
used in distilled water in a 5 per cent solution, which
is approximately isotonic. It should be emphasized that
such a solution is extremely alkaline (pa almost 11)
and cannot be given intrathecally or subcutaneously
but only intravenously. 6 The sodium salt proved to be
of great value. When it first became available it was
given only to those patients who were unconscious or
comatose and unable to swallow sulfapyridine. Later
we employed it also in treating those patients in whom
the concentration of the sulfapyridine in the blood and
spinal fluid remained low during the oral adminis-
tration of the drug. In such cases one or two daily
intravenous injections of the sodium salt served to
bring the concentration of sulfapyridine in the blood
and spinal fluid to high levels. The intravenous admin-
istration of the sodium sulfapyridine proved to be of
great value also for those patients who persistently
vomited sulfapyridine given by mouth. At the present
time we believe that the oral administration of sulfa-
pyridine should be combined with a regular course of
the sodium salt given intravenously. The plan of treat-
ment which we now recommend and which we have
employed in treating the last four patients, all of whom
recovered, is as follows :

The oral administration of the drug is instituted
on admission and continued in the manner already
described. In addition, intravenous therapy with a 5
per cent solution of sodium sulfapyridine in distilled
water is begun. An initial dose of 0.1 Gm. per kilo-
gram of body weight is injected. Following this, 0.03
Gm. of the sodium salt per kilogram of body weight is
given intravenously every six hours until the patient
shows definite clinical signs of improvement and until
two successive lumbar punctures are sterile. After this,
the sodium sulfapyridine is given only twice a day for
several days longer, and then it is discontinued. Intra-
venous therapy should be resumed at the first indication
that a relapse has occurred.

None of the patients treated with sulfapyridine
received antipneumococcus serum. Forced spinal drain-
age was not employed and lumbar punctures were done
only for diagnostic purposes and occasionally to relieve
pressure symptoms. Supportive measures, such as the
administration of intravenous fluids and frequent blood
transfusions, were given as necessary. Myringotomy
was performed in six cases but it was thought advis-
able in only two cases to attempt to eradicate the orig-
inal focus of infection by extensive surgical methods.
A mastoidectomy was performed on one of these

K-' Jr., and Long, P. I
sodium Sulfapyridine, J. A. SI. A. 11S: 16

The Intravenous Use of
(April 29) 1939.

patients (patient 3), who recovered, but it was very
doubtful that the operation exerted any definite effect
on the course of the meningitis. In the other case the
meningitis apparently followed pneumococcic panoph-
thalmitis of one eye. Enucleation was not followed by
any improvement in the patient’s condition, and he
eventually died.

CONCENTRATION OF SULFAPYRIDINE IN BLOOD
AND SPINAL FLUID

With a modification of Marshall’s 6 method for sulf-
anilamide, the concentration of free sulfapyridine in the
blood and spinal fluid was determined on a number of
occasions in twelve cases. It was found that when the
drug was given orally there was great variation in
the concentration of sulfapyridine. There was no good
correlation between the dose of the drug given by
mouth and the level of sulfapyridine in the blood and
spinal fluid. The concentration of the drug in the spinal
fluid in those patients who received the drug by mouth
varied only from 1.1 to 11.4 mg. per hundred cubic
centimeters. It was generally higher in those patients
who also received sodium sulfapyridine intravenously.
In one such case the concentration in the spinal fluid

Table 1 . — Treatment of Pneumococcic Meningitis at Sydenham
Hospital, 1930-1939

Adequately Treated Oases
All Cases Excluding 24 Hour Deaths

, * \ f K X

Recovered Recovered

Number Per Number Per

Treatment

Treated

Number

Cent

Treated

Number

Cent

Before use of sulf-
anilamide and sulf-
apyridine (no
nntfpneumococcic
serum)

29

0

0

14

0

0

Sulfanilamide

17

1

c

12

1

8

Sulfapyridine

17

8

47

13

8

61

reached 29 mg. per hundred cubic centimeters. The
concentration of sulfapyridine in the blood was usually
from 30 to 50 per cent higher than it was in the spinal
fluid.

TOXIC EFFECTS OF SULFAPYRIDINE
During the course of treatment with the large doses of
sulfapyridine and its sodium salt which were employed,
a number of toxic effects of the drug were noted. The
drug produced nausea and vomiting in more than half
the patients, but these symptoms were severe in only
one case. Cyanosis of mild degree was seen in four
of the patients; it was accompanied by no untoward
effects. The drug did not produce anemia of appre-
ciable degree in any of the cases. In one adult (D. C.)
mild leukopenia was noted, and in one child (C. M.)
severe granulocytopenia developed. Owing to an
oversight, this child continued to receive the drug ten
days after it was believed to have been withdrawn.
The white blood count dropped to 4,000 cells, of which
96 per cent were lymphocytes. The granulocytopenia
was accompanied by fever of 104 F. and by mem-
branous pharyngitis. The drug was discontinued and
supportive measures were instituted. The patient
improved almost at once and the temperature became
normal in six days. The white blood cell count rose
gradually until it reached 9,500 with 70 per cent poly-
morphonuclear leukocytes ten days after the discovery
of the granulocytopenia.

f ) Ia r shal J; E. K„ Jr., and Litchfield, J. T„ Jr.: The Determination
of Sulfanilamide, Science S8:85 (July 22) 1938.

1616

PNEUMOCOCCIC MENINGITIS— MODES ET AL.

Joos. A. St. A
On. 28, III)

In three of the cases the administration of sulfa-
pyridine caused gross hematuria. In the first case
(case 2), the hematuria appeared on the fifth day after
the institution of suifapyridine therapy. The hematuria
was not accompanied by oliguria, hypertension or an
increase in the nonprotein nitrogen of the blood.
Within four days after withdrawal of the drug, the
urine was normal microscopically; the number of
formed elements as measured by the Addis count was
within normal limits, and phenolsulfonphthalein tests

pyridine therapy was begun again and was continued
for the next four days. During this time gross hema-
turia reappeared and persisted until two days after the
drug was again discontinued.

In a third case (case 17) hematuria developed four-
teen hours before death. Autopsy showed very clearly
that death was not caused by the hematuria but was
due to very extensive meningitis which had apparently
not been affected by suifapyridine. Gross examination
showed that the pyramids, calices, pelves and ureters

Table 2.-

-Rcsults in Seventeen Cases of Pncuuwcoccic Meningitis Treated with Suifapyridine and Sodium Suljaftriim

Case

No.

Name,

Age, Clinical

Color, Condition on
Sex Admission

Original

Focus

of

Infec-

tion

I Blood
Culture*
Type
Pneumo-
coccus

Type

Pneumo-

coccus

in

Spinal

Fluid

Spinal

Fluid

Sterile

(Days

After

Treat-

ment

Begun)

Duration

of

Fever

After

Sulfn-

pyridinc

Begun,

Dnys

Trentmcnt

Concentration of
Free Suifapyridine,
Mg. per ICO Cc.

/ » V

Spinal
Blood Fluid

Toxic
Effects of
Drug

Results

1

G. J. Critically ill;

Pneu-

25

25

17

5

Suifapyridine by mouth

1.7-4 .8

1 .1-4.0

None

Recotmd

2

34 yrs. comatose;
Negro d temp. 104.4 F.

A. P. Moderately ill;

monia

Otitis

Negative

1

2

3

only

Suifapyridine by mouth

Not done

Not done

Hema-

Recovered

3

7 yrs. temp. 103 F.

White d

C. M. Critically ill;

media

Otitis

Negative

5

1

0

only

Suifapyridine by month

Not done

Not done

turia

A granulo-

Recovered

4

11 yrs. comatose;
Negro 9 temp. 103 F.

C. B. Critically ill;

media

Not

Negative

9

o

3

and sodium suifapyridine
intravenously; mastoidectomy
Suifapyridine by mouth 3.2-8.0

2.7-4.0

cytopenia

None

Pecoreri'l

5

32 yrs. comatose;

Negro d temp. 103 F.

D. C. Critically ill;

known

Not

2 a

23

30

4

and sodium suifapyridine
intravenously
Suifapyridine by mouth

1.8-25,0

1.3-13.3

Moderate

Recovered

G

49 yrs. delirious;

Negro d temp. 103.S F.

D. G. Moderately ill;

known

Not

12

12

5

3

and sodium suifapyridine
intravenously
Suifapyridine by mouth

4.1-14.0

4. 5-7.5

leuko-

penia

None

RctoTtmi

10

12

13

U

16

17

3.1 yrs.
Negro cf

A. T.

45 yrs.
White 9
G. M.

11 yrs.
White cf

B. S.

6 yrs.
White 9
A. E.

23 yrs.
Negro d
J. W.

9 BIOS.
Negro d

C. N.

5 mos.
White d

D. N.

1 yr.
Negro d
D. W.

10 mos.
Negro d
C. J.

31 yrs.
Negro d
C. W.

12 yrs.
White d
W. H.

54 yrs.
Negro d

temp. 100 V.

known

Critically 111;
delirious;
temp. 102 F,

Critically 111;
profound coma; media
temp. 101 F.
Moderately 111;
temp. M3 F.

Otitis

media

Otitis

Otitis

media

Negative

Negative

Moribund:
temp. 105 F.

Moribund;
temp. 100.2 F.

Moribund;
temp. 101.4 F.

Moribund ;
temp. 103 F.

Critically ill;
temp. 102.4 F.

Critically ill;
comatose;
temp. 105 F.
Critically ill;
delirious;
temp. 102.2 F.
Critically ill:
comatose:
temp. 102.2 F.

Not

known

Otitis

media

Otitis

media

Not

known

Pneu-

monia

12

29

29

14

Pan- Negative 23

ophthal-
mitis

Otitis Negative 19

media

Pneu-

monia

Negative 31

Not

sterile

Not

sterile

Not

sterile

Not

sterile

Not

sterile

Not

sterile

Not

sterile

Not

sterile

and sodium suifapyridine
intravenously
Suifapyridine by mouth
and sodium suifapyridine
intravenously
Suifapyridine by mouth
and sodium suifapyridine
intravenously
Suifapyridine by mouth
and sodium suifapyridine
intravenously
Suifapyridine by mouth
only

Suifapyridine by month
and sodium suifapyridine
intravenously
Suifapyridine by mouth
only

Suifapyridine by mouth
and sodium suifapyridine
intravenously
Suifapyridine by mouth
only

Suifapyridine by mouth
only; enucleation of
right eye

Suifapyridine by month
and sodium suifapyridine
intravenously
Suifapyridine by mouth
and sodium suifapyridine
intravenously

1I.0-2S.5 13.9-20.0 None

11.1-15.3 5.S-15.0 None

Trace-8.7 Trace-5.2

Severe

vomiting.

Kecorerri

Retort*!

Pied ,
(ecretdilt

hematuria

Not done Not clone None

Not done Not done None

10.4

7.5

None

lG.fl-30.5 Not done None

8.2

4.7-10.5

6.4-11.4 None

1.9-7 .5

None

Not done 12.0-29.0 None

Not done Not done

Hema-

turia

Diet! In
less than
21 hours
Died in
less than
21 hoars
pMlrr

loss than

21 hoars
Died In
Jess fhtfil

21 hoots
pied

Died

Pied

Died

were normal. Apparently no permanent damage to the
kidney resulted from the hematuria.

In the second case (case 9) hematuria developed on
the fourth day of treatment with suifapyridine and its
sodium salt. In this case also the hematuria was not
accompanied by changes in blood chemistry or by
elevation in blood pressure, and there was no oliguria.
Fluids were forced but, since the spinal fluid cultures
were still positive, the intravenous administration of
sodium suifapyridine was continued. The spinal fluid
became sterile two days after the onset of hematuria,
and when the sodium suifapyridine was withdrawn
four days later both the urine and the spinal fluid were
normal. About two weeks later the patient showed
clinical evidence of a relapse, and is was suspected that
she was suffering from a brain abscess. Sodium sulfa-

well as the bladder,

i i ' TTorv J" Q

Bratton ' 1(1

These calculi were very rough

contain^
with

of both kidneys, as
gravel-like calculi.

manv pointed spicules. Dr. A. Calvin ^

Dr. E. K. Marshall Jr.’s laboratory showed tna

• ■ entirely

small calculi were made up almost

Ollictil — .. .

cent) of the acetyl derivative^ of sulfapyow ^ , j )3 ,j

scopic sections showed that the calculi a P P‘
eroded the epithelial cells lining the pe '

ureter 5

C1UUCU U1C * » . fO ^

and bladder and bad caused hematuria by t i j pr

underlying capillaries. No crystals of s 1?- anc j r o
calculi were found in the glomeruli or ,. n( p
evidence of injury to these structures ua JC( j [w
It appears, therefore, that the hema . ur ; n ar?
suifapyridine is due to mechanical injur} Jicitii-

tract. I t seems reasonable to suppose

7. Personal communication to the authors.

Volume in PNEUMOCOCCIC MEN IN GIT IS — HODES ET AL. 1617

Number 18

turia will not be accompanied by serious or permanent
interference with renal function, unless tbe precipitation
of tbe acetyl sulfapyridine is so extensive as to produce
blockage of tbe tubules or ureters.

Dr. E. K. Marshall Jr. T offers the following expla-
nation for the formation of calculi of acetyl sulfa-
pyridine in the urinary tract: When sulfapyridine is
ingested, part of it is acetylated and is excreted in the
urine with some free sulfapyridine. The amount of
sulfapyridine which is acetylated varies greatly with the
individual patient. Acetyl sulfapyridine, which is not
very soluble at best, is even less so in acid mediums.
It is probable that even when the concentration of this
substance is high in the blood it remains in solution in
the glomerular filtrate. However, as the urine becomes
more concentrated and more acid as it passes down
tbe tubular system, precipitation of the crystalline acetyl
sulfapyridine may occur. These sharp-edged crystals
and small calculi formed around them probably cause
hematuria by mechanical injury. Dr. Marshall sug-
gests that with a given dose of sulfa-
pyridine the danger of the occurrence
of hematuria might be lessened by
the administration of alkali and by
supplying an adequate fluid intake.

results following

TREATMENT

Table 2 summarizes our experience
with the use of sulfapyridine and its
sodium salt in pneumococcic menin-
gitis. As already stated, eight of the
seventeen patients treated (47 per
cent) recovered. Up to the present
time no sequelae of any kind have
been noted and these patients appear
to be entirely well. This result is
particularly striking when the condi-
tion of the patients on admission to
the hospital is considered. Four were
moribund and died in less than
twenty-four hours ; ten were critically
ill and delirious or comatose, while
three were only moderately ill. Of the thirteen
patients who survived more than twenty-four hours,
only five failed to recover. Among the seventeen
patients there were four under 12 months of age ; all
these infants died in less than twenty-four hours after
the beginning of treatment with sulfapyridine. Three
of the five children between the ages of 6 and 12 years
recovered, as did five of the eight adults in the group.

In those patients who recovered, clinical improve-
ment was noted very soon after treatment with sulfa-
pyridine was begun. Usually the first evidence of
beneficial action of the drug was improvement in the
patient’s mental status. On a number of occasions
the patient who had been stuporous or irrational became
oriented and alert within twenty-four hours after the
beginning of treatment. Among the patients who recov-
ered, the temperature reached normal within four days
and the spinal fluid cultures became sterile within five
days, with the exception of one (patient 1), whose
spinal fluid cultures showed pneumococci for seventeen
days. In two cases (5 and 7) a relapse occurred with
the transient appearance of pneumococci in the spinal
fluid. A very dramatic example of the prompt effect
of the drug is shown in the accompanying chart.

Pneumococci were recovered from the blood cultures
on admission of four of the patients who recovered.

The blood cultures in these cases became sterile within
a few days after the beginning of treatment.

Three of the patients who recovered showed paralysis
of the facial nerve of the peripheral type during the
course of their illness. During convalescence, however,
the paralysis gradually became less marked and all
three patients eventually regained complete use of their
facial muscles.

In one instance death was caused by a cerebellar
abscess. At autopsy tbe meninges were found to be
perfectly normal. Apparently treatment with the sulfa-
pyridine had brought about complete resolution of the
infiltration and infection in the meninges but had not
caused healing of the brain abscess.

COMMENT

It seems evident that the mortality rate from pneu-
mococcic meningitis can be reduced by the use of sulfa-
pyridine and its sodium salt. The outlook for the
average patient with this disease has been improved,

perhaps by 50 per cent. Our experience indicates that
the drug is effective against all types of pneumococci.

One of the great handicaps encountered in treating
meningitis with sulfapyridine is the irregularity of the
absorption of the drug, which probably accounts for
the great variation in its concentration in the blood
and spinal fluid. This drawback may be eliminated
by the use of the sodium salt of sulfapyridine. By
administering the sodium salt at regular intervals, as
we have done in treating our last four patients, all of
whom recovered, the concentration of sulfapyridine in
tbe spinal fluid may be maintained at any desired level.
We believe that this is the important function of the
sodium salt, which should be used in amounts sufficient
to maintain the spinal fluid concentration of sulfa-
pyridine between 10 and 15 mg. per hundred cubic
centimeters.

That the use of sulfapyridine may be accompanied
by serious toxic effects is, of course, well known.
However, in dealing with meningitis, the most dan-
gerous of all pneumococcic infections, it may be nec-
essary to continue treatment with the drug despite
these untoward effects. For example, we believe that
the drug should be given even in the face of hema-
turia, since the patient’s life depends on the action of
the drug.

Sulfapjrifiln*

Salfanllaaid* ^ sodHn

kaeus SulfapTTl&ln*

1618

PNEUMOCOCCIC MENINGITIS— HODES ET AL.

There remains the possibility that better results
might be obtained by combining sulfapyridine with
antipneumococcus serum. On this point we have no
data to offer.

Jour. A. 51. X
Oct. 28, IB

REPORT OF CASES 8

Case 2.— A. P., a white boy aged 7 years, was admitted
to the hospital Jan. 16, 1939, and discharged well February 4.

Five days before admission, the child complained of pain in
the right ear. The next day he became drowsy and remained
so until admission to the hospital. On the night before entry
he became “dizzy” and complained of a great deal of pain in
the back of his neck when he attempted to raise his head.

On arrival at the hospital the patient, who was well developed
and well nourished, did not appear to be critically ill. His
neck was slightly stiff and Kernig’s sign was present. On
otoscopic examination the left drum was seen to be bulging,
but no mastoid tenderness or edema was present. Physical
examination otherwise was entirely negative.

Oil admission the spinal fluid showed 2,000 cells per cubic
millimeter but no organisms were seen on smear. Sulfanilamide
therapy was begun at once. Myringotomy of the left ear drum
was done with the release of a large amount of thick pus.
The next day, type I pneumococci were recovered from cultures
of the spinal fluid and of the pus from the ear and from the
throat, and sulfapyridine therapy was begun. Six Gm. a day was
given for four days. On the fourth day of sulfapyridine treat-
ment, hematuria developed with passage of a few blood clots.
Sulfapyridine was immediately discontinued and within the
next five days the urine became clear and negative micro-
scopically. All kidney function tests were normal one week
after the hematuria had appeared.

The spinal fluid cultures were negative at the time the sulfa-
pyridine was discontinued, and the patient did not require any
further medication.

The temperature on admission was 103 F. and returned to
normal on the second day. On the fourth day the temperature
rose to 102 F. At this time the left ear drum was reopened
and pus was obtained, following which the temperature returned
to normal.

On admission the patient was found to be strongly sensitive
to a test dose of rabbit and horse serum, and consequently
antipneumococcus serum could not be used.

On discharge the left ear was completely healed. The urine
was normal and no residual changes were present.

contained 4,300 cells, nearly all of which were polymorpho-
nuclear leukocytes. On smear there were present numerous
gram-positive diplococci which proved on culture' to be type V
pneumococci. The patient was treated with sulfanilamide for
two days without improvement, and a simple left mastoidectomy
done twenty-four hours • after admission was not followed by
any change in her condition. At the end of the patient’s
second day in the hospital the temperature was 105.6 F. She
was in a comatose condition and appeared to be moribund.
At this point she was given 70 cc. of a 5 per cent solution
(3.8 Gm.) of the sodium salt of sulfapyridine intravenously and
oral administration of sulfapyridine (6 Gm. a day) ivas begun.
During the next twenty-four hours the temperature dropped
to normal ; the patient became conscious and was able to speak
rationally. She received 6 Gm. of the drug each day for
fifteen days and then 4 Gm. a day for the next seven days,
after which time the sulfapyridine was discontinued. In addition
to the sulfapyridine by mouth, she was given daily injections
of the sodium salt of sulfapyridine intravenously for five days.

As noted, the temperature fell from 105.6 F. to normal within
twenty-four hours after the first intravenous injection of
sodium sulfapyridine. Thereafter it did not rise above 100.6 F.
(rectal) until on the twenty-eighth day in the hospital, when
it rose to 103 F. owing to the onset of agranulocytic angina.
Ten days later the temperature became normal and remained
so until discharge.

The mastoid wound healed uneventfully and at the time of
discharge only a small granulating area still persisted.. The
spinal fluid count decreased from 4,300 cells on admission to
13 cells eight day’s later. The spinal fluid became sterile within
twenty-four hours after the beginning of sulfapyridine therapy
and remained so thereafter.

The chart is a graphic illustration of the patients course
during the first nine days in the hospital.

LABORATORY DATA

The spinal fluid cultures were positive for pneumococci
(type V) February 11 and 13, and sterile February Id, n
and 23.

The blood cultures were sterile February 11 and 15.

Blood counts showed: February 11, hemoglobin conten

.Djuuu tuuiua snuwcu. rcutuoij — *

Gm., white blood cells 14,000 with 88

nuclears; March 10, white blood cells 4,100 with 2 per
polymorphonuclears and 98 per cent mononuclears; J arc ’
white blood cells 9,500 with 70 per cent polymorphonticiB •
Cultures of material taken from the ear and from the mas
were positive for pneumococci (type V). « s

Examination of the urine showed 5 or 6 white 00
per high power field, 2 plus albumin and a trace o

Subsequent examinations were negative. .

Culture of material taken from the throat at the h® , . £
brane appeared in the throat showed many beta

streptococci, group A, Lancefield.

SUMMARY

1. Seventeen patients with pneumococcic ^

>-■ 1 nrl with sill f.'l mTl'rii ne or With Slllfap)

LABORATORY DATA

Spinal fluid cultures were positive for pneumococci (type I)

January 16 and 17 but sterile thereafter.

Culture of pus taken from the left ear was positive for pneu-
mococci (type I) January 16.

Culture of material taken from the throat was positive for
pneumococci (type I) January 17.

The urine was normal, except for gross hematuria oil the
fourth day in the hospital, which cleared in five days and
remained normal thereafter. The Addis count was normal.

Nonprotein nitrogen was 40.2 mg. per hundred cubic centi-
meters of serum at the time of hematuria.

Blood culture was sterile January 17.

Case 3.— C. M„ a Negro girl aged 11 years, was admitted
to the hospital Feb. 11, 1939, and discharged well March 24.

Six days before admission the patient noticed a copious dis-
charge from her left ear. The next day her gait became
unsteady. She continued to have fever and became increas-
ingly weak until on the day of admission to the hospital she
suddenly became unconscious.

Physical examination on admission showed that she was well muavaiuua — . . 5111111-

developed and well nourished; she appeared critically ill. She regular intervals. The concentration . at 3

— *; — 1 ^;i*a tr> .she was nvridine in the spinal fluid- should De man -

level of front 10 to 15 mg. per hundred cubic

ntening; 115

were treated with sulfapyridine or
and its sodium salt. a

2. Eight of these seventeen patients ; (47 pc ^

recovered completely. Four of the nine a ^ ef

to survive died in less than twenty-four hours
admission to the hospital. . , , : rre! ru-

3. Sulfapyridine given by mouth is absorjj ■
larly and only m limited amounts. It is recon ^
that the use of this drug be supplement d J

that the use of this drug be supplement a ^ at
intravenous administration of sodium sunap) ^

was irrational and failed to respond to stimuli. She was
in opisthotonos. There was an internal squint of the left eye.
Foul pus drained from the left ear and there was a watery
nasal discharge. The Kernig and Brudzinski signs were pres-
ent. Lumbar puncture revealed cloudy spinal fluid which

level of from
meters.

4. Certain toxic symptoms caused by su, ^P]”)1o-
rmntpred. These include g .

have been encountered. These , ; n an y

penia and hematuria, neither of which wa
of our cases.

S Owinc to lack of space reports of only case 2 and case 3 are
included in The Journal. Reports of all seventeen cases mil be found
in the authors’ reprints.

Volume 113
Number 18

ANGINA PECTORIS— RANEY

1619

5. Hematuria occurring during treatment with sulfa-
pyridine has been shown to be due to the formation of
small calculi made up chiefly of the acetyl derivative
of sulfapyridine. These calculi apparently produce
hematuria by injury to the pelves, ureters and bladder.

6. It appears that the prognosis in pneumococcic
meningitis may be greatly improved by the use of
sulfapyridine and its sodium salt.

Harford Road at Herring Run.

A HITHERTO UNDESCRIBED SURGICAL
PROCEDURE RELIEVING ATTACKS
OF ANGINA PECTORIS

ANATOMIC AND PHYSIOLOGIC BASIS

RUPERT B. RANEY, M.D.

LOS ANGELES

Despite the various approaches to the problem of
angina pectoris, uniformly complete relief from the
condition by surgery or medicine has not been here-
tofore attained. On the assumption that coronary
spasm occurs during attacks and is responsible for
anginal pain, another operation lias been designed
which, so far as my experience permits of statements,
seems to give uniform relief not by anesthesia but by
prevention of coronary spasm.

It seems to be fairly generally accepted that coronary
spasm occurs during seizures, but the mechanism is a
much disputed question, confusion arising primarily
from the reasonably well established normal behavior
of these vessels. Any discussion on the surgical
treatment is hardly complete without mentioning the
name of Sir James Mackenzie, 1 whose timely criticism
marks the dividing line between faulty speculation and
sound scientific reasoning. 2 He suggested that a rein-
vestigation of the entire subject was necessary before
any conclusions whatever could be drawn.

PHYSIOLOGIC BASIS FOR OPERATION

Following the suggestion of Mackenzie, Anrep and
Segall 3 reported from their results in animal experi-
mentation that sympathetic impulses under normal
physiologic conditions induced coronary dilatation, a
finding which would be expected from the known
emergency function of the sympathetico-adrenal
mechanism. 4 The work of Anrep and Segall was later
verified by Kountz, Pearson and Koenig 5 by experi-
ments conducted on human heart-lung preparations.

' They further observed that when the normal physiologic
conditions in the coronary system were altered, for
example, arteriosclerosis and change in hydrogen ion
concentration of the perfusion fluid, the action was
variable, often reversed.

The reversed action following sympathetic stimulation
with reference to other organs of the body has been

From the Department of Surgery of the University of Southern Cali*
A 0rni ? School of Medicine and the Neurosurgical Service of the Los

Angeles County Hospital.

i f'lachenzie, James: Plea for Clinical Physiology, Brit. M. J. Is
o' 1 !? 5 (Jur ! e 28 > I924 -

*>. Mackenzie, James: Surgical Treatment of Angina Pectoris, Lancet
2S 695-697 (Oct. 4) 1924.

r .^*. Anrep, G. V., and Segall, H. H.: Regulation of the Coronary
wrculatwn, Heart 13: 239-260 (Sepf. 29) 1926.

n, T r 1 f t, ?• J* F. : Physiology of the Nervous System, New "York,
University Press, 1938, chapter 12.

on K £« nt *’ W * G.; Pearson, E. F., and Koenig, K. F.: Observation
of • j CC i Vagus and Sympathetic Stimulation on Coronary Flow
1934 VlVe “ Human Heart, J. Clin. Investigation 13: 1065*1078 (Nov.)

established by Morat, 0 Doyon, 7 Veach, 8 McCrea and
McSwiney 0 and numerous others. Also it is well
known that the action of efferent nerve impulses,
whether sympathetic or otherwise, depends on the
conditions at the myoneural junction rather than on
the character of the impulse. This is best shown by
experiments with crossed nerve sutures, of which the
most pertinent are those of Langley and Anderson, 10
Cannon, Binger and Fitz, 11 Horrax, 12 Ballance 13 and
Duel and Ballance. 14

A survey of the literature forces one to agree with
Wiggers 10 that “the nervous control of the coronary
circulation and its physiological importance have not
been demonstrated as definitely as the uninitiated are
led to believe.” Furthermore, Anrep 10 has attached
considerable significance to pathologic changes in the
coronary arteries with reference to altered function. He
states (p. 94) that:

The experiments made of fresh human material are far too
few to allow us to draw definite conclusions. Still fewer are
the experiments made on human hearts which show some
pathological changes of the coronary system. Anitchkov and
his colleagues have worked on resting human hearts some
hours after death. They report that, in cases of arterioscle-
rosis and diphtheria, adrenalin, even in large doses, ceases to
have any effect on the coronary blood vessels. We have had
no opportunity of verifying this result ; there is no doubt,
however, that in arteriosclerotic conditions the coronary blood
vessels behave quite differently from normal.

Unfortunately the older clinical impression that
sympathetic impulses were coronary constrictor in their
action during an attack of angina pectoris was discarded
and replaced by the more recent concept of the normal
action, the altered or reversed action resulting from
pathologic changes not being taken into consideration.
White 17 expressed this more recent and fairly general
clinical opinion, which is well brought out by the fol-
lowing quotation (p. 235) :

Why resection of the superior cervical ganglion alone, as
recommended by Coffey and Brown, should relieve a certain
number of cases of angina pectoris remains a mystery. No
afferent neurons have been found in the upper portion of
the cervical sympathetic trunk (cf. chapter III). The only
plausible explanation put forward was that a greater portion
of the coronary constrictor fibers run through the superior
cardiac nerve, and that its interruption increases the irriga-
tion of the myocardium. In view of the more recent physio-
logical findings, however, this can no longer be regarded as a
valid explanation.

6. Morat, J. P.: Sur quelques particularity de l'innervation mortice
de Pestomac et de l’intestin, Arch, de physiol, norm, et path. 5: 142-153,
1893.

7. ' Doyon, J. : Recherches experimentales sur l’innervation gastrique
des oiseaux, Arch, de physiol, norm, et path. G: 887-898, 1894.

8. Veach, H. O.: Studies on Innervation of Smooth Muscle;
Splanchnic Effects on Lower End of Esophagus and Stomach of Cat,
J. Physiol. 60: 457-478 (Oct.) 1925.

9. McCrea, E. D., and McSwiney, B. A.: Effect on Stomach of
Stimulation of Peripheral End of Splanchnic Nerve, Quart. J. Exper.
Physiol. 18:301-313 (May) 1928.

10. Langley, J. N-, and Anderson, H. K. : On the Effects of Joining
the Cervical Sympathetic Nerve with the Chorda Tympani, Proc. Roy.
Soc., London, s.B. 73: 99, 1904; On the Union of the Fifth Cervical
Nerve with the Superior Cervical Ganglion, J. Physiol, 30: 439-442,
1903-1904.

11. Cannon, W. B.; Binger, C. A. L., and Fitz, Reginald: Experi-
mental Hyperthyroidism, Am. J. Physiol. 36: 363-364 (March) 1915,

12. Horrax, G., cited by Cushing, Harvey: Studies in Intracranial
Physiology and Surgery, London, Oxford University Press, 1926, footnote
on pages 75-76.

13. Ballance, Charles: Anastomosis of Nerves: Experiments in Which
the Central End of the Divided Cervical Sympathetic Nerve Was Anas-
tomosed to the Peripheral End of the Divided Facial Nerve and to the
Peripheral End of the Divided Hypoglossal Nerve, Arch. Neurol &
Psychiat. 25:1-28 (Jan.) 1931.

14. Dud. A. B., and Ballance, Charles: Note on Result Which Follows
Grafting of Raw Peripheral End of the Divided Cervical Sympathetic

,c' Q A° Another Nerve in the Vicinity, Brain 55:226-231 (June) 1932.
p „ T?' r J 'V Dl5t ? T sc ° f . the Coronary Arteries and Cardiac

Pam, edited by R. L. Levy, New- York, Macmillan Company, 1936, p. 97.

16. Anrep, G. V.: Lane Medical Lectures; Studies in Cardiovascular
R eg ul at ion .Stanford Umv. Publ., Umv Scries, M. Se. 3: 199-312, 1936.

: -E L-: The Autonomic Nervous System: Anatomy. Physi-

ology and Surgical Treatment, New York, Macmillan Company, 1935?

1620

ANGINA PECTORIS— RANEY

Jour. -A. M.A.
Oct. 28, 1933

The afferent mechanism, therefore, became the cen-
ter of surgical attention, and moderation of seizures or
relief from them by operations on the cervical sympa-
thetic trunk was explained on the basis of interruption
of the afferent pathway. The results reported by
Jonnesco 18 from cervical ganglionectomy could be
explained on this basis, but not those reported by Coffey
and Brown. 10 Therefore, modifications of the Jonnesco

peration for more extensively interrupting the afferent
Sechanism were recommended by Penfield,- Reicl and
mdrus. 21 Coleman and Lyerly, 22 Richardson and P. D-
Write, 23 Leriche and Fontaine, 24 J. C. White* and
thers And, although some of the results reported
.ere more encouraging than those reported by Jonnesco,
'ey w ere far from satisfactory. Horner’s syndrome

IS. Jonnesco, T, Operative Care of Angina Pectoris, Bull. Acad, de
icd., Paris 84:93 (Oct. 5) 192U- „ . Surgical Treatment of Angina

Is Relation to Surgical Therapj, nm- J

;bral Alcohol Injection, Am. J. AI- S . 1 ica , Trea tment of Angina
24. Leri Whatit IsandWhat’ if Should Be Am HtartJ-*-
71 Ct °(Ang.) 192S; De l'existence dans^annea^.^ fragment

&&£«*«-

Nov 26) 1928: Un sev ■■ i ■ . m ed.. 89 : 61-65 (Feb. 5)

July 12) 1932.

invariably accompanied the operations and seizures
frequently continued to recur even though pain had
been abolished. •

While the assumption that sympathetic .impulses
cause coronary spasm iir angina pectoris has' no direct
evidence for support, certain other indirect evidence is
available. The prevailing clinical opinion is that 'coro-
nary' spasm occurs in angina pectoris and is responsible
for precordial pain. Leriche, Herrmann and Fontaine ■*
iiave shown that typical seizures characteristic of
angina pectoris can be precipitated in animals by con-
striction of a major coronary artery with ligatures.
Now, during an actual attack of angina pectoris, all
outward signs are those of sympathetic overactivity:
(1) peripheral vasoconstriction, (2) tachycardia, (3)
excessive perspiration, (4) gastric dilatation and the
like. Therefore it seems reasonable to assume that n
coronary spasm occurs during a seizure, as it is observed
to occur in peripheral vessels, the same mechanism is
responsible for the two phenomena.

Moreover, the study of the action of- drugs otters
considerable indirect evidence in support of this view.
The action of epinephrine during a seizure lias
observed to aggravate the seizure, and its ■ const t
action on peripheral vessels is established. .
other hand, nitrites, which relieve an attack presun.

ceniical K

iat. .

spinothamte

of the 5 ^ 1

ig. 2.-— Solid lines show U>e 3 i L“ 1 rv ° r ^stls. ,,tl

ig. 2.— Solid lines show the spmal < ’"“ sse l s . The bl«* 'IfT P tv
etic efferent pathways to the ^ corona y oronar y vessels oi
points of section for denenatilig the
•lionic sympathetic efferent tiers e supply-

relaxing coronary spasm, are action <3 n

.tation on peripheral vessels, w coron ary VC3 ‘
rally be observed. Nous since he co ^
themselves have not -been during

inal seizure in man, the inference^ __

Leriche, R.; Herrmann, Ij-' *n«art. Comfl- 1

arie gauche et fonction card a
de biol. 107:545-546 (June 5) 1931.

Volume 113
Number 18

ANGINA PECTORIS— RANEY

1621

seizure they respond to these drugs in the same fashion
as their observed action on peripheral vessels cannot
be logically disposed of.

Furthermore, the interruption of sympathetic efferent
pathways is' known to have given relief from attacks in
a fair percentage of cases. This was shown by Coffey
and Brown 19 when they reported their results from
resection of the left superior cervical ganglion, and,
since the superior cardiac nerve is now known to be

Fig. 3. — The artist’s conception of the operation after exposure of the
sympathetic chain and rami communicantes.

almost entirely efferent, the contribution accordingly was
of exceptional value, because it shows that attacks were
occasionally prevented by partially checking the inflow
of sympathetic efferent impulses. Certainly the afferent
mechanism was not sufficiently altered by the operation
to explain the results (fig. 1). This evidence likewise
must be taken into account.

Thus, although it appears that the normal and pre-
dominant action of sympathetic impulses in coronary
physiology is to produce dilatation, the contention arises
that under pathologic conditions — for example angina
pectoris — the action is reversed; that is, such impulses
produce coronary constriction. If this contention is
sustained, we then have a single explanation for all
the manifestations of the disease ; an operation designed
to interrupt this discharge of impulses could therefore
be reasonably expected to give relief. However, before
an operation is designed, the reaction of blood vessels
to preganglionic and postganglionic sympathetic dener-
vation must be taken into consideration.

The Meltzers 27 and Elliott 28 showed that, following
postganglionic sympathetic denervation of smooth
muscle, a permanent spastic condition developed from
the direct action of epinephrine, muscle metabolites and
other products normally found in the blood ; they fur-
ther observed that, following preglanglionic denervation,
spasm did not occur. Thirty years later Smithwick,
Freeman and White 29 verified these observations on

smooth muscle of blood vessels. They then applied
preganglionic denervation in the treatment of Raynaud’s
disease with remarkable success.

ANATOMIC CONSIDERATIONS

On the assumption, then, that an abnormal action of
sympathetic impulses resulting from pathologic changes
at the myoneural junction is responsible for an attack
of angina pectoris, an operation was planned to inter-
rupt the pathways conveying, these impulses. Ana-
tomically it is possible to avoid tbe production of a
Horner’s syndrome, and at the same time to remove
completely the sympathetic influence on the cardiac
mechanism (fig. 2). The anatomy is well described
by Ranson, 30 Kuntz, 31 Heinbecker 32 and others. To
remove completely this influence it would be necessary
to operate on both sympathetic trunks; however,' uni-
lateral (left) section so far is all that has been required
for complete relief from attacks.

CHOICE OF ANESTHESIA

The choice of anesthesia is of considerable importance
and should perhaps receive some attention here. All
factors likely to increase emotional stress should be
eliminated for the purpose of preventing the possibility
of a fatal seizure. Leary 33 pointed out that death can
occur from prolonged coronary spasm, even without
thrombus formation. Adequate sedation should there-
fore be employed during the hospital interim prior to
operation. If avertin with amylene hydrate is admin-
istered thirty minutes before the patient is conveyed to
the operating room, it will do away with the emotional
stress usually associated with this unpleasant trip; of
further advantage, its action is vasodilator on the vascu-
lar tree. Finally, infiltration of the operative field with
procaine hydrochloride gives a satisfactory anesthesia.

27. Meltzer, S. J., and Meltzer, Clara: A Study of the Vasomotor
Nerves in the Rabbit’s Ear Contained in the Third Cervical and in the
Cervical Sympathetic Nerves, Am. J. Physiol. 9: 57-68, 1903; The
share of the Central Vasomotor Innervation in the Vasoconstriction
by Intravenous Injection of Suprarenal Extract, ibid. 9J 146-
On the Difference in the Influence upon Inflammation Between
the Section of the Sympathetic Nerve and the Removal of the Sym-
pathetic Ganglion, J. M. Res. 10: 135-141, 1903; On the Effects of
Subcutaneous Injection of the Extract of the Suprarenal Capsule upon
Vessels of the Rabbit’s Ear, Am. J. Physiol. 9 : 252-261,- 1903.
1905 ^ lott * T. R.: The Action of Adrenalin, Brit. M. J. 2: 126-130,

29. Smithwick, R. H.; Freeman. N. E,, and White, J. C. : Effect of
-pinep. brine on Sympathectomized Human Extremity: Additional Causes
•me .J* ure Operations for Raynaud’s Disease, Arch. Surg. 29:

<Nov.) 1934.

TECHNIC OF OPERATION

The operation is done through a paravertebral incision
extending from the lower border of the second rib to
the upper border of the sixth rib; whether on the left

.me fiuaiuniy oi me -uervi
delphia v XV. B. Saunders Company, 1931, p. 351.

„ 31 * Albert: The Autonomic Nervous System, cd. 2, Philadelphia.

Lea & Febiger, 1934, pp. 128-140.

„ Hcinbeckcr, Fcter : Anatomic and Physiologic Criteria for Surgical
Relief of Cardiac Pam, J. Thoracic Surg. 2: 517-526 (June) 1933.

33. Leary, Timothy: Coronary Spasm as a Possible Factor in Pro-
ducing Sudden Death. Am. Heart J. 10: 338-3-M (Feb.) 1935

1622

ANGINA PECTORIS— RANEY

or on the right side, the technic is the same. A short
portion of each of the third, fourth and fifth ribs is
resected ; the intercostal muscles are removed ; thus the
neurovascular bundles are exposed. The sympathetic
chain from the second to the fifth dorsal ganglion and
their corresponding rami communicantes are then
exposed extrapleurally (fig. 3). Lastly, the operation
is completed by section of the rami communicantes from

Fig. 5. — Electrocardiograms taken April 23, before the operation. Note
particularly the abnormal inversion of the T wave in lead 1.

the intercostal nerves and section of the sympathetic
chain between the fifth and sixth dorsal ganglions
(%• 4).

Exceptional care should be exercised in separating
the parietal pleura from the vertebral column, since a
sudden mediastinal shift from a spontaneous pneumo-
thorax might prove disastrous. Furthermore, a blind
approach into the mediastinal structures will almost
certainly lead to uncontrollable technical difficulties.
To the surgeon experienced in this field these remarks
are no doubt unnecessary, but to the novice they should
convey the gravity of the situation at hand.

REPORT OF CASES

Eleven patients have been operated on by the pro-
cedure outlined. There have been no deaths, and all
have obtained complete relief from what had previously
been desperate attacks of angina pectoris. The follow-
ing cases were selected and are presented in detail
because they show the results that can be obtained
even in the face of other major complicating disorders.

Case l . 34 — Daily attacks of angina pectoris for three years
i a middle aged man. Moderate arteriosclerotic hypertensive
cart disease and diabetes mcUitus. Partial relief by nitrites
uring attacks. Electrocardiographic evidence of coronary
iscasc. Complete relief from anginal seizures by preganglionic
action of rami and trunk.

F. S., a man aged 52, had spent the greater part of three
ears preceding the operation in the hospital because of dady
ttacks of angina pectoris. Since the onset he had suffered
rom five to ten attacks daily. They were partially relieved
y nitrites but occasionally morphine was required. The
ttacks were initiated by a feeling of tightness m the throat
nd upper part of the chest that rapidly became painful. There
salivation severe perspiration, oppressive abdominal dis
!• IndT’fear of impending death. The pain then became
gonizing and spread ove r the precordium and down the ulnar

, . in oreliminary report read before the CaJi-

As^U^Pa^a in Mar 1938.

Joe. A. M. A
Oct. 28, 1531

distribution of the left arm. Palpitation, pallor, a rise in blocd
pressure and tachycardia were also observed. The attacks
were precipitated by slight exertion or emotional stress, and
frequently they occurred from the mere anticipation of in
attack. He continually kept nitrite tablets on his person; k
would not even go to the bathroom without them. For tit
last eight or nine years he had been suffering from a mild
form of diabetes mellitus. This was discovered incidentally
to an examination during a siege of pneumonia. Insulin tai
occasionally been employed, although dietary measures have
usually been sufficient.

On examination the blood pressure averaged 150 systolic
and 100 diastolic. The retinal as well as the peripheral ves-
sels showed moderately advanced arteriosclerosis. Repeated
electrocardiographic examinations gave definite evidence of
advanced myocardial damage. On two occasions cardiac
decompensation had occurred. The general examination was
otherwise negative.

Since the history and examinations indicated that consider-
able degenerative changes in the myocardium bad already taken
place, I was somewhat dubious about recommending the opera-
tion. The patient, however, was desperate and even after I
had explained the danger he still had no hesitancy about accept-
ing the chance of relief. The operation was performed the
following day, May 1, 1937. Through a left paravertebral
incision a short section was taken from each of the third,
fourth and fifth ribs. The parietal pleura was separated from
the vertebral column, and the rami communicantes from the
second to the fifth dorsal ganglion inclusively were destrojed
by electrocoagulation. The sympathetic chain was then sec-
tioned between the fifth and sixth dorsal ganglions.

After two weeks the, patient was allowed out of bed but,
because of severe myocardial damage, complicated by diaW ES
mellitus and hypertensive heart disease, was kept in the os
pital an additional four weeks for observation. There »
no return of anginal seizures. At the time of discharge, m
erate exercise was recommended. By the end of four mon
he was walking from 2 to 3 miles a day. He has fait “
returned at monthly intervals for observation, and w b en
seen twenty months after operation there had been no re u
of anginal seizures.

aa). jauic *».»«*** -

compared to the record taken four days betore.

Here was a patient who almost beyond qu oJ ; s

uttering from an advanced degree of coronary 0 f

ind most probably had had one or more
oronary thrombosis but was able to ob ai sona b!e
elief from the nitrites. It therefore seems _ ^eik

o assume that an abnormal action o ) , er ccd
mpulses, on the basis of the pnncip c tlian s imP' !
ction, was responsible for attacks rat

3LV1IE U3
JMSER IS

ANGINA PECTORIS— RANEY

1623

irrowing of the lumen of the vessels from arterio-
lerotic coronary disease presumably present. More-
'er, the assumption that the reversed action of
mpathetic impulses was responsible for the presumed
ironary spasm during attacks seems justified, since the
leration gave complete relief. Furthermore, coexist-
g disease which has been demonstrated in this case
iviously was not a contraindication to the operation.

Case 2.— Frequent attacks of angina pectoris in an elderly
an for fifteen months. Temporary relief during seizures by
e nitrites. General arteriosclerosis , moderate hypertensive
■art disease and at least one major attack of coronary throm-
<sis. Complete relief from seizures by preganglionic section
' rami and trunk.

T. H., a man aged 72, had been suffering for the past
'teen months from attacks of distress in the upper part of
e abdomen; they usually occurred after eating, exercise or
notional stress and left him in a state of exhaustion. In
ebruary 193S, one year after the onset, he suffered a more
vere attack, which came on after a game of golf and an
>ening meal; it started as had the previous ones. The storm
:h "felt stuffed as though it were filled with mud”; about
i hour after the onset pain in the chest developed which
idiated into both arms, more markedly on the left side. A
lysician was summoned and morphine was administered for
:lief. After a few days the patient felt well except for per-
sting minor attacks. For these he took nitrite tablets, which
ave relief. During the succeeding two months he suffered
vo additional severe attacks similar to the first; each time
:lief was obtained by taking nitrite tablets. During the past
:ar the patient had lost 20 pounds (9 Kg.); he starved him-
:lf in attempting to prevent attacks.

The past history was of importance, since he had always
:en nervous and had occasionally suffered from what he
died “nervous indigestion.” As a young man he had suf-
:red from “nervous spasm in the lower part of the rectum.”
‘he attacks had usually occurred while lying down and were
dieted on sitting up. For the past five years he had suffered
'om an anxiety state and episodes of mental depression, during
'hich time he had two “nervous breakdowns.”

On examination April 21, 1938, he was poorly nourished;
e was 6 feet (183 cm.) tall and weighed 128 pounds (58 Kg.),
'he pulse rate was 65 beats a minute, the temperature was
8 F., and the blood pressure was 150 systolic and 110 dias-
dic. There was generalized arteriosclerosis, and electrocar-
iograms repeatedly showed a deep inversion of the T wave
i lead 1. Roentgenograms of the chest and gastrointestinal
■act were negative. The Wassermann reaction of the blood
■■as negative; the blood urea was 16 mg. per hundred cubic
entimeters. Routine examinations of the blood and urine were
ssentially negative. Since medical measures and rest had failed
o control the attacks, operation was recommended.

Two days later the patient was admitted to the Hospital
f the Good Samaritan for observation prior to operation,
fhe following day electrocardiograms showed changes com-
atible with coronary disease (fig. 5). That afternoon the
latient suffered a sudden attack of abdominal distress and dis-
ention; the heart rate became fast and there was a sensation
d tightness and weight in the chest and throat ; pallor and
excessive perspiration on the forehead and upper extremities
rere observed, and nitrite tablets again afforded relief.

The next morning (April 25) a preganglionic ramisection
vas done on the left side; the rami communicantes from the
econd to the fifth dorsal segment of the spinal cord were
lestroyed by electrocoagulation, and then the sympathetic chain
ietween the fifth and sixth dorsal ganglions was sectioned.
Jurmg the operation the patient showed no evidence of car-
hac embarrassment or other ill effects; Horner’s syndrome
■vas not produced.

On the second postoperative day another electrocardiogram
vas taken which showed the T wave in lead 1 to have returned
toward the normal upright position (fig. 6). The patient’s sub-
sequent postoperative course was likewise uneventful. He was
1'smissed from the hospital at the end of four weeks. When

last seen eight months after the operation he had gained 30
pounds (13.6 Kg.), was taking exercise and had remained free
from attacks.

Here again is a patient with angina pectoris and
major complications, viz., coronary thrombosis and
hypertensive heart disease, yet operation was accom-
plished without untoward effects and complete relief
from the attacks was obtained. Of further interest was
the almost immediate change in the electrocardiograms
from a pathologic character one day before operation
toward a normal character the second day after oper-
ation. Although this observation was striking, no
conclusions were drawn because they would necessarily
be speculative. Other patients having had simillar
studies made showed no change whatever in the electro-
cardiograms ; however, complete relief from seizures
was obtained. Finally, the management of this patient’s
psychiatric problem was greatly facilitated, not only
because of relief from pain and anxiety concerning
attacks but also because of improvement in his general
physical condition.

SUMMARY

Eleven patients have been treated by the operation
here described. There have been no deaths, and all
have obtained complete relief from what had previously
been desperate attacks of angina pectoris.

The operation is based on the assumption that in
angina pectoris the sympathetic action on the coronary
vessels is reversed, because of pathologic changes occur-
ing about the myoneural junction; i. e., sympathetic
impulses in such cases produce coronary constriction.

Other operations heretofore recommended in the
surgical treatment of angina pectoris have given relief
at the expense of postganglionic fibers or afferent fibers
or both. Such postganglionic operations are subject to
the same criticisms that have brought about discard of
this type of operation in the surgical treatment of Ray-
naud’s disease. Operations devised to relieve pain
by the interruption of afferent pathways are only palli-
ative measures ; they remove the warning signal of an
impending seizure but do not attack the patient’s real
trouble.

The operation here described is a preganglionic oper-
ation; the major portion of the afferent mechanism is
left intact and thus the warning signal is not removed ;
Horner’s syndrome is not produced, and the efferent
pathways on the operated side are almost entirely inter-
ruped. A complete interruption of the efferent pathways
to the coronary system theoretically would necessarily
involve a bilateral operation; however, operation only
on the left side is all that has been required to give
complete relief from attacks.

727 West Seventh Street.

A Truly Black-Skinned Child. — How this sorting out and
recombination of the genes takes place is shown in our accom-
panying color-plate. We can see by this why a truly black-
skinned child can be produced only if both parents carry some
Negro-skin-color genes. This should dispose of the old super-
stition, common in yesterday’s fiction, of how a woman with
some hidden Negro blood, “passing” as white and married to
a White, might give birth to a coal-black baby. Where a
black baby does unexpectedly turn up, it can be taken for granted
that (a) both parents have Negro ancestry or (6) that the
parentage is doubtful. In reverse, it would be equally impos-
sible for a Negress with hidden white blood to be mated with
a full-blooded Negro and give birth to a white child. — Scheinfeld,
Amram: You and Heredity, New York, Frederick A. Stokes
Company, 1939.

.VCOL OF NU^SIHG

RG624V1EW b\\i>^iJ9lAGNOSIS OF SYPHILIS— KLAUDER AND COWAN

CORNEAL EXAMINATION AND SLIT
LAMP MICROSCOPY

IN DIAGNOSIS OF LATE CONGENITAL SYPHILIS,
ESPECIALLY IN ADULTS

JOSEPH V. KLAUDER, M.D.

ALFRED COWAN, M.D.

PHILADELPHIA

A cornea once involved with interstitial keratitis
caused by congenital syphilis presents, almost without
exception, certain sequelae which persist for the rest of
the patient’s life. Although the characteristic signs
of an old interstitial keratitis can often he detected by
oblique illumination and ophthalmoscopic examination,
a proper study should and often can he performed only
by biomicroscopy. With the corneal microscope and
slit lamp a diagnosis of old interstitial keratitis can
invariably be made, regardless of the age of the patient.
We believe that the importance of slit lamp exami-
nation in clinical syphilology has not been sufficiently
emphasized. The changes observed may be the only
evidence of congenital syphilis. Their presence in adults
and old patients may explain the absence of the history
of infection, and they may serve as a means of inter-
preting positive or weakly positive results of Wasser-
mann or precipitation tests. In the presence of other
signs of. syphilis a diagnosis of old interstitial keratitis
determines the status of infection — congenital syphilis
— and therefore has an important hearing on treatment
and prognosis.

Briefly, it may be stated that interstitial keratitis is
characterized by an infiltration throughout the entire
thickness of the cornea, particularly the middle and
deep layers, by the formation of blood vessels in the
superficial, middle and deep layers (fig. 1) and by
the association with uveitis. When caused by congenital
syphilis it is always bilateral. As a consequence both
corneas remain more or less permanently scarred and
vascularized.

It should he emphasized that in many cases of inter-
stitial keratitis the cornea recovers to such an extent
that the scarring may be so faint and the remaining
blood vessels so few and small that they can be detected
only by means of slit lamp microscopy. Furthermore,
the location, character and extent of the corneal haze
and of the vessels, which are often impossible to deter-
mine by the ordinary methods of examination, are
extremely important in diagnosis of old interstitial
keratitis. The remains of a previous uveitis may be
and often are detected only by slit lamp microscopy.

Regardless of the extent of involvement of the cornea,
it is possible to make an almost certain diagnosis of a
previous interstitial keratitis in nearly every case and
after any length of time. One experienced m slit lamp
microscopy can generally differentiate other forms of
interstitial keratitis from the syphilitic type. When
caused by syphilis the cornea presents a classic slit
lamp picture.

EXAMINATION OF THE CORNEAS OF PATIENTS
WITH OLD INTERSTITIAL KERATITIS

The corneas of 100 patients who had interstitial
keratitis were inspected grossly, by oblique illumina-
tion. and were ex amined with the ophthalmoscope and

■ From the Wills Hospital. , , an d Syphilology at the Nine-

tie,f Annu1r e sSo S „ e of°th 0 e n A D meri?an fledica! Association. St. Louis.
May IS, 1939.

Jon. A. M
0a 23, lit

by slit lamp microscopy to demonstrate evidence of c!J
interstitial keratitis. The patients were both cliildic
and adults. The age range was from 6 to 65 year*.
The majority were under 30. Ninety-three o’i ft;
patients had been patients in Wills Hospital at the tfct
their interstitial keratitis was active. Corneal exami-
nation for old evidence of interstitial keratitis ms
made on these former patients from one to twenty
years after the onset of interstitial keratitis. For sera
patients the interval was still longer, in some cast-
as long as fifty years. Some of these patients had ra
. knowledge of ever having interstitial keratitis, but they
were included in the series since they showed by
lamp microscopy the classic picture of old interstitial
keratitis.

The corneas were inspected grossly to determine
the presence of opacities. Inspection by oblique illumi-
nation facilitated

seeing corneal opac-
ities. Ophthalmo-
scopic examination
was performed with
the plus 20 lens in
order to see old
blood vessels and
corneal opacities,
which are sequelae
of interstitial kera-
titis. If blood ves-
sels were not seen
with the pupil undi-
lated, examination
was repeated after
dilating the pupil.

Dilation may be
necessary in order
to see vessels pres-
ent only toward
the periphery 7 of the
cornea. In some
cases corneal opaci-
ties not seen on
gross inspection or
by oblique illumina-
tion were visible
only 7 after the pupil
had been dilated
and examined with
the ophthalmoscope

Fig, 1. — Section through ' f ,b Jj
seen with a narrow slit of he ti ,,
microscopy. The direc l 1 .“ 1 ] 0 not BorirccD
actually seen is perpendicular, aoi
as is indicated in the UttlW'nB. -- n f rc e*.
of the vessel that seems to term.M ^
indicates the depth, or the j> j inter
cornea in which ‘AL v dee" r'*--

stitia! keratitis vessels lie in any '

Old

when the eye was turned in different direc 1 ' ^
blood vessels as seen through the oph ia - ^
appear as black threads against the red tun j sc c
(fig. 2). They 7 resemble scratches on a g a dually
and are commonly referred to as brusmi r e. - ^
they are numerous and ate scattered throt & ^pit-
cornea; at times they number only 7 a few an Ac c0 u rk
mentioned, are confined to the periphery. i. er atiti=
other pathologic processes , notably inters i ' • | cnCC d

of other than syphilitic origin, that are la e
by opacities and old blood vessels should ^ ^ p-jr-

be

brief'. 1 '

acitf

in differential diagnosis. Although it is
pose to discuss differential diagnosis, it rlia }
stated that the history, the location o Jfctir.:
and the arrangement of the vessels are p . for

features. Slit lamp microscopy may he
differential diagnosis. « c cei# 1 '

In the cases studied, the ordinary rue m pro-

and old J

Udliuil, txs L * 1 '-J , * . ’

vessels, did not always confirm the micro.cop

nation, as far as they concerned opacities v j esv - ir.

Volume 133
Number 18

DIAGNOSIS OF SYPHILIS — KLAUDER AND COWAN

.1625

the slit lamp examination. In this examination opacities
were present that were not apparent on gross inspec-
tion and old blood vessels were seen that could not be
seen with the ophthalmoscope.

With the plus 20 lens of the ophthalmoscope, old
blood vessels could be seen in corneas that had or had
not gross opacities. Ophthalmoscopic examination is
therefore more reliable than is gross inspection in diag-
nosis of old interstitial keratitis. On the other hand,
corneas that were grossly clear, and in which blood
vessels or other faint sequelae of interstitial keratitis
were missed when examined by the ophthalmoscope
and by oblique illumination, presented by slit lamp
microscopy aforementioned changes that justified a diag-
nosis of old interstitial keratitis. Slit lamp microscopy
is therefore more reliable in diagnosis of old interstitial
keratitis than is study by oblique illumination and the
ophthalmoscope. We are unacquainted with reports of
studies of slit lamp microscopy in patients with old
interstitial keratitis as an aid in diagnosing congenital
•syphilis. ' It is .well known that opacities resulting from
interstitial keratitis may persist indefinitely, and oph-
thalmologists are cognizant of the fact that residual
blood vessels usually remain permanently. Igersheimer 1
■recorded the ' statement that folds in Descemet’s mem-
brane ' arising from descemetitis accompanying inter-
stitial keratitis may remain for the rest of the patient’s
life, and Ronne,- in referring to corneal opacities,
referred to “not a few cases where at a later stage, by
the help of the residual maculae cornea, I have diag-
nosed congenital syphilis.”

Case 1 concerns a 49 year old woman who presented
the type of folds in Descemet’s membrane to which
Igersheirrier referred. Other changes seen by slit lamp
■microscopy were regarded as diagnostic of interstitial
keratitis.

Case 1. — A Negro woman aged 49 came to the eye clinic
.on account of poor vision. She was married and had had
.one miscarriage; there were no living children. She was the
third born of a family of four. Both eyes were “sore” at about
the age of 7 and remained inflamed for about three months.
She received only local treatment to the eyes. She had no
knowledge of ever receiving antisyphilitic treatment.

She had no stigmas of congenital syphilis. On gross inspec-
tion both corneas showed scattered fine opacities and old blood
vessels by ophthalmoscopic examination. The vision of the
right eye with correction was 6/60 and of the left eye with
correction was 1/60. The Wassermann reaction was 44 — ;
the Meinicke reaction was 4 plus.

The diagnosis of old interstitial keratitis with uveitis was
made by slit lamp examination. The corneas were thinned,
irregular and hazed throughout with considerable increase in
relucency in the posterior portions. There were numerous folds,
wrinkles and ruptures in Descemet’s membrane. There were
numerous blood vessels in the cornea and precipitates on the
posterior surface of the cornea. The iris was atrophied and
showed a few small synechiae.

clinical application of slit lamp microscopy
in diagnosis of congenital syphilis

Slit lamp examination in diagnosis of old interstitial
keratitis as evidence of congenital syphilis is of most
value in the clinical examination of adults whose
Wassermann or precipitation reactions are in some
degree positive, without history of infection and with-

t. IsershUmer, Josef: Syphilis und Auge, in Jadassohn, Josef: Hand-
, " der Haut- und Geschlechtskrankheiten, Berlin, Julius Springer, 1928,
vol. 12 .

2, Ronne, Henning: Treatment of Tardive Congenital Syphilis Seen
’ boclaI Light, Acta Ophth. 13: 213-219, 1934.

out other evidence of congenital syphilis. Such exami-
nation of children with stigmas of congenital syphilis
and positive Wassermann reactions is of course not
necessary. However, in such patients, in the absence
of corneal opacity and of history of “sore ej'es,” slit
lamp examination definitely determines whether the
cornea lias or has not been involved with interstitial
keratitis.

The diagnosis of old interstitial keratitis by slit lamp
microscopy is valid evidence of congenital syphilis. 3
Of course a diagnosis of congenital syphilis in an adult
interprets the positive Wassermann reaction and defines
the status of infection, which is necessary for proper
treatment of syphilis. This is illustrated in case 2,
which concerns a 5S year old patient who had objec-
tive signs of tabes and a 4 plus Wassermann reaction.
Slit lamp microscopy established the diagnosis of old
interstitial keratitis. The administration of antisyphi-
litic treatment to this patient would be of questionable
value. 4

Fig, 2. — Blood vessels in the cornea after interstitial keratitis as they
appear with the ophthalmoscope against the reflex light front the retina.

Case 2. — A man aged SS came to the clinic because of poor
vision. He had always had poor eyesight and had worn glasses
for many years. He was an only child. He remembered
having sore eyes when a child but could not recall any details.
He stated that he had never had a genital lesion. After a
“blood” test ten years before he received injections in the arm
at intervals for three months.

The pupils were unequal and irregular in outline. The right
pupil was fixed to light. The left reacted slightly to light.

3. Interstitial keratitis occurring in acquired syphilis is extremely rare.
Although it has been reported, we have never observed a case. Such of
the reported cases as we reviewed we did not regard as valid since slit
lamp examination was apparently not performed. Other conditions that
resemble interstitial keratitis were therefore not definitely excluded.
Igersheimer stated that when syphilis is acquired in early childhood symp-
toms characteristic of congenital syphilis may later appear. He held that
in such patients interstitial keratitis first appears in adult or late adult
life. Such occurrence is apparently included in the following statistics as
to the ratio of interstitial keratitis in acquired and in congenital syphilis.
Grounew stated that the ratio is 1: 133; Igersheimer gave 1:247; and in
Adamantiadis’ .series it was 3: 1,000 (for further discussion see Igers-
heimer. 1 Granstrom, K. O.: Die Keratitis Parenchymatosa in spaterem
Alter, Acta Ophth. 12: 122, 1934. Adamantiadis, B.: Kcratite pustuli-
forme profonde et les diverses formes de la keratite parenchymateuse
syphilitique acquise, Ann. d’ocul. 172: 304 [April] 1935).

4. As a principle of treatment in patients with late congenital syphilis,
it may be stated that the higher the age when the disease is first dis-
covered, the less the indication for the administration of syphilitic therapy.
The chief hazard of congenital syphilis is interstitial keratitis. After the
age of 20 its incidence greatly decreases. The transmission of the infec-
tion from persons with congenital syphilis to their progeny— third genera-
tion syphilis-— is rare. The prognosis of congenital syphilis in adults in
relation to the occurrence of cardiovascular involvement and ncurosyphvlis
is not pertinent, as it is for patients of the same age with acquired syphilis.

1626

diagnosis OF SYPHILIS—KLAUDER

Gross inspection of the corneas showed faint opacities. The
vision with correction was right eye 6/15, left eye 6/30 On
sht lamp examination of the right eye the central portion of the
cornea was gray with a moderate loss of smoothness The pos-

nu r Xr U of a ol/M a f fair!y 0paque and “Gained a

dw l7fi f bIo ? d vesse[s d «P?y situated. Examination of
the left eye showed essentially the same features.

The patellar reflexes were absent and the Romberg sign was

and had ThC f t,ent presented no stl 'enias of congenital syphilis
iSoTthS / symptoms of tabes. The Wassermann
2 tdus tL H c i°„ -!, aS 4 pIus and the Meinicke reaction
in al” phaIJs P1 " a ^ exam,nation ^dccl negative results

With regard to the value of slit lamp examination

oertin f U< T! of . adults ’ t!ie following comments are
pertinent. The incidence of congenital syphilis in the
general population, as given by different writers, ranges
from 0.5 to 3 per cent and the incidence of interstitial
keratitis among patients with congenital syphilis ranges
from 25 to 50 per cent. b

It is a remarkable fact that many patients who have
had interstitial keratitis cannot in later life remember
ever having had ;‘sore eyes.” It is to be recalled that
interstitial keratitis may occur as early as the age of 1
year and that it may pursue, even in the absence of
treatment, a mild course, retrogressing without the
occurrence of corneal opacities and without much
impairment of vision.

Patient 3 had no knowledge of having had interstitial
keratitis. There were no stigmas of congenital syphilis.
Ihe presence of corneal opacity suggested old inter-
stitial keratitis. Slit lamp microscopy confirmed the
diagnosis.

Case 3.-— A man aged 32 was seen by one of us (J. V. K.)
in the surgical ward of a hospital. He had a fractured femur.
The Wassermann test routinely conducted showed a 2 plus
reaction. He denied ever having a genital lesion; lie had no
knowledge of ever having “sore eyes" or receiving antisyphilitic
treatment or a previous blood test. He had no stigmas of con-
genital syphilis. On examination for evidence of syphilis a faint
opacity of the cornea was noted. The diagnosis of old inter-
stitial keratitis was made by slit lamp examination.

A considerable percentage of patients with congenital
syphilis do not have any of the well known stigmas
of their disease. In studies 5 of such stigmas among
patients with interstitial keratitis it was observed that
17.5 per cent had hutchinsonian teeth, 29 per cent had
chronic periostitis of the tibia (saber-shaped, or Four-
nier’s, tibia), 45.5 per cent had the physiognomy of
congenital syphilis and 18 per cent had symmetrical
serous synovitis (Clutton’s joints). It is 'to be recalled
that these stigmas are less likely to be recognized or
are absent in adults. Clutton’s joints are seen only in
children. Hutchinsonian teeth may have been extracted,
or their notched surfaces, through use, are less apparent.

The physiognomy of congenital syphilis is less typical
in adults, especially after middle age.

A number of patients with congenita! syphilis attain
adult life without evidence of their infection except a
positive Wassermann reaction. Such patients deny all
knowledge of infection. It is well known that patients
with acquired syphilis may give no history of infection.

A certain percentage, therefore, of adult patients whose
Wassermann reactions are positive and who are with-
out history of -infection are congenitally syphilitic. In a
certain percentage of this group corneal examination in

5. Klauder, J. V., and Robertson, H. K: Symmetrical Serous Syno-
vitis {Clutton’s Joints), Congenital Syphilis and Interstitial Keratitis,

J. A. M. A. 103: 236-240 (July 28 ) 1934.

and cowan

Jobs- A. M. A.
Oct. 28, 1935

the manner herein discussed may be the means of fo-
osing or confirming a diagnosis of congenita! syphilis.

■ P^ t . 4 :~ A gi . rl . aged 10 was first seen in April 1917, with

course ThS ratlt ‘ S ° f ^ " Sht eye wh!ch ? wsud a ««
ourse. There were no stigmas of congenital svphiiis The

admfnls” react, °n was 5 plus. Antisyphilitic treatment ms
administered. Interstitial keratitis which subsequently appeared
in the left eye was mild and of short duration
Twenty-two months after the patient was first seen the
corneas were grossly clear. A former opacity of the right
ornea had disappeared. Small opacities confined to the upper
portion of both corneas were visible only with the ophthalmo-
scope^ and with the pupil dilated. A few blood vessels were
seen m the left eye. The vision in both eyes was 6/9 and the
Wassermann reaction was still 4 plus.

. sht lamp examination of the right eye the posterior por-
tion of the cornea, particularly in the center, was increased in
relucency. Also in the posterior portion of the stroma there
was an irregular area of thin opacities. There were some deep
vessels above. The anterior chamber was clear. The iris was
intact. Examination of the left eye showed essentially the same
changes.

There are few reported studies showing how long
the Wassermann reaction of patients with congenital
syphilis remains positive. In Saul’s 6 series of eiglity-
one patients with old interstitial keratitis reexamined
from thirteen to twenty-eight years later the Wasser-
mann reaction of sixty-five was positive and of the rest
negative.

In our observation of patients in late adult life with
congenital syphilis for whom the diagnosis of old inter-
stitial keratitis was made, the Wassermann reaction
was variable. It ranged from negative to strongly
positive. Apparently, therefore, the positive Wasser-
mann reaction of congenital syphilis may remain posi-
tive throughout the patient’s life in treated as well as
untreated patients (cases 1, 2, 3, 6). On the oilier
hand it may become negative even in the absence of
treatment. The following record of a case serves as
an illustration :

Case 5. — E. W., a white woman aged 27, unmarried, was the
third child of a woman receiving antisyphilitic treatment >*
the clinic. The mother had had no miscarriages or stiHM )
She had three sons and a daughter (E. W.) who had sm
eyes” when a child. Both the daughter’s eyes were inron
for about a year and apparently only local treatment vas

diA/ui it year aiiu apparently umy —

administered. The patient was frail and underweight-
had no subjective complaint and had no knowledge of e ' e (
having received antisyphilitic treatment. There were no stigmas
of congenita! syphilis. The Wassermann and Mcinicfce rca
tions of her blood were negative. Diagnosis of old infersti '
keratitis was made by slit lamp examination. This examina io
showed old blood vessels running from the limbus towan
center of the cornea, through which blood was cirra a
There were numerous scattered punctate deposits in the
layers of the cornea and a general haziness throughout- ^

One older and one younger brother showed no. evidence
congenital syphilis on clinical and serologic examination.

The patient showed how benign a course congenital sjp ^
can pursue. Slit lamp microscopy definitely established
interstitial keratitis, which diagnosis was suggested by t e
tory of “sore eyes” and the fact that her mother was sjp"

We believe that every patient who has * iad
stifial keratitis will subsequently present, probably P
manently, a diagnostic picture of old interstitial kcra ^
by slit lamp examination. This picture constitu Cl-
one sense a stigma of congenital syph ilis.' -

6. Saul, Hugo: Uebcr das Schtck&al der fa lenten inti Keralilh r
cbymatosa, Ztschr. f. ^Augenh.^ 86:^199^ syV^‘ if T f>

_ atosa, /.tsenr. t. Augenn. at,: w . .

7. What arc popularly called the stigmas of ccngenw ,
fundamentally to structural changes of a permanent io t- 1

sonian teeth and saber-shaped, or Fournier's, tibia.
concept Clutton's joints and ocular changes caused by inters*
would not be included.

Volume 113
Dumber 18

DIAGNOSIS OF SYPHILIS— ICLAUDER AND COWAN

1627

, Patient 6 presented on gross and ophthalmoscopic
■ examination evidence of old interstitial keratitis, more
■ -definitely revealed, however, by slit lamp microscopy.

■■ Case 6. — A man aged 65 complained only of poor vision, for
; w hich lie came to the clinic for refraction. He was the oldest
of a family of seven, of whom six were living. His wife had
; had many miscarriages but only one child, who died at the age
' of 3. He stated that he had never had a genital lesion. He
"'.had no knowledge of having “sore eyes” when a child or of
' ever having received antisyphilitic treatment.
r ; Results of the general physical examination were essentially
: - negative. The teeth were absent. There were no stigmas of
' • congenital syphilis. Both corneas on gross inspection showed
faint opacities and old blood vessels by ophthalmoscopic exami-
* : « nation. The vision of the right eye was 6/30, with correction
•■■t 6/21, and of the left eye 6/60, with correction 6/30. Positive
diagnosis of old interstitial keratitis was made by slit lamp
examination. Throughout the entire corneas of both eyes there
: were opacities of varying densities, particularly in the upper
.- portions. There were some deep blood vessels. The aqueous
was clear and the iris was intact.

Repeated examination of the blood showed a 1 plus and a

- ~ 2 plus Wassermann reaction and a 2 plus Meinicke reaction,
r

v' The clinician and the syphilologist should be con-
scious of the cornea and the sequelae of interstitial
... keratitis as herein discussed when examining children
.' . and adults suspected of having or known to have syphi-
lis. Inspection of the cornea for opacity, even though
... faint, of which the patient may not be cognizant, and
. examination by oblique illumination and also with the

- plus 20 lens of the ophthalmoscope are clinical pro-
cedures easily conducted. These examinations may

/. suggest the more valid means of diagnosing old inter-
im stitial keratitis — slit lamp microscopy. In the exclu-
sion of congenital syphilis in a patient of any age,
'.. examination is not complete unless slit lamp microscopy
. , has been performed. A negative outcome of this exami-
nation is evidence that the patient has not had inter-
stitial keratitis, though of course it does not prove the
absence of congenital syphilis.

T 1934 Spruce Street — 1930 Chestnut Street.

ABSTRACT OF DISCUSSION
Dr. James R. Driver, Cleveland: The paper of Drs. Klauder
.... and Cowan brings to our attention an important diagnostic
- method for the recognition of certain eye symptoms in late
congenital syphilis. The use of the slit lamp in the examination
of the cornea in syphilitic patients is of course not new. How-
; ever > I agree with the authors that in the past this procedure
^ has been neglected by syphilologists. I know of no textbook on
syphilis that mentions or recommends its use. We as syphilolo-
U 6' s ts must depend on the ophthalmologists for the examination
and largely the interpretation of these observations. We have
* ,ere an example of the importance of the close cooperation
which the syphilologist must have with all other branches of
'y medicine if the best in diagnosis and treatment of syphilitic
/ - Patients is to be achieved. For two years at the University
Hospital in Cleveland we have been using slit lamp microscopy
as a routine procedure in the examination of all cases of con-
/ Genital syphilis and in suggestive cases. More than sixty cases
con S e nital syphilis have been examined so far. In discussing
the work with Dr. L. V. Johnston, who has made all of the
examinations, I find that he agrees with the authors that (1)
'S are ‘’Stances in which it was possible to make a diagnosis

01 old healed interstitial keratitis when oblique illumination and
>' ophthalmoscopic examination failed to reveal its presence and
j . the picture of old interstitial keratitis as seen by the slit
, an, P is almost pathognomonic of the disease. The authors
,, ofonght out, and I agree, that all patients with unexplained

{,< p . osltI '' e serologic tests either of the blood or of the spinal fluid
h.' s '°uld have their corneas examined by the slit lamp. In this
' ^ a '' congenital syphilis may be diagnosed in patients show-

ing perhaps no other stigmas of the disease. Of course, it is
taken for granted that slit lamp examination simply supplements
complete ophthalmoscopic study for other evidences of the dis-
ease in the eye. The paper deals only with the subject of late
changes due to interstitial keratitis. I should like to mention
that in our work with the slit lamp we have found its use
valuable in giving a prognosis for patients showing active inter-
stitial keratitis. Parents, guardians or social agencies want to
know whether the individual so affected will be able to see.
Plans for the future must often be made in advance. Now,
since the character and severity of the disease can best be
determined by slit lamp examination, this becomes easier. We
have found that in several cases in which the cornea is thickened,
owing chiefly to edema, even in the presence of much exudate
the prognosis is good provided there is not extensive vasculariza-
tion of the cornea.

Dr. John McLeod, Kansas City, Mo. : At the clinic for
congenital syphilis in the Children’s Mercy Hospital in Kansas
City we have used the slit lamp in a large number of cases as
an aid in the diagnosis and prognosis of congenital syphilis.
We have found that slightly vascularized opacities offer much
better prognosis than those more heavily vascularized. It must
be remembered that treatment of interstitial keratitis by hyper-
pyrexia may produce complete clearing of the cornea in occa-
sional cases, so that even in a relatively short time thereafter
no traces are evident. Rigorous slit lamp examination of the
cornea six months after the subsidence of the disease may show
absolutely nothing. In most cases there are associated with the
keratitis certain other ocular stigmas, of some of which a directly
syphilitic origin is uncertain. Among these may be mentioned
the filming or veiling of the iris, described by Lemoine in 1934,
consisting of a very fine veil, probably of connective tissue, over
the entire iris and filling up the crypts. This is common in
interstitial keratitis and in juvenile tabetic dementia paralytica,
the type of patient in which one sees an enlarged vertically oval
pupil fixed to light and accommodation but reacting to drugs.
Our records, dating back to about 1916, show an incidence of
interstitial keratitis of something over 5 per cent. In 24 per
cent of these, I think, the spinal fluids have been positive. In
practically all there has been some other ocular stigma of
syphilis : typical syphilitic chorioretinitis, veiling of the iris,
adhesions between the iris and lens or some of the minor fundus
changes. These minor fundus changes vary from the so-called
salt and pepper fundus on up through the peripheral chorio-
retinitis which is frequently associated with interstitial keratitis
and, on the other hand, downward to almost complete normality,
with a little more than normal pigmentation around the periphery
of the retina. In using the slit lamp for the diagnosis of syphilis,
one must bear in mind that tuberculosis produces a keratitis
which may in its late stages resemble closely syphilitic interstitial
keratitis. The recommendation for the use of the slit lamp as
an aid in diagnosis of old congenital syphilis is excellent, but its
use should be combined with a complete ophthalmoscopic and
perhaps perimetric examination of the eye as well.

Dr. Joseph V. Klauder, Philadelphia : The slit lamp should
be used in study of all cases of interstitial keratitis. In fact, I
think it is the court of final appeal in the diagnosis of the dis-
ease. I do not believe that the diagnosis of interstitial keratitis
can be made in 100 per cent of cases by other methods. That
has been apparent in the number of cases we see at the Wills
Hospital in Philadelphia. I do not believe that slit lamp micros-
copy in the acute stage of interstitial keratitis is always helpful
in making a prognosis. It is well known that opacities in the
acute stage disappear to a variable degree, at times to a con-
siderable degree, so that the end result is unexpectedly good.
Poor vision after interstitial keratitis does not alone concern
residual blood vessels or opacities, of course excepting leukoma.
An important factor is the disturbance of the normal contour of
the anterior and posterior surfaces of the cornea. Patients in
adult life frequently do not recall their interstitial keratitis of
childhood. The absence of history of “sore eyes” may not have
any significance. Moreover, it is thought by some that inter-
stitial keratitis may occur in intra-uterine life. It would be
interesting to examine by slit lamp microscopy the oldest child
of parents with syphilis. I say the oldest child, since interstitial
keratitis is more likely- to appear in the first born.

1628

TOXEMIAS OF PREGNA NCY — REID AND TEEL

CARDIAC ASTHMA AND ACUTE PUL-
MONARY EDEMA COMPLICATING
TOXEMIAS OF PREGNANCY

FURTHER OBSERVATIONS

DUNCAN

HAROLD

E. REID,

AND

M. TEEL,

BOSTON

M.D.

M.D.

Recently we called attention to an interesting and
dramatic symptom complex which occasionally com-
plicates the severe nonconvulsive toxemias of preg-
nancy. 1 It is characterized by the sudden appearance
in a previously comfortable patient of extreme
orthopnea, dyspnea, cyanosis and cough productive of
frothy and often pinkish sputum. Numerous crepitant
rales appear with the onset of the attack, and they per-
sist, at least in the lung bases, for a variable period
thereafter.

Attacks have usually occurred in patients while at
rest in bed. They close!}' resemble severe attacks of
cardiac asthma such as occur characteristically in non-
pregnant persons with conditions that impose a burden
on the left venticle, notably severe hypertensive dis-
ease, aortic insufficiency and nephritis with hyperten-
sion.

We referred to this complication of nonconvulsive
toxemias of pregnancy as “cardiac asthma and acute
pulmonary edema.” It has been encountered only in
patients with severe toxemia. Hypertension, albumi-
nuria and edema, all of marked degree, were present
in all cases for two or more weeks preceding the first
seizure.

In our original report, the suggestion was made that
the mechanisms of origin of the pulmonary edema in
these cases and in eclampsia were similar or identical
and that this mechanism is essentially left ventricular
heart failure. It was also pointed out that a background
of vascular hypertension is often found in toxemic
patients who develop this symptom complex. However,
six cases were reported in which cardiac asthma and
acute pulmonary edema complicated simple acute pre-
eclampsia without a background of cardiovascular or
renal disease.

During the past two years we have had subsequent
opportunity to observe a number of toxemic patients
in whom this complication has developed. In this com-
munication we present certain observations on the
clinical nature and pathologic physiology of such
attacks, as illustrated by several case histories. In
contrast to the cases previously reported, these patients
had backgrounds of some degree of hypertensive dis-
ease, although none have had attacks resembling
paroxysmal dyspnea or cardiac asthma except during
the latter half of pregnancy, when the superimposition
of toxemia of pregnancy resulted in exaggeration of the
hypertension with the appearance of generalized edema.

That the increase in hypertension accompanied by
the appearance of marked albuminuria and edema in
these patients indicated the superimposition of pre-
eclampsia on hypertension, rather than renal insuffi-
ciency or progression of their vascular disease,
indicated by the observation that none of them

Jour. A. !I.

. 0 a. 2!, ij;j

significant azotemia and all were able to concenirsk
urine normally. That we are justified in terming th
condition preeclampsia is also indicated by the fas
that, coincident with the attacks, these patients showed
the marked sudden changes of hemoconcentration and
other conditions found on laboratory examination which
are characteristic of this disease. In one of these cases,
after repeated severe attacks of cardiac asthma with
acute pulmonary edema there developed severe head-
ache, temporary amblyopia, torpor and marked rapid
hemoconcentration following a typical eclamptic con-
vulsion. We present this patient’s history in some
detail :

Case L — K. C., aged 39, was admitted to the Boston Lying-in
Hospital Nov. 3, 1937, in the twenty-ninth week of her eleventh
pregnancy with the history of three severe attacks of paroxysms!
dyspnea and manifestations of marked hypertension, alburoiniiA
and edema.

The family history revealed that her mother and one sister
had hypertension.

There was nothing in the past history to suggest glomerulo-
nephritis or pyelonephritis. There had been ten previous preg-
nancies, of which the first four were entirely normal. The last
six pregnancies had been complicated by mild asymptomato
hypertension without significant albuminuria or edema. Tre
maximum blood pressure recorded was in the fifth pregnane;,
when it was once found to be 160 systolic and 110 diastd.c
The sixth pregnancy ended in spontaneous abortion, hut a.
others ended in term deliveries of large live babies.

The patient has been examined between pregnancies
times in this clinic during the last seven years. At t*
examinations the blood pressure was found to be from
150 systolic and 100 diastolic. Except for slight obesity,
were no other abnormalities. At each examination tic um
contained no albumin. Her subjective health had been exce ^
with no cardiovascular or renal symptoms, in spite of t c
that she did all the housework for a family of nine.

The last menstrual period began April 15, 1937. Excep
little more than usual nausea and vomiting during t ie ^
month, this pregnancy progressed asymptomatically up , .

twenty-fourth week, when the patient first noticed edema n
mg the face, hands and feet. When the edema had Pf •
for about two weeks, she began to drink large amounts o
up to twelve or more glasses a day, on the advice o a
who was a nurse. Several days after the adoption ot 1 f "
she was awakened at 4 o’clock in the morning wi 3 f
and frightening choking sensation. The attack "JIT w ’tt
ized by extreme orthopnea and dyspnea, cough and ui i
expiration. "I had to sit up to get my breath. A ' va ' [

to come right up over my chest and I couldn t re
seemed as if each breath would be my last.’ The acu £ al71 3 ,
lasted some two hours, during which time members o cv,
tried to persuade her to lie down, but she had to sl

remained in bed for twenty-four hours, _ after wluci s

her duties about the house. The forcing of nui s v ^
tinued for about a week, because the patient 113 3S( ^n 3

resume it, having associated it with her attack of car ^ tl.<
However, at the insistence of her family and c ^ ■<
forcing of fluids was resumed. After several days cr ..

second attack, which came on while she was. res ing^ ^ gr;

hour after dinner. This episode was essentially jr.-

one, but it was some five hours until the extreme ji>:

orthopnea were gone. The next day the patien^ ^ ^ c0

afraid to

bed or lie down. Five days later there was ® - ty

about again. Indeed, she stated that, she was ---

This time she sat in a chair with her head res .MS (0S

for the first hour. She iound this position decid J fat

fortable. Next day she reported to the clinic tor .

IS

had

From the Department of Obstetrics of Harvard Medical School and
~ . - r : - Hospital and the Department of Child Hygiene of

the Boston Lying-in .....
the Harvard School of Public Health.

1 Teel H. M-; Reid. D. E.. and Hertig, A. T.:
and Acute’ Fulmonarv Edema. Compilations of Nonce
of Pregnancy, Surg., Gvntc. & Oust. 64. 39 U^n.)

Cardiac Asthma
of Nonconvulsive Toxemia

mjc icjjuiiv-u «•***' tvcnneiCf

The patient was large, well developed and (i).p ^ (N
moderate generalized edema.. There was no cya '^5 It' 1
veins of the neck were not distended. The pu 5 «

the heart moderately enlarged and the rhythm no p rc :r- r !
was a systolic murmur over the precordium. > e x( scN
was 230 systolic, 160 diastolic. Auscultation ollhc . h aij0Y c r‘
numerous crepitant rales at both bases, ex cn

TOXEMIAS OF PREGNANCY— REID AND TEEL 1629

Volume 113
Number 18

niidscapular and inidaxillary regions. The liver was neither
enlarged nor tender, and the uterus was consistent in size with
a scant seven months pregnancy. The urine showed 4 plus
albumin.

The patient was admitted to the hospital and placed on a
regimen of fluid restriction, and digitalization was begun.
There was a mild attack of cardiac asthma the first night.
Although she lost 6 pounds (2.7 Kg.) during the first twenty-
four hours, rales persisted at the lung bases. On the second
hospital day, a 7 foot x-ray plate of the chest showed the heart
considerably enlarged in its transverse diameter and diminished
radiance of both lung bases with haziness of the costophrenic
angles.

The vital capacity, as determined on the second hospital day
after subsidence of the acute seizure, was 1,700 cc. 2 Reti-
noscopy revealed blurring of the disk margins and patches of
“cotton wool” exudate. The arteries were constricted and the
veins overfilled, but there were no hemorrhages.

On the morning of the third hospital day, the patient awakened
with severe frontal headache and blurred vision. The condi-
tion grew worse, and in the afternoon she became irrational.
A lumbar puncture was done, and clear fluid under 300 cm. of
water pressure was obtained. Withdrawal of 30 cc. reduced
the pressure below ISO cm. of water.

Forty minutes following the lumbar puncture there was a typ-
ical eclamptic convulsion. Magnesium sulfate given intravenously
resulted in prompt improvement, and repetition controlled the
patient’s irritability and symptoms. Forty-eight hours later
labor was induced and a stillborn 2 pound 1 ounce infant
(935 Gm.) was delivered spontaneously. Subsequent recovery
was rapid; within three days the lungs were free from rales
and the vital capacity had risen to 2,700 cc. At the time of her
discharge from the hospital on the fourteenth postpartum day
there was neither dyspnea nor orthopnea, the blood pressure
was 160/100, the urine contained 1 plus albumin, and the vital
capacity was 2,850 cc.

This patient has been seen several times during the
six months since delivery. She has no cardiac, vascular
or renal symptoms and has resumed all the housework
for -a family of nine. The blood pressure is 140 sys-
tolic, 90 diastolic and the urine is free from albumin.
Repetition of the 7 foot x-ray plate of the heart shows
no enlargement in the transverse diameter, although
there is a slight aortic knob.

The maximum value for nonprotein nitrogen in the
blood was 40 mg. per hundred cubic centimeters ante
partum and 43 mg. one week post partum. Blood uric
acid ante partum was 4 mg. per hundred cubic centi-
meters. Of considerable interest is a sudden change in
hemoconcentration, which occurred at the time of the
convulsion. The hematocrit reading a few hours before
the convulsion was 29.99 per cent. Shortly after the con-
vulsion the hematocrit reading was 39.50 per cent. At
the time of her discharge from the hospital fourteen days
post partum the hematocrit and hemoglobin values were
respectively 34.37 per cent and 10.4 Gm. We have
repeatedly observed these sudden marked shifts in
hemoconcentration in other patients with eclampsia,
particularly when complicated by pulmonary edema.

This patient’s history is presented to illustrate the
occurrence of severe cardiac asthma with acute pul-
monary edema as a complication of preeclampsia super-
imposed on mild asymptomatic hypertensive disease.
1 hat the marked increase in blood pressure, edema and
albuminuria were fairly interpreted as preeclampsia was
confirmed by the facts that the patient subsequently had
a typical eclamptic convulsion without evidence of renal

2. We have determined the vital capacity on a number of these
patients •’ — — a : — asthma or between attacks. The proce-
dure is m , and the first effort invariably gives

the maxi the procedure, signs of moisture in the

‘wngs ai i one subject an immediate seizure of

cardiac asthma with acute pulmonary edema followed determination of
the vital capacity.

failure and that she recovered promptly following
termination of the pregnancy'. We would emphasize
that the patient has never suffered from cardiac symp-
toms and has never had an attack suggestive of
nocturnal or paroxysmal dyspnea before or since the
pregnancy' described.

The specificity of pregnancy toxemia in causing
cardiac asthma with acute pulmonary edema in a pre-
viously and subsequently well compensated hyperten-
sive patient is better illustrated by the following case:

Case 2. — F. M., aged 38, was admitted to the hospital in the
fifth month of her ninth pregnancy because of severe hyper-
tension, edema and history of recurrent attacks of paroxysmal
dyspnea for two weeks.

The patient was known to have had an elevated blood pressure
for at least six years. Her last pregnancy eighteen months
before had been terminated in the sixth month in another
hospital because of a severe toxemia of pregnancy complicated
by seizures of dyspnea and orthopnea. Recorded conditions
prior to termination of the pregnancy were essentially massive
peripheral edema, numerous crepitant rales, a blood pressure of
260 systolic, 140 diastolic, and 4 plus albumin in the urine.
Following termination of the pregnancy there was prompt
improvement with disappearance of dyspnea, albuminuria and
edema and decrease in blood pressure.

At repeated examinations during the eighteen months between
this pregnancy and the present one, the blood pressure ranged
from 180 to over 200 mm. of mercury systolic, but there was no
edema, and there had been no further seizures of dyspnea and
no other symptoms referable to the heart.

The present pregnancy had progressed without incident until
two or three weeks before examination, when generalized
peripheral edema appeared. Some days later the patient began
to have recurrent seizures typical of cardiac asthma with cough
productive of frothy sputum.

Examination revealed essentially peripheral edema, dyspnea,
cardiac enlargement, numerous crepitant rales over the lower
lobes of both lungs and a blood pressure of 240 systolic, 160
diastolic. The urine did not contain albumin.

The patient was placed on a regimen of restricted fluid intake
and digitalized, and the pregnancy was terminated by abdominal
hysterotomy and sterilization. There was rapid marked improve-
ment with disappearance of peripheral edema, dyspnea and signs
of pulmonary edema and decrease in blood pressure. The patient
was discharged seventeen days post partum with no signs or
symptoms of cardiac decompensation.

The patient has been followed for eighteen months, since
delivery. The blood pressure ranges from 180/110 to 240/120
and she has considerable headache, but the lung bases have
remained clear and she has had no recurrence of the seizures
of paroxysmal dyspnea.

This patient is the only one in our series without
marked albuminuria who has had typical cardiac asthma
appear for tile first time as a complication of toxemia
of pregnancy. It should be added that her antecedent
hypertensive disease was the most marked of any
patient in the series. The point of particular interest
to us is that, although she is known to have had marked
hypertension for six years, she has never suffered from
seizures <?f cardiac asthma or pulmonary edema except
as described in the last two pregnancies, when marked
increase in blood pressure, edema and (in the first
pregnancy) albuminuria indicated the superimposition
of preeclampsia.

The third case illustrates the futility of prolonged
expectant treatment when attacks of cardiac asthma
with acute pulmonary edema have occurred in the
course of severe toxemia of pregnancy.

Case 3. — M. B., a quintipara aged 37, was transferred from
another hospital to this clinic in the thirty-sixth week of preg-
nancy because of toxemia complicated by marked choking
sensations, dyspnea and orthopnea.

1630

TOXEMIAS OF PREGNANCY — REID AND TEEL

Fig. 1 (case 4). — Degree of pulmonary
congestion and cardiac dilatation at the height
of an attack of “cardiac asthma.”

She was known to have had some degree of toxemia with
her last two pregnancies. Her family physician knew that her
blood pressure was definitely above normal early in the present
pregnancy. In the seventh month of pregnancy there was a
definite increase in the blood, pressure, with the appearance of
edema of the lower extremities and albuminuria. Simultaneously
the patient began to have attacks of nocturnal dyspnea and
was obliged to lead a bed and chair existence. On admission
to a private hospital two weeks later the blood pressure was
200 plus systolic and from 100 to 120 diastolic, and the urine

showed 4 plus albu-
min. Over a period of
two weeks siie was
observed by her physi-
cian to have several
attacks of nocturnal
dyspnea during which
the chest was full of
fine and coarse rales.
She was digitalized.

On admission to this
hospital, physical ex-
amination revealed the
following : The patient
was frail, with marked
orthopnea and cyano-
sis. There was only
a slight degree of pe-
ripheral edema. The
blood pressure was
220/140 and there was
marked sclerosis of the
retinal vessels. The heart was enlarged and the lungs were
full of rales. The vital capacity was 1,500 cc., and the hemato-
crit reading was 42.59.

Some twenty-four hours after admission (during which
interval several attacks of paroxysmal dyspnea had been
observed), labor was induced by artificial rupture of the mem-
branes. Several hours later she delivered a living baby
normally. Her condition was only fair for several days post
partum. There was one rather mild attack of pulmonary edema
on the tenth postpartum day. However, two weeks following
delivery the vital capacity had risen to 2,280 cc. and the hemato-
crit reading had decreased to 33.S0. 3 She was discharged much
improved with the blood pressure still 190/110.

She has been observed for two years following delivery.
She has had no subsequent attacks of paroxysmal dyspnea
and she is able to do light housework with no discomfort. The
blood pressure at the last observation was 220/114. The urine
is free from albumin. She has been sterilized by x-rays.

Although this patient was reasonably well treated by
bed rest, restriction of fluid intake and digitalization,
the attacks persisted and tended to become worse dur-
ing the three weeks until the pregnancy was terminated.
We have had similar experience with other patients
observed and treated for shorter periods.

The final history to be reported here is that of a
primipara about whose blood pressure we have no
information prior to or early in pregnancy. From her
physical examination at the time of the attack and her
subsequent course we suspect that there was antecedent
hypertension.

Case 4. — D. W., a primigravida aged 33, entered the hospital
for emergency treatment in the thirty-eighth week of preg-
nancy. Her complaints were dyspnea, orthopnea and swelling of
the lower extremities. The past and family histories were non-
contributory. It is known that at examination six years pre-
viously the urine contained no albumin, the sediment was negative
and the specific gravity was 1.030.

, The cel! volume two weeks post partum (33.50 _per cent) is con-

the seizures of cardiac asthma.

Jour. A. JI. A.
Oct. 23, l9Jf

re P atlcnt was ^ ar 8' e ar) d edematous, weighing 214 pounds
(97 Kg.), and had moderate cyanosis. The blood pressure was
294/118. Auscultation of the chest revealed fine to coarse rales
throughout. While the patient was being turned to facilitate
examination, a severe attack of acute pulmonary edema devel-
oped. Several hours later the vital capacity was found to be
1,820 cc. Immediately following this procedure the patient was
seized with a second similar attack of orthopnea and dyspnea,
with marked exacerbation of pulmonary edema. A 7 foot x-ray
plate of the heart taken at this time and repeated nine weeks
post, partum indicates the degree of pulmonary edema and’
cardiac dilatation associated with these episodes of acute pul-
monary edema (figs. 1 and 2).

The urine contained 4 plus albumin. There were numerous
white blood cells, occasional red blood cells and granular casts
in the sediment. Chemical examination of the blood was nega-
tive except for a total protein value of 5.77 Gm. per hundred
cubic centimeters.

The patient was given morphine in libera! doses. Fluids were
restricted and she was rapidly digitalized. She was delivered
by cesarean section twenty-four hours later. The baby weighed
5 pounds 5 ounces (2,410 Gm.) and survived. The mother’s
condition improved rapidly. There were no subsequent attacks
of pulmonary edema, and one week later her chest was clear.
The vital capacity two weeks post partum had risen to 2,540 cc.

The patient has been followed for two years since deliver)’
and has shown a progressive increase in blood pressure with
albuminuria. Only within the past two months have attacks
of paroxysmal dyspnea recurred, and subjectively they are of
the same character as those which the patient experienced for
the first time when pregnant.

Studies of the vital capacities and hemodynamics of
these patients show changes similar to those reported
in classic cardiac asthma. All showed a marked
decrease in the vital capacity, which increased rapidly
with clinical improvement following delivery. Changes
in the cell volume as determined by hematocrit read-
ings indicate marked hemoconcentration associated
with the seizures.

Peripheral venous
pressure and circu-
lation time 4 were
found to be within
the upper limits of
normal.

Although, as we
have pointed out,
cardiac asthma and
acute pulmonary
edema may compli-
cate simple acute
preclampsia in pa-
tients without a
background of hy-
pertensive or renal
disease, this symp-
tom complex is . •

more commonly encountered when preeclampsia
superimposed on such a background.

Our previous report dealt primarily with the co
plication in patients with simple preeclampsia. 4n
study, on the other hand, some degree of vasci
hypertension formed a background for the preeclamp

in all cases. , __i:

We believe that general recognition of this comp
tion of nonconvulsive toxemia is impor tant or _ __

Fig. 2 (case 4).-
after delivery.

-Appearance

: week*

4. Venous pressure was determined by f th 5i. DruS^ i fl
Tabora (Ueber erne Methodc, beim Menschen den pSs

flachlichcn Venen exakt zu besUmmea, .Deutschra Arch- " aBd U««
475, 1910) and the circulation time by the method os l pgJmom „ and
(A Method for tbe Measurement of the s; 650 iJ“ oc]

Peripheral Venous Blood Flow m Man, Am. Heart j
1933).

Volume 113
Number 18

TUBERCULOSIS— ALLISON AND MYERS

1631

reasons: First, its frequency is greater than is gen-
erally appreciated. 5 It is one of the more common
immediate causes of death from nonconvulsive toxemia.
Its early recognition combined with suitable therapy
will aid in reducing the mortality in nonconvulsive
toxemia. Second, consideration of the probable similar-
ity in the mechanisms of origin of cardiac asthma with
acute pulmonary edema in the nonconvulsive toxemic
patient and acute pulmonary edema in the eclamptic
should lead to more rational and effective therapeutic
protection of the heart in eclampsia.

We have found no cause to modify our original view
that the immediate cause of the symptom complex is
left ventricular heart failure. We would point out that,
in general, marked degrees of acute pulmonary edema
more often accompany the seizures in patients with pre-
eclampsia than in nonpregnant hypertensive patients
with cardiac asthma. In addition, in most instances
signs of pulmonary edema persist between attacks until
delivery is accomplished. The increased capillary
permeability, edema and low serum proteins which are
characteristic of preeclampsia would appear to offer a
reasonable explanation for this difference.

Immediate treatment of the acute seizures involves
the use of morphine in large doses, and venesection or
peripheral venostasis if pulmonary edema is marked.
After a brief period, temporary improvement is the rule.
However, from knowledge of the clinical courses of
some fifteen cases we have come to the conclusion that
prolonged expectant therapy, even including suitable
cardiac measures, is undesirable. Once the patient has
had such attacks, the improvement has been temporary
and recurrence of attacks is the rule until the patient is
delivered. For this reason termination of the preg-
nancy by suitable means is desirable when the patient
has been prepared by preliminary fluid restriction and
full digitalization. This should be a matter of from
twelve hours to, at the most, three or four days.

Again, it must be emphasized that the immediate
prognosis must be guarded in undelivered patients in
whom this -symptom complex develops. Death may
occur during the attack. However, it is equally impor-
tant to realize that, once such patients are successfully
delivered, the outlook is not a dismal one. The occur-
rence of such attacks in the presence of pregnancy can-
not be regarded as evidence of the rapidly progressive
vascular disease which it denotes in the nonpregnant,
but rather of a temporary removable burden to the vas-
cular system produced by the toxemia of pregnancy. In
our experience these patients, with one exception, have
continued to enjoy relatively normal lives without
recurrence of the attacks described.

SUMMARY AND CONCLUSIONS

Nonconvulsive toxemia of pregnancy characterized by
marked hypertension, albumin and edema is occasionally
complicated by sudden left ventricular heart failure,
as indicated by seizures of cardiac asthma with acute
pulmonary edema. Both patients with previously nor-
mal vascular and renal systems and with antecedent
hypertension may have such attacks, although they are
more common in the latter. Once such attacks have
occurred, lasting improvement is not to be expected
until the pregnancy is terminated.

. 5* .* n a recent report of a fatal case of nonconvulsive pregnancy

toxemia by Harrison and his associates, acute pulmonary edema would
Tr^ci. * 1 ° have been the immediate cause of death (Harrison, D. A.,
^T'L^belton, J. H., and Carrithers, C. M.: Postmortem Cesarean Section
i with Delivery of Two Living Babies, J. A. M. A.

110:2066 [June 18] 1938).

Therapy consists in large doses of morphine with
venesection, or in peripheral venostasis when indicated
by severe pulmonary edema, followed by rapid digitali-
zation and dehydration and delivery within a few days.

The immediate prognosis is grave, but if delivery
is survived the ultimate prognosis is good.

We believe that the distressing pulmonary edema
often encountered in severe and fatal eclampsia is also
a result of acute left ventricular heart failure. For this
reason, rapid full digitalization of all eclampsia patients
is indicated.

171 Bay State Road.

THE TREATMENT OF PULMONARY
TUBERCULOSIS WITH
SULFAPYRIDINE

STANTON T. ALLISON, M.D.

AND

ROBERT MYERS, M.D.

NEW YORK

The encouraging results of sulfanilamide therapy in
infections caused by the hemolytic streptococcus, the
meningococcus, the colon bacillus and the gonococcus,
and the more recent results of sulfapyridine therapy in
pneumococcic pneumonia have made us hopeful that
eventually some such chemotherapeutic agent might be
discovered which would influence the course of pul-
monary tuberculosis in a favorable manner. The reports
from England as well as those from America have
indicated that sulfapyridine is an impressive drug,
powerful in effecting a cure in pneumonia yet relatively
nontoxic as far as permanent harm or death of the
patient is concerned. We felt that this drug might have
some bactericidal effect on the tubercle bacillus, and
since there had been no reports on its use in treating
tuberculosis we decided in December 1938 on the inves-
tigation which we are now reporting. Recently there
has appeared in the literature a paper on the effects of
sulfapyridine on experimental tuberculosis in the guinea
pig by Feldman and Hinshaw. 1 These observers report
that in their investigation sulfapyridine exerted a
definite and striking modification and retardation of
the expected course of experimentally induced disease.
The most impressive effects were those related to the
spleen. The spleens of the untreated animals presented
without exception severe progressive tuberculosis, while
those in the treated animals, with one exception, showed
no gross signs of tuberculosis.

For the study of the action of sulfapyridine on the
clinical course of pulmonary tuberculosis in human
beings we agreed that certain requirements must be met
in the selection of our cases. In the first place we
decided that only cases presenting exudative processes
with little tissue defect (cavity formation) would be
used, since, it was argued, if these cases did not respond
to the drug certainly it could be assumed that long
standing cases of fibrocavernous phthisis would not
respond. Secondly, it seemed wise to use only patients
whose sputums were positive for tubercle bacilli at the
time so that there would be no doubt in our minds of
the diagnosis. It was further decided that this would

from the Tuberculosis Service, First Medical Division. Bellevue Hos-
pital, and the Department of the Practice of Medicine, College of Phvsi-
cians and Surgeons, Columbia University.

The sulfapyndme used in this work was supplied by Merck & Co., Inc.

Clin.- wfm'(Mirc”-’l3 a ) nd IM8? Sha "’ C: ^ Staff Ma >°

1632

TUBERCULOSIS— ALLISON AND MYERS

Jour. A. M. A.
Oct. 28, 1939

be a short period study to ascertain, if possible, the
effects if any on the pulmonary process.

As the average adult pneumonia patient receives
from 20 to 25 Gm. of sulfapyridine to effect a cure, it
appeared reasonable to assume that in treating patients
with pulmonary tuberculosis we should use from two
to four times this amount over a longer period of time.

No attempt was made in our study to determine the
blood level (estimates of sulfapyridine concentration in
the blood). REPORT OF CASES

Case 1. — E. H., a man aged 49, a Russian, was admitted to
Bellevue Hospital Dec. 30, 1938, with a history of cough of
two months’ duration productive of 150 cc. of thick gray,
nonfoul sputum daily. At the onset of his illness there had
been a hemoptysis of one half ounce (15 cc.) of blood, followed
by streaking for several days. He had noticed some dyspnea
and had had night sweats for several weeks. Hoarseness had
been present for about the same period. He had had no chills
and apparently no fever. His past history revealed that he
had been a heavy drinker for the last five years. Fifteen years
before he had had a primary syphilitic lesion for which he
had received antisyphilitic therapy.

Examination of the chest revealed bilateral apical dulness,
greater on the right, with bronchovesicular breath sounds over
both apexes. No rales were heard. The initial roentgenogram
of the chest (Jan. 1, 1939) showed a mixed type process, but
predominantly exudative, involving to some degree all the
right lung but especially the upper half with a nodular dis-
tribution. No cavities were visible. The left lung showed a
bronchiogenic spread to the first and second intercostal spaces.

The laboratory observations were as follows : The urine
was normal. The Wassermann reaction of the blood was nega-
tive. Concentrated sputum was positive for tubercle bacilli.

A blood count Jan. 2, 1939, showed hemoglobin 87 per cent,
red cells 4,910,000, white cells 7,150, polymorphonuclear leuko-
cytes 74 per cent, lymphocytes 25 per cent and monocytes 1 per
cent. On January 5 it showed white cells 11,200, polymorpho-
nuclear leukocytes 72 per cent, lymphocytes 24 per cent and
monocytes 4 per cent.

The patient was started on sulfapyridine 1 Gm. every four
hours. He received a total of 57 Gm. in fourteen days.

After the second and third doses of the drug the patient
complained of epigastric “burning” and nausea but there was
no vomiting. This disappeared as soon as the drug was with-
drawn and did not return when the drug was resumed two
days later, although he did have slight dizziness. The tem-
perature range was between 98 and 100.6 F. (rectally) during
his stay in the hospital and did not appear to be affected by
the drug. February 7 a second roentgenogram of the chest
revealed no clearing of the tuberculous process. A third and
final roentgenogram of the chest on February 27 revealed no
essential change in the tuberculous process. Sputum examina-
tion continued to be positive for tubercle bacilli. The patient
showed no improvement and was discharged to a sanatorium
February 28, having been observed for two months.

Case 2. — F. B., a man aged 27, a Filipino, was admitted to
Bellevue Hospital Jan. 14, 1939, having been transferred from
Mount Sinai Hospital. He gave a history of sudden onset of
chills, fever, sweats and marked weakness two weeks before
admission. There was slight cough with scanty white sputum.
He had lost 15 pounds (6.8 Kg.) in the last few weeks. Recently
he had noticed a tender swollen gland in the lower right
anterior cervical region, which had been aspirated at Mount
Sinai Hospital and culture of the pus reported positive for
tubercle bacilli. The past history was irrelevant.

On examination the patient was thin and acutely ill, with
rapid respirations, hot moist skin, a temperature of 105 F.
(rectally) and pulse 130. The chest appeared normal except
for harsh breath sounds throughout. No rales were heard.
The spleen was palpable.

The initial roentgenogram of the chest January 14 revealed
the finely nodular symmetrical infiltration evenly distributed
from apexes to bases so characteristic of hematogenous miliary
tuberculosis. The laboratory observations were as follows:
The urine showed a trace of albumin. The Wassermann reac-

tion of the blood was negative. Concentrated sputum was
negative for tubercle bacilli.

A blood count January 17 showed hemoglobin 65 per cent,
red cells 2,970,000, white cells 11,300, polymorphonuclear
leukocytes 80 per cent, lymphocytes 11 per cent and monocytes
9 per cent. On January 18 it showed white cells 10,800,
polymorphonuclear leukocytes 70 per cent, lymphocytes 26 per
cent, monocytes 3 per cent and eosinophils 1 per cent. On
January 23 it showed white cells 11,200, polymorphonuclear
leukocytes 68 per cent and lymphocytes 32 per cent.

The patient was given sulfapyridine 1 Gm. every four hours.
He received a total of 18 Gm. in five days.

Twelve hours after sulfapyridine was started, the temperature
dropped two degrees and the pulse was slightly lower. On
the second day after sulfapyridine administration the patient
complained of abdominal cramps and nausea. Shortly after
this vomiting set in, and after the patient had received only
18 Gm. of the drug it was necessary to discontinue it. From
then on the course of the disease was rapidly progressive to
a fatal termination. Death occurred January 28, on the four-
teenth day of his stay in the hospital. A roentgenogram of
the chest taken the day before his death (January 27) revealed
the process in the lungs to be more extensive, especially at the
bases.

On postmortem examination hematogenous miliary tubercu-
losis was revealed in the lungs, the heart, the serous membranes,
the spleen, the liver, the adrenals and the kidneys'.

Case 3. — S. M., a man aged 38, an Italian, was admitted
to Bellevue Hospital Dec. 29, 1938, with the history of a rather
sudden onset of chest cold three weeks before admission. He
expectorated 1 ounce (30 cc.) of mucopurulent sputum daily
and complained of right anterior chest pain of two weeks
duration and left anterior chest pain of three weeks’ duration.
There had been weakness and fatigue for two weeks, some
anorexia and the loss of 5 pounds (2.3 Kg.) in weight. The
past history was irrelevant.

Examination of the chest revealed dulness on the left fro™
the apex to the fourth rib anteriorly and the fourth thoracic
spine posteriorly, with a patch of medium moist rales an
increased breath sounds in the posterior axillary line at ' e
level of the seventh thoracic vertebra. The right side ot
chest showed dulness to the fourth rib anteriorly and the four
thoracic spine posteriorly with amphoric breathing at the ape*-
There was bronchovesicular breathing on the_ right * rom . V
infraclavicular region to the fifth rib and posteriorly to the sj*
thoracic spine with medium moist rales over this area,
rales at the right apex had a consonating quality. ,

The initial roentgenogram of the chest December 39 5
a diffuse exudative infiltration involving the right upper
with multiple cavitations in the apical and subapical reg
The lower half of the right lung showed a diffuse, n ™ ,
finely nodular infiltration. The left lung showed an ex
nodular infiltration below the first rib, particularly 1
periphery of the second and third intercostal spaces. ,
The laboratory observations were as follows. ^

was normal except for a very faint trace of a , , f ,|

Wassermann reaction of the blood was negative. on
sputum was positive for tubercle bacilli. A bloo c0l j , teJ
1939, showed white cells 8,800, polymorphonuclear leu >

76 per cent and lymphocytes 24 per cent. | lour s,

The patient was given sulfapyridine 1 Gm. every i , ]C
but after receiving only 9 Gm. of the drug in j 10sp ;tal.
became so nauseated that he insisted on leaving . „

Case 4.-W. M„ a man aged 44, Polish admitted tc
Hospital Jan. 9, 1939, had for seven months had a tr ^ flf
cough which had become productive of 1 ounce i Thcrc
mucopurulent sputum daily in the )ast t, ' re ^ '' T. ese nt for
had been no hemoptysis. Hoarseness had bee p e
five weeks with slight pain on swallowing. Jue p

was irrelevant. . . , , • ,i,„ ; n fraclavicU'

Examination of the chest revealed dulness in th c f

lar areas, especially on the right side, with some c ^ , vcre
dulness over most of the right side of the chest {r0 „t

bronchovesicular breath sounds over most ot me ^

and back, with rales of all types. Consonating ra
in the right infraclavicular area'.

Volume 113
Number 18

TUBERCULOSIS— ALLISON AND MYERS

1633

The initial roentgenogram of the chest January 11 revealed
extensive bilateral tuberculosis, chiefly exudative, with a pneu-
monic process involving the right upper lobe and a 5 by 6 cm.
cavity at the right apex. There was a typical bronchiogenic
miliary spread to the bases.

The laboratory observations were as follows : The urine was
normal. The Wassermann reaction of the blood was negative.
Concentrated sputum was positive for tubercle bacilli.

A blood count January 13 showed hemoglobin 85 per cent,
red cells 4,980,000 and white cells 12,150.

January 14 it showed red cells 4,730,000, white cells 14,850,
polymorphonuclear leukocytes 91 per cent and lymphocytes 9 per
cent.

January 15, red cells 4,940,000, white cells 11,250, poly-
morphonuclear leukocytes 88 per cent and lymphocytes 12 per
cent.

January 16, white cells 10,550, polymorphonuclear leukocytes

85 per cent and lymphocytes 15 per cent.

January 17, white cells 9,050, polymorphonuclear leukocytes

86 per cent and lymphocytes 22 per cent.

January 18, white cells 10,200, polymorphonuclear leukocytes
78 per cent and lymphocytes 22 per cent.

January 19, white cells 7,800, polymorphonuclear leukocytes
65 per cent and lymphocytes 35 per cent.

January 21, red cells 4,500,000 and white cells 10,000.

January 28, white cells 11,200, polymorphonuclear leukocytes
81 per cent and lymphocytes 19 per cent.

The patient was given sulfapyridine 1 Gm. every four hours
and received a total of 108 Gm. in twenty-five days. After
the first slight epigastric “burning,” which was relieved by
sodium bicarbonate, he had no ill effects from the drug in
any way that we were able to determine. After receiving 6 Gm.
of the drug his temperature fell from 103.6 to 101.6 F. and
after 12 Gm. of the drug became normal. In spite of the
continuance of the drug, however, the temperature from then
on fluctuated between 101 and 101.6 F. A second roentgenogram
of the chest January 26 showed that there was some spread
of the tuberculous process at the bases; otherwise there was
no change from the film taken January 11. Subsequent sputum
tests were positive for tubercle bacilli. After a total of 108 Gm.
of sulfapyridine had been given it was apparent from signs,
symptoms, x-ray examinations and the sputum that the patient
had not been benefited by the drug. He now appeared weaker
and was transferred February 15 to Seton Hospital, where he
died of tuberculosis March 13.

Case 5. — C. V., a Puerto Rican woman aged 24, was admitted
to Bellevue Hospital March 27, 1939, with the history of a
productive cough of two weeks’ duration. The sputum was
not foul. There had been no hemoptysis. She had lately noticed
sweats at night and thought that she had been feverish. The
past history was irrelevant.

Examination of the chest revealed dulness and loud bronchial
breathing over the upper half of the right lung with medium
moist and a few crepitant rales over this area. Aside from
some harsh breath sounds at the apex the left lung appeared
clear.

The initial roentgenogram of the chest, March 28, revealed
a dense pneumonic process from the right apex to the fourth
rib, the base of the shadow being outlined by the interlobar
fissure. There was slight rarefaction in the first intercostal
space. The left lung showed an exudative infiltration in the
second and third intercostal spaces.

The laboratory observations were as follows : The urine
was normal. The Wassermann reaction of the blood was nega-
tive. Initial sputum was negative for tubercle bacilli but two
concentrated specimens of sputum taken soon after this were
positive, as were all subsequent specimens.

A blood count March 31 showed hemoglobin 60 per cent,
white cells 12,160, polymorphonuclear leukocytes 89 per cent
and lymphocytes 11 per cent.

On May 3 it showed hemoglobin 79 per cent, red cefls

4.840.000, white cells 5,880, polymorphonuclear leukocytes 79
per cent and lymphocytes 21 per cent.

On June 2 it showed hemoglobin 64 per cent, red cells

4.130.000, white cells 10,800, polymorphonuclear leukocytes 82
per cent and lymphocytes 18 .per cent.

The patient was given sulfapyridine 1 Gm. every four hours
with no apparent effect on her temperature, which ranged
between 101 and 103 F. After five days of sulfapyridine therapy
the patient, having received a total of 19 Gm., complained of
pain and tenderness over the region of the left kidney and
she began to have hematuria. Sulfapyridine was stopped and
soon the hematuria did likewise. She continued to have pain
in the left costovertebral angle, and an intravenous pyelogram
was made which showed incomplete filling of the pelvis of the
left kidney. Cystoscopy was carried out, revealing an obstruc-
tion of the left ureter near the kidney pelvis. With considerable
difficulty a number 5 catheter was finally passed to the kidney
pelvis, resulting in a rapid flow of clear amber urine. Follow-
ing this procedure the pain and tenderness in the left kidney
region cleared up almost immediately and she had no more
trouble in this respect. A second intravenous pyelogram after
this cystoscopic treatment showed a normal functioning left
kidney. It was thought that the ureteral obstruction was due
to acetylsulfapyridine crystals settling out in the kidney pelvis
and passing into the ureter, forming an impaction.

A second roentgenogram of the chest April 17 revealed a
spread of the tuberculous process in the left second intercostal
space and likewise to the right base. A roentgenogram of the
chest May 15 showed that the process in the left lung had
spread considerably since her previous examination. A roent-
genogram of the chest May 26 showed that both entire lung
fields were almost completely involved with the tuberculous
process. The patient is still in the hospital as this paper is
being written, and apparently within a few weeks this case will
terminate fatally.

Case 6 . — C. S., a white woman aged 20, was admitted to
Bellevue Hospital March 24, 1939, with a history of pleurisy
on the left side one year before, following which she was
apparently well until September 1938, when she began to cough
and expectorated half a cupful of nonfoul sputum daily. She
had noticed some loss of weight, some weakness and dyspnea
in the last two months. The past history, prior to her pleurisy
one year before, had been essentially irrelevant.

On examination the patient appeared thin and chronically ill.
She had “shotty” cervical glands. The trachea appeared to
deviate slightly to the right. There was right apical dulness,
and medium moist rales could be heard from the right apex
to the fourth thoracic spine posteriorly. The left side of the
chest showed dulness from the apex to the fourth rib anteriorly
and to the fourth thoracic vertebra posteriorly. Over this area
there were bronchovesicular breathing and medium moist and
a few coarse rales.

The initial roentgenogram of the chest, March 25, revealed
a mixed type process, predominantly exudative however, in the
right first intercostal space and below the fifth rib. The left
lung showed an exudative infiltration and small cavitation in
the second intercostal space and some involvement of the left
base.

The laboratory observations were as follows : The urine
was normal. The Wassermann reaction of the blood was nega-
tive. Concentrated sputum was positive for tubercle bacilli.

A blood count April 6 showed hemoglobin 85 per cent, red
cells 4,950,000, white cells 7,400, polymorphonuclear leukocytes
70 per cent, lymphocytes 24 per cent, monocytes 4 per cent and
basophils 2 per cent.

April 16, red cells 5,400,000, white cells 8,450, polymorpho-
nuclear leukocytes 74 per cent, lymphocytes 11 per cent, mono-
cytes 7 per cent, transitionals 7 per cent and basophils 1 per
cent.

April 22, red cells 5,090,000, white cells 9,500, polymorpho-
nuclear leukocytes 85 per cent, lymphocytes 12 per cent, mono-
cytes 3 per cent and basophils 1 per cent.

April 27, white cells 8,600, polymorphonuclear leukocytes 72
per cent and lymphocytes 9 per cent.

The patient was given sulfapyridine 1 Gm. every' four hours ;
she received 103 Gm. in twenty-three days.

After receiving sulfapyridine for two days she became nau-
seated and vomited and the drug was withdrawn for twenty-four
hours. It was resumed without a return of her vomiting and
with only slight nausea at times.

1634

THECA CELL TUMO RS— COLLINS ET AL.

Jour. A. M: A.'
Oci. 28, 1939

A roentgenogram of the chest taken April 7 showed no
essential change from the film of March 25. One taken April 15
showed no essential change from the previous plates, but that
taken April 28 showed considerable spread of the process in
the left lower lobe. The sputum was still positive and the
patient appeared to be going downhill rather rapidly. It was
felt that in order to save the patient’s life, if indeed this was
possible, it was expedient to stop sulfapyridine, which had
apparently done her no good after 103 Gm., and collapse the
left lung at once. Accordingly this was done.

A roentgenogram May 13 showed approximately 20 per cent
collapse of the left lung; the right lung showing no change.
A roentgenogram of the chest May 31 showed 60 per cent
collapse of the left lung with closure of the cavity in the second
intercostal space. For the first time the contralateral lung
showed some clearing. Although the sputum was still positive,
the patient appeared better.

Case 7.— F. S., an Irishman aged 33, was admitted to Bellevue
Hospital March 22, 1939. He had been discharged from the
Raybrook Sanatorium for Tuberculosis six years previously
as having arrested pulmonary tuberculosis. Six months before
admission to Bellevue a cough had developed productive of a
cupful of mucoid sputum daily. During the last few months
he had lost 18 pounds (8 Kg.) and had night sweats. He
entered the hospital because of recent onset of pain in the
left anterior part of the chest, intensified by coughing and deep
inspiration. His temperature on admission was 102. F.

Examination of the chest showed a respiratory lag on the
left. There was tubular breathing with increased whispered
and spoken voice from the second to the fourth rib on the left
between the anterior and midaxillary lines. Over this area
there were dulness and many fine rales. The right side of the
chest showed a few scattered fine rales throughout.

An initial roentgenogram of the chest March 23 revealed
a fine infiltration throughout the right lung with thickening
of the pleura. The left lung showed some light infiltration at
the apex and dense pneumonic infiltration from the second to
the fifth rib.

The laboratory observations were as follows : The urine
was normal. The Wassermann reaction of the blood was nega-
tive. Initial sputum was positive for tubercle bacilli. Sputum
culture showed type V pneumococcus.

A blood count March 23 showed hemoglobin 100 per cent,
red cells 3,290,000, white cells 15,920, polymorphonuclear leuko-
cytes 86 per cent and lymphocytes 14 per cent. March 29 it
showed white cells 8,090, polymorphonuclear leukocytes 77 per
cent, lymphocytes 19 per cent and monocytes 4 per cent.

The patient was given sulfapyridine 1 Gm. every four hours.
The temperature, which on admission had been 102 F., fell to
99 within forty-eight hours of starting sulfapyridine therapy.
The patient became so nauseated and vomited so much that
after taking 5 Gm. of the drug it was discontinued. A roent-
genogram of the chest April 1 revealed some slight clearing of
the pneumonic area in the left lung. The process in the right
lung remained the same. Roentgenograms of the chest taken
April H, April 19 and May 4 showed progressive clearing of
the pneumonic process in the left lung, with no change in the
tuberculous process on the right.

It was believed that we were dealing with a case of pulmonary
tuberculosis in which type V pneumococcus pneumonia of the
left upper lobe had developed. This pneumonia cleared under
sulfapyridine therapy but the tuberculosis was not affected.
In this case even as little as 5 Gm. of the drug appeared to
have cleared the pneumococcic infection.

SUMMARY AND COMMENT

Seven patients who had been diagnosed as having
pulmonary tuberculosis were treated with sulfapyridine.
Patient 2 had acute generalized miliary tuberculosis,
which was proved at autopsy, and was the only patient
who had a negative sputum. He was in a moribund
condition when he arrived at the hospital. We do not
feel that sulfapyridine affected his disease in any way
nor do we believe that it contributed to his death.
Patient 4 received the largest total amount of the drug,
10S Gm., and patient 7 received the smallest, a Gm.

Hematuria and pain and tenderness developed in case 5
in the region of the left kidney after 19 Gm. of the
drug had been given. An intravenous pyelogram fol-
lowed by cystoscopic examination revealed an obstruc-
tion in the upper portion of the left ureter near the
kidney pelvis. With considerable difficulty a catheter
was passed to the left kidney pelvis and the obstruction
was relieved. It was thought that this obstruction was
due to the formation of ureteral stone or impaction
from the settling out in the kidney pelvis of acetylsulfa-
pyridine crystals.

Nausea and vomiting were the two most common
toxic manifestations in our series, the former occurring
in five of the seven cases, the latter in three. In three
cases it was necessary to withdraw the drug perma-
nently because of these symptoms. In one case it was
necessary to withdraw the drug because of hematuria
and ureteral obstruction. Two patients in this series
have died of their disease. Patient 6, after 103 Gm.,
was showing such rapid spread of her pulmonary tuber-
culosis that her left lung was collapsed, following which
she improved somewhat.

CONCLUSIONS

Seven patients with active pulmonary tuberculosis,
one with acute generalized miliary tuberculosis, were
treated with sulfapyridine. The object of our study was
to ascertain the immediate effects of the drug on the
tuberculosis over a relatively short period of time.
Under the conditions described, no evidence was
obtained to indicate that sulfapyridine influenced the
course of the tuberculosis in these cases.

555 Park Avenue.

THECA CELL TUMORS OF
•THE OVARY

CONRAD G. COLLINS, M.D.
GEORGE VARINO, M.D.

AND

JOHN C. WEED, M.D.

NEW ORLEANS

Solid ovarian tumors, especially those producing
endocrine changes, have been the subject of muc
discussion and investigation both by the pathologis
and by the gynecologist during the past few y e: j rs '
Robert Meyer’s 1 work, reported in 1931, was probably
the spark that first aroused interest in America, m
this publication he described the dysgerminorna ovarii,
the granulosa cell tumor and the arrhenoblastoma.
Later numerous reports of these tumor types appear
in the literature at frequent intervals, as dm a
reports of Brenner cell tumors; Bland and Golds e
reviewed the literature and collected sixty cases o
latter type of tumor in 1935. Loeffler and Fries
in 1932 recorded six cases of ovarian tumors, Whicn u v
termed “fibroma theca cellular i xanthomatodes mar »
and in 193 4 the same authors 4 reported four addition
cases of this type. In the same year Melnick a
Kanter 5 reported two similar cases, the first to ay
in the American literature, for which they adop c .

From the Departments of Gynecology, Tulane University of Louis
larity Hospital of Louisiana and Touro infirmary. /v c v.) 1 9SU

l- & c» oh*. «•

WaXy.’Sd Priesel, A, Beit, , path. Ana,, u. * -te ^
^4. 1 ifoefflerf* E., and Priesel, A.: Wien. med. Wchnschr. S4:«*

T'^lniekiV J., and Kanter, A. E.: Am. J. Ob*, ft Gyne^ -7-
(Jan.) 1954.

'X

Volume 113
Number 18

THECA CELL TUMORS— COLLINS ET AL.

1635

term “theca cell tumors of the ovary.” Geist, c in a
series of papers, reported a large number of tumors
which clinically simulated granulosa cell tumors of the
ovary and pathologically resembled fibromas of the same
organ. He proved by an extensive study of his cases,
which embraced clinical, microscopic, chemical and
biologic methods, that although theca cell tumors simu-
late granulosa cell tumors clinically and fibromas of the
ovary microscopi-
cally they are a def-
inite clinical entity.

To date only
twenty - four cases
of theca cell tu-
mors have been re-
ported in the liter-
ature, and to this
number we add two
cases which have
come under our ob-
servation during
the past year.

HISTOGENESIS

The histogenesis
of solid ovarian tu-
mors has not been
definitely estab-
lished. One school,
the disciples of
Pfliiger’s theory,
maintains that the
granulosa cells and the theca interna cells of the ovary
are derived from the gonadal epithelial covering. Fischel
believes that the epithelial cells are derived from the
mesenchyme of the ovary and that the germinal epithe-
lium acts only as a nonfunctioning layer surrounding the
ovary and contributes in no way to its structure. Accord-
ing to Robert Meyer, 1 granulosa cell tumors arise from
mesenchymal embryologic rests (“granulosaballen”), in
the hilus of the ovary, a view which is also supported
by Walter Schiller. 7 Recently Voigt 8 reported a case
of primary granulosa cell tumor of the retroperitoneum,
and the fact that this primary tumor developed in a site
far removed from functionless ovaries certainly lends
strength to Fischel’s theory. Geist 0 is of the opinion
that granulosa cell tumors and theca cell tumors arise
from differentiated mesenchymal cells which are
potentially capable of becoming either granulosa or
theca cell in type. Novak 10 is of the same opinion
and for this reason opposes segregation of theca cell
and granulosa cell tumors. Greenhill and Greenblatt 11
recently reported a case of combined theca and granu-
losa cell tumors and concluded that this case gives
much weight to the theory that theca cell tumors and
granulosa cell tumors originate in a common type cell
of the ovarian mesenchyme, the “progranulosa cell.”

Recent experimental production, by means of x-rays,
of theca and granulosa cell tumors in the ovaries of
mice, some of which showed definite lutein change, have

Fig. 1 (case I). — Cut surface of theca cell
tumor showing islands of yellow tissue sepa-
rated by bands of fibrous tissue.

6. Geist, S. H., and Spielman, Frank: An Unusual Ovarian Tumor

. . >r T- . r A + £\A . Oil? ( T MO. 1 c »

8. Voist, W. W.: Am. J. Obst. & Gynec. 3G:6SS (Oct.) 1938.

9. Geist, S. H., in discussion on paper by Traut and Butterworth.

10. Novak, Emil, and Gray, L. A.: Am. J. Obst. & Gynec. 31:213
(Feb.) 1936.

11. Greenhill, T. P„ and Greenblatt, R. B. : Am. J. Obst. & Gynec.
3G:68I (Oct.) 1938.

been carried on by Furth and Butterworth 12 and by
Traut and Butterworth. 13 Through these experiments,
evidence is produced that, in experimental animals at
least, granulosa cell tumors might arise from surviving
adult granulosa cells. Certainly, although the exact
manner of origin of theca cell tumors and of the closely
related granulosa cell tumors is still a matter of con-
jecture, the preponderance of evidence is in favor of
Fisc hel’s theory of mesenchymal origin of the theca
and granulosa cells.

PATHOLOGY

Theca cell tumors vary in size from a few centi-
meters in diameter to the size of a large grapefruit.
On vaginal examination the consistency is that of a
fibroma of the ovary or of a fibromyoma of the uterus.
The same consistency is noted when the tumor is
examined following removal. Externally the growth
is slightly irregular in outline and varies in color from
yellowish brown to yellowish red. On cut section the
tumor is encapsulated and composed of many islands
of yellow tissue separated by bands of connective tissue ;
occasionally small cystic areas may be noted through-
out the tumor. Microscopically, theca cell tumors are
made up of interlacing bands of spindle or epithelioid
cells irregularly distributed and separated by strands
of connective tissue containing hyaline plaques. The
nuclei are oval and rod shaped with an occasional mitotic
figure present. Fat stains show the presence of intra-
cellular and extracellular lipoid material, which, accord-
ing to Geist, is doubly refractile and probably consists
of cholesterol or cholesterol esters.

CLINICAL FEATURES

Theca cell tumors of the ovary are usually unilateral
and are of the consistency of a fibroma of the ovary
or fibromyoma of the uterus. They occur at any age,
the oldest reported case being that of a woman aged
90 and the youngest that of a woman aged 18. All
but three of the reported cases occurred at or past the

Fig. 2 (case 2). — External surface of theca cell tumor showing irregular
outline and dilated blood vessels, ranging in color from lemon yellow to
orange.

menopause. That theca cell tumors are biologically
active is evidenced by the atypical bleeding found in the
menopausal and postmenopausal cases and by the occur-
rence of endometrial hyperplasia in a large number of
these cases. In younger women, periods of amenorrhea,
preceded or followed by menorrha gia, is the usual his-

1936’ Furth ’ and butterworth, J. S.: Am. J. Cancer 28:66 (Sept.)
9S; 3 (De'2) l 'l93V F ” and Bmt ""' orth - j- s - : Am - J- Obst. & Gynec. 31:

1636

THECA CELL TUMO RS— COLLINS ET AL.

tory. Although only one case has been examined by
hormone assay, the finding of a large amount of the
estrogenic substance in this case and the frequency
with which hyperplasia of the endometrium has been
encountered in other cases of this type present sufficient
evidence to indicate that usually the estrogenic sub-
stance is found in these cases in larger quantities than
in normal ones.

REPORT OF CASES

Case 1. — History. — A. M. C., a woman aged 24, admitted to
Charity Hospital Nov. 27, 1937, complained chiefly of pain in the
right side and amenorrhea. She stated that she had not menstru-

Jovs. A. M. A.
Oct. 28, 1919

Pathologic Reports.— G ross : The tumor measured 5 cm. by
5 cm. and was yellowish red and firm.. Cut section revealed
the tumor to be made up of numerous islands of yellow tissue,
separated by bands of connective tissue. On exposure to air
the yellowish color deepened.

Microscopic: Uterine scrapings were examined microscopic-
ally.. Section of the endometrium showed inactivity and hypo-
plasia of glandular elements. Slight secondary infection was
noted. Section of the ovary showed the tumor to be made up
of numerous bands of interlacing fibrous connective tissue
separating masses of irregularly arranged spindle shaped cells.
Fat stains showed the presence of lipoids in large amounts both
intracellularly and extracellularly.

_ Pollow-U p. — The patient menstruated five weeks after opera-
tion and has menstruated regularly ever since, menstrual periods
occurring approximately every twenty-eight ' days and lasting
from three to four days.

Case 2. — History. — Mrs. L. B. aged 22, admitted to Touro
Infirmary April 19, 1938, complained chiefly of amenorrhea.
The patient missed her October 1937 period but menstruated
at the end of November. She did not menstruate in December
1937 or January 1938 but did in February and March. All
periods were normal when present. Menstrual periods began
at the age of 12 years and occurred at from twenty-eight to
thirty day intervals, lasting from four to five days. Severe
dysmenorrhea was present on the first day of each period, but
the flow was normal in amount and character. She had never
missed a period before October 1937., She was married in
July 1937 and had used contraceptives ever since and had never
become pregnant. Prior to admission she had not menstruated
for seven weeks. There were several attacks of pain in the

Fig. 3 (case 2 ). — Cut surface of tumor shown in figure 2. Note
islands of tumor tissue separated by bands of connective tissue.

ated since Jan. 13, 1937. Prior to that time her menstrual periods
had occurred approximately every twenty-eight days and had
lasted for a period of three days. The menstrual cycle began
when the patient was 10 years old. She had been married for
ten years and had been pregnant once, resulting in a normal
delivery nine years before. Her last menstrual period began
Dec. 15, 1936, and continued until Jan. 13, 1937. For four months
prior to admission she experienced pain in the right side and
right lumbar region. There had been a slight leukorrheal dis-
charge, and the patient had noticed a mass in the right side for
three weeks. Other features of the history were irrelevant.

Examination. — On physical examination the blood pressure
was 140 systolic, 80 diastolic. The breasts were flabby' and a
mass was felt in the right side of the abdomen. Otherwise,
the general physical examination was negative.

On vaginal examination, the external genitalia and Skene’s
and Bartholin’s glands were normal. A mild cystocele and
rectocele were present. The cervix was slightly enlarged and
soft with a moderate degree of infection. The size, shape,
position and mobility of the uterus were normal. There was a
mass in the right adnexa the size of a golf ball, not attached
to the uterus, and of firm consistency.

Laboratory examination of the urine was negative. The
Wassermann reaction was negative. The blood pressure was
within normal limits. X-ray examination of the chest and of
the sella turcica showed no evidence of pathologic changes.
X-ray films of the kidney, ureter and bladder were negative.
The blood count was well within normal limits. The basal
metabolic rate was minus 5.

The preoperative diagnosis was chronic cervicitis and lutein-
ized granulosa cell tumor of the ovary.

Operation .— This consisted of dilation and curettage and of
laparotomy. On examination of the pelvis, the uterus was found
to be normal in size, shape and mobility'. The left adnexa were
normal. On the right side a large, firm, yellow ovarian tumor
approximately 5 cm. in diameter was found. It was freely'
movable and involved the whole of the ovary'. Ascites was
not present. A right oophorectomy was performed and the
abdomen was closed in anatomic layers. The patient had a
normal postoperative course and was discharged on the tenth
postoperative day.

Fig. 4 (case 1).— Theca cell tumor under low power cSntafo* 0 *

baped cells separated by bands of connective
yaline plaques.

awer right quadrant for two months, the pain radiati ff ..
ito the pelvis. Otherwise the patient's history was ^
Examination . — The blood pressure was 1-0 s > 5 o gon
iastolic. The breasts were small, and aside r °!?„ rn ~ wc re 110
f masculine distribution of the pubic hair
bnormalities noted. . ; n tact

Vaginal examination . revealed a nulhparo garth-

erineum, no cystocele or urethrocele and no in e uterus

[in’s or Skene’s glands. The cervix was small.

Volume 113
Number 18

THECA CELL TUMORS— COLLINS ET AL.

1637

was normal in size, shape and mobility. The left ovary was
palpable but of normal size. The right ovary was enlarged
to the size of a small grapefruit and very hard and firm.

The Wassermann reaction was negative. The urine was
normal and a blood count was within normal limits.

The preoperative diagnosis was theca cell tumor of the right
ovary.

An operation was performed April 21 with a subumbilical mid-
line incision. Exploration of the pelvic cavity showed that the
uterus was normal in size, shape, position .and mobility. The
right tube was normal but the right ovary was large, the size
of a small grapefruit and freely movable. The tumor occupied
the entire ovary, was freely movable, slightly irregular in out-
line and of yellowish red. The tumor was firm and there was

no evidence of ascites. A right oophorectomy and appendectomy
were performed. The abdomen was closed in anatomic layers.

Pathologic. Report. — Gross : The tumor measured 10 by 12
cm. in diameter and occupied the entire ovary ; it was slightly
irregular in outline and of very firm consistency. The external
coloring varied from yellowish red to yellowish brown. A few
dilated blood vessels coursed over the surface of the ovary.
On cut section the tumor was found to be solid and made up
entirely of areas of yellow tissue separated by thin septums
of connective tissue.

Microscopic: Section of the ovary showed that it was made
up of bundles of elongated cells with nuclei that were oval and
rod shaped, separated by small amounts of intracellular sub-
stance. An occasional mitotic figure was noted, although the
cells were for the most part well differentiated. Histologically
it was a supportive cell neoplasm. No epithelial elements were
demonstrated. A fibroma was present.

A corrected pathologic report demonstrated a theca cell tumor
of the ovary and chronic appendicitis. Fat cells showed presence
of intracellular and extracellular lipoid material in large
amounts.

Follozi’-Up , — The patient menstruated four weeks after opera-
tion and has menstruated at regular intervals ever since.

COMMENT

As a general rule, theca cell tumors occur at or past
the menopause. Of the twenty-four cases reports of
which have appeared in the literature, only three have

occurred in younger women (Loeffler and Priesel, one
case; Geist, two cases). Both of our cases occurred in
young women, and, in contrast to the menorrhagia at
the menopausal age, both of our patients had a period
of amenorrhea of varied duration. This is true also of
the cases of theca cell tumors that appeared in younger
women which were reported by Loeffler and Priesel
and by Geist. The history of periods of menorrhagia
followed by or preceded by periods of amenorrhea and
accompanied by the clinical finding of a unilateral solid
ovarian tumor should arouse suspicion as to the exis-
tence of a theca cell tumor, even in a young female.
In the second case, although the first pathologic report
was that of fibroma, we were so confident that such
was not the case that we persuaded the pathologist to
restudy the slides and make special fat stains of the
tumor. This led to a corrected diagnosis of theca cell
tumor. Undoubtedly a number of cases of theca cell
tumors have been reported in the past as fibromas of
the ovary. Correlation of the clinical history of abnor-
mal bleeding and the luteinized appearance of the tumor
should suggest the possibility of theca cell tumor, and
extensive microscopic study should be made by the
pathologist to determine its presence. Otherwise we
are certain that the majority of these cases will be
reported as fibromas. Unfortunately we failed to obtain
any endometrium from our second case. The first case,
however, showed an inactive endometrium with hypo-
plasia of the glandular elements. This finding we are
unable to explain. The majority of theca cell tumors
reported have shown definite hyperplasia.

In both cases unilateral oophorectomy was per-
formed. The uterus, both tubes and the remaining
ovary were allowed to remain in situ, as the tumors were
grossly benign and only two of the reported cases have
been malignant. Since removal of the tumors, normal
menstrual cycles have been reestablished in both cases.

CONCLUSIONS

1. Theca cell tumors are a definite clinical entity and,
though occurring most frequently at the menopause,
may occur at any age.

2. From the reported cases and our two cases of theca
cell tumors occurring in young women, it would seem
that theca cell tumors may produce menorrhagia in
younger women but that amenorrhea of varying periods
is the rule. In women near the menopause, menor-
rhagia is the rule.

3. Unless fat stains and special studies are made of
solid ovarian tumors, especially when associated with
amenorrhea or menorrhagia, a number of theca cell
tumors will continue to be erroneously diagnosed as
fibromas.

1430 Tulane Avenue.

First Recorded Pandemic Plague. — The first recorded
pandemic of plague according to Wu was that of Justinian in
the sixth century, starting in Egypt in 542 A. D. and spread-
ing to Constantinople. It lasted fifty to sixty years, and its
victims are estimated at 100,000,000. The second plague pan-
demic, the “Black Death,” took place in the fourteenth century
in Europe and claimed 25,000,000 victims or about one fourth
of the population. In Great Britain from half to two thirds of
the people perished. The great plague epidemic of London,
1664-1666, is said to have killed 70,000 persons out of a total
population of 450,000. Plague disappeared from England in
about 16S0, having been almost continuously present for nearly
140 years, with five epidemics.— Herms, William B.: Medical
Entomology, New York, Macmillan Company, 1939.

1638

SEPTICEMIA— THORNHILL ET AL.

Clinical Notes, Suggestions and
New Instruments

SULFANILAMIDE IN STAPHYLOCOCCIC SEPTICEMIA

TWO CASES WITH RECOVERY

William A. Thornhill Jr., M.D.; Howard A. Swart, M.D.,
AND Clitton Reel, M.D., Charleston, W. Va.

Staphylococcic septicemia has long been considered as almost
invariably fatal, and the finding of staphylococci in the blood
stream of a patient with septicemia has led to the rendition of
many a hopeless prognosis.

The recent introduction of sulfanilamide, and its use in infec-
tions of all types, has been of interest to all medical prac-
titioners.

We have found one report of staphylococcic septicemia
successfully treated with sulfanilamide. Morris 1 reports the
use of antitoxin, transfusions and sulfanilamide for treating a
white man aged 37 whose blood cultures showed Staphylococcus
albus on four occasions.

REPORT OF CASES

Case 1.— A white man, aged 31, was admitted to the Charles-
ton General Hospital, Aug. 17, 1938, with the history of having
jabbed the end of a pick into his knee nine days before admis-
sion while working as a coal miner. The patient noticed that
shortly afterward the knee became painful and swollen. His
doctor gave him tablets of mercury bichloride to dissolve in
water for bathing the knee. In spite of this treatment the knee
became worse.

Examination on admission revealed that the knee was swollen
and tender. There was a small, unhealed puncture wound,
which showed some infection, over the patella. The thigh was
also swollen and tender. X-ray examination of the knee was
negative. The patient’s temperature on admission was 98 F.
This rose to 102 F. at 4 p. m. and to 103.8 F. at 8 p. m.
Urinalysis August 17 showed albumin (1 plus), no sugar, casts
(1 plus), an occasional red blood cell, pus (1 plus) and mucus
(1 plus). Treatment by means of continuous warm moist dress-
ings to the knee and thigh was started.

August 18 his temperature was 104.4 at 8 p. m. Sulfanilamide
20 grains (1.3 Gm.) every three hours was started. This was
accompanied by sodium bicarbonate IS grains (1 Gm.) twice
a day.

August 19 the swelling of the knee had receded. The patient
was coughing and complaining of inability to breathe. A
roentgenogram of the chest was negative. His temperature on
this day was 102.5 F. at midnight.

August 20 a blood culture was reported as showing 5 colonies
per cubic centimeter of an organism, probably Staphylococcus
aureus. The hemoglobin, which had been 70 per cent August 19,
had dropped to 59 per cent. Widal and undulant fever tests
were reported negative, as was the blood Kline test. The
sulfanilamide concentration in the blood on this date was 1.5
mg. per hundred cubic centimeters.

The patient was very ill at this time, being delirious and
nonccoperative. His condition seemed precarious. A transfusion
of 500 cc. of blood was given August 20. On this day his tem-
perature rose to 105.4 F. The pulse during this time was running
between 120 and 140. The abdomen was somewhat distended
and the patient perspired freely.

August 21 the temperature dropped to 100.4 F. at 8 a. m.
However, it rose again to 103.4 F. at 8 p. m. On this day the
hemoglobin was 70 per cent, erythrocytes 4,600,000 and leuko-
cytes 16,000. The sulfanilamide concentration in the blood had
risen to 3.5 mg.

August 22 cellulitis on ' the lateral side of the thigh was

Jove. A. 31. A.
Oct. 28, 19J9

August 23 a second culture showed Staphylococcus aureus
with not as many colonies as in the first culture. The blood
sulfanilamide concentration at this time was 5 milligrams per
hundred cubic centimeters.

The patient was given sulfanilamide during this time and
had transfusions of 250 cc. of blood every other day. His tem-
perature varied from 102 F. to 103 F. and on August 2)
fluctuation was detected on the lateral side of the left thigh.
The same day, tinder local anesthesia, an incision was made
and 300 cc. of thin yellow pus was evacuated. Warm moist
dressings were again started.

Following this procedure the leg drained thin yellow pus in
increasingly smaller amounts and the temperature slowly
receded. Blood sulfanilamide determinations were reported as
10.5 mg. August 26, August 29 and September 1.

A third blood culture was reported August 26 as showing
Staphylococcus aureus haemolyticus, and culture from the pus
of the abscess showed Staphylococcus aureus, slightly hemolytic.
September 9 blood culture showed only one colony of Staphylo-
coccus aureus after four days’ growth. The blood sulfanilamide
ranged from 10.5 mg. September 1 to 6.8 mg. September 2.

The patient made a slow but continuous improvement. Sep-
tember 12 there was practically no drainage from the leg, and
warm moist dressings and sulfanilamide were discontinued.
However, because of reports that improvement following the
use of the drug was not maintained after its withdrawal, the
administration of sulfanilamide was started again.

September 12 blood culture was reported as follows: “Plates
sterile, slight growth of staphylococcus in broth.” September
20 blood culture was sterile after seven days and on Septem-
ber 26 a similar report was made. October 3 the culture was
sterile after eight days.

September 20 the sulfanilamide was again stopped. While the
patient felt very much better, his temperature never droppe
below 100 F. for any length of time and his leg still drama
pus. He complained also of pain in his left shoulder, and a
slightly tender swelling eventually appeared in the left axnlaO
space.

He had received 5,450 cc. of blood in thirteen transfusions
over a period of thirty-nine days. His hemoglobin rose 0
72 per cent October 6.

A roentgenogram of the femur October 5 showed subacu e
osteomyelitis, distal two thirds, shaft of femur, with irregua
bone absorption and slight periosteal thickening. The proccs
involved the knee joint.

It was considered inadvisable for the patient to go on
because of the continued elevation of temperature and axi
swelling, but he became very anxious to leave and " as .
charged October 7, fifty-one days after admission. He re u
to the hospital October 28, twenty-one days after isc 1 ’

complaining of pain and swelling under the left arm. e
found to have marked axillary adenitis and cello ii is
shoulder region. Roentgenograms were negative. At »
the leg wound was healed but there was little mo ion

Jcricc I

His temperature on readmission was 102.6 F. by rnou
4 P . m. His blood count showed 52 per cent h«n<rfo™
2,800,000 erythrocytes and 21,500 leukocytes, _ of whicl
cent were neutrophils. Urinalysis was essentially neg

Treatment was instituted by means of warm mois ! j

to the region of the shoulder, sulfanilamide a grains
every hour and blood transfusions. d3yS

Ail axillary abscess formed, and on Rovember -, { j ief ja
after the second admission, it was incised under o
and 200 cc. of thin yellow pus evacuated. , . .. c y ; t

Blood cultures on this visit were sterile after
hours and after seven days. Culture of the pus ^
showed Staphylococcus aureus, slightly hemolytic. UoC j

Sulfanilamide was continued until Novcmber^^ ^ om t hc

AU”USi L22 tcuuuua uii uil lULLitu muv. vi. v**-o-* — - Fin in a PC J

definitely present. The temperature ranged from 101.4 F. at sulfanilamide rose to 11.8 mg. at this ' . . t y(

4 a. m. to 104.4 at 8 p. m. The patient did not respond to wound gradually subsided, leaving the siiou uc j ^ Wo0( j

Questions Roentgen therapy was given, also a transfusion of He received three blood transfusions, 1, a • ? cl
1 tr;. i,„mnrrlnhi'n. which was J- i

Slits.

250 cc. of blood.

I. Morris John F. : Staphylococcus Septicemia, West Virginia M. J-.
J5:1S6-1S7 ’(April) 1939.

all, at this visit. His hemoglobin which - ag3: -

October 29, dropped to 36 per cent November / but
to 62 per cent November 17.

Volume 113
Number IS

BACTEREMIA— GOLDBERG AND SACHS

1639

He was again dismissed from the hospital December 9, at
which time tiie axillary wound was almost completely healed.
The shoulder was very stiff. There was little motion in the
left knee and some weakness of the external lateral ligament
of this knee.

Because of the bad roads and inaccessibility of his home, he
was not seen again until March 9, 1939, three months after
leaving the hospital. At this time he had complete and painless
motion in the left shoulder. He had only 20 degrees flexion of
the left knee, however. The wound of the leg was healed and
he walked with a cane.

He returned to the hospital May 22, at which time it was
found that there was drainage again from the sinuses on the
lateral surface of the thigh. The knee was stiff in a position
of 165 degrees extension. He was again treated with warm
moist dressings and traction and when last seen there was still
some drainage of pus from the thigh.

Case 2. — J. B., a white boy aged 15 years, was first seen by
F. C. R. on tbe third day of his illness complaining of pain in
the left upper jaw, for which he had consulted his dentist the
preceding day. He was referred as having no dental lesion.
His family and past histories were noncontributory except for
tonsillectomy in 1937.

The patient was apparently healthy and cooperative. The
left side of the face was generally swollen and red, including
both eyelids. There was injection of the conjunctivae and
limitation of the excursion of the eyeball. The infra-orbital area
medial to the foramen was tense, and palpation yielded a sensa-
tion of fluctuation. The left side of the nose was blocked by
edematous, reddened mucous membrane and seropurulent drain-
age. The antrum was dark on transillumination. There was
some pharyngeal congestion and slight cervical adenopathy.
Antral irrigation produced a few cubic centimeters of fine
granular pus.

The patient was admitted to an eye, ear, nose and throat
hospital the following day because of an increase in his cellulitis
and a rise of temperature to 103.2 F. His blood count was
reported to show 70 per cent hemoglobin, 3,900,000 erythrocytes
and 14,600 leukocytes, with 86 per cent polymorphonuclear
forms, 11 of which were immature. Nasal smear and cultures
revealed both a streptococcus and a staphylococcus. The urine
showed albumin, pus and an occasional red blood cell and
granular cast.

On the fifth day of his disease the infra-orbital abscess was
incised and pus evacuated. The fever level remained about
104 F. By the eighth day an abscess which had formed in the
left tonsillar fossa was incised and drained profusely. The same
day he developed proptosis of the right eye with marked injec-
tion, and small hyperemic areas over the left anterior superior
iliac spine and right heel with scattered petechiae over the
extremities. His leukocytic count was 18,400 with essentially
the same differential picture. There was less albumin and pus
in the urinary specimen. He became semicomatose, but his
response to intravenous fluids was gratifying.

At this point he was seen by one of us (W. A. T.), and
transferred by ambulance to a general hospital with a clinical
diagnosis of septicemia and a cavernous sinus thrombosis, sec-
ondary to a spontaneous left infra-orbital abscess. Blood culture
was taken, sulfanilamide therapy instituted, and transfusion
performed. The blood culture showed 50 colonies per cubic
centimeter of hemolytic Staphylococcus aureus. The leukocyte
count was 20,400 per cubic millimeter. Eighty-six per cent of
these cells were polymorphonuclears. There were 4,000,000
erythrocytes with 68 per cent hemoglobin. His blood sulfanil-
amide level was maintained between 4.0 and 7.65 for the first
sixteen days of his second hospitalization with constant dosage.
He was then given a respite of one week and returned to a
steady dosage for nineteen more days. He received during the
course of his illness 865 grains (56 Gm.) of sulfanilamide.
Transfusions of 250 cc. of citrated blood were given on fourteen
occasions between the fifteenth and fiftieth days of his illness.

Bilateral proptosis prompted a diagnosis of bilateral cavernous
sinus thrombosis and he had a paralysis of the left fourth nerve.

which did not clear up until some three months after his acute
stage. There was also transient paralysis of his seventh and
ninth nerves on the left. Ten days after his hospital transfer
thick yellow pus was aspirated again from his infra-orbital
abscess, and incision and drainage were performed. An acute
bilateral otitis media developed but subsided without drainage.

He was discharged on the fiftieth day of his illness but con-
tinued to have a low grade fever at home for some weeks.
He also had a subcutaneous infection on his right forearm,
which persisted unchanged for about two weeks in spite of
roentgen treatment and eventually had to be opened during his
convalescence in Florida. A roentgenogram of the arm indicated
periostitis. After incision and bone scraping, drainage persisted
for one month. He has at this date still some periostitis and
drainage from the forearm, though he otherwise is quite well.

COMMENT

It has been thought desirable to report these cases because
of the failures in treating staphylococcic septicemia and because
of the widespread interest in the use of sulfanilamide. How
much of the credit for the cure must be given to the blood
transfusions and roentgen treatment in the one case is difficult
to decide. The transfusions bolstered up the patient’s hemo-
globin, which was attacked by both the infectious process and
the sulfanilamide. The roentgen therapy undoubtedly' helped to
localize the abscess in the leg.

The use of so many therapeutic agents in the treatment of
this disease is evidence that no one of them is effective in every
case. Another point brought out by a study of the literature
is that the number of cases of the disease is comparatively small
and few men become proficient in its treatment. Sulfanilamide
is much more easily procurable than either antitoxin or bac-
teriophage, and if further successes follow its use in this disease
it would seem to be the method of choice.

CONCLUSION

Two patients with Staphylococcus aureus haemolyticus
septicemia with formation of localized abscesses recovered fol-
lowing the use of sulfanilamide, blood transfusions and drainage
of the abscesses.

SULFAPYRIDINE IN THE TREATMENT OF STAPHYLO-
COCCUS AUREUS BACTEREMIA

Samuel L. Goldberg, M.D., and Allan Sachs, M.D.

Chicago

Much interest has been aroused by the advent of sulfapyridine.
Although its use has been almost limited to the treatment of
pneumonic processes, its efficacy in other conditions has been
briefly reported.

Instances of the use of the drug in staphylococcic septicemia
or bacteremia of necessity are few and brief. Fenton and
Hodgkiss 1 reported its use in a case with an aty'pical clinical
picture. A single culture of the blood revealed Staphylococcus
aureus. The only significant finding was x-ray evidence of
pleural thickening. The temperature dropped markedly twenty-
four hours after administration of the drug. O’Brien and
McCarthy - reported staphylococcic bacteremia following furun-
culosis, with a dramatic drop in temperature and sterile blood
culture following therapy with sulfapyridine. Maxwell’s 3
patient had staphylococcic bacteremia coincidental to pneumonia.
Staphylococci were recovered from two cultures of the blood.
The temperature dropped to normal in forty-eight hours and
culture of the blood became sterile seven days later. Long-<
mentions rapid sterilization of the blood after the institution

The Department of Bacteriologj-, Dr. Katharine M. Hotvell, director
cooperated in dome the bacteriologic work. ’

1. Renton, W. J., and Hodzkiss, Fred: Lancet 2: G67 (Sept. 17) 1938
193s’ 0 Bnen ’ E ' J'’ aml McCarthy, C. J.: Lancet 2: 1233 (Dec. 3)

3. Maxwell. James: Lancet 2: 1233 (Nov. 2d) 1938.

1939’ L ° n,: ’ r ' U " Sulfa Pi'ridinc, J. A. .VI. A. 112: 333 (Feb. 11)

1640

BACTEREMIA— GOLDBERG AND SACHS

Joint. A. M. A.
Ocr. 28, 1939

of sulfapyridine therapy in three of five patients ill with
staphylococcic bacteremia. This is what he expected as a result
of his experimental work with animals.

REPORT OF CASES

To these brief reports can be added our two cases :

Case 1. — M. K., a white girl aged 28 months, entered Sarah
Morris Hospital Feb. 3, 1939, with complaints of swelling and

leg, which was symmetrical from the knee to the ankle with
tightly stretched skin. The anterior tibial surface was red,
warm and indurated. A diagnosis of osteomyelitis with sub-
periosteal abscess was made.

The patient was operated on under, ethylene anesthesia. A
subperiosteal collection of pus was found at the upper portion
of the tibia. Drill holes were made, and pus was obtained
from the marrow cavity. A window of bone was cut out and

pain of the left lower leg. There was a history of previous
furunculosis with a large carbuncle on the buttock. One week
before admission this carbuncle had been accidentally injured,
following which there was purulent drainage. During the next

petrolatum packing inserted. Cultures of the pus o a'
showed hemolytic Staphylococcus aureus.

After operation, the course was marked with daily
perature spikes from 102 to 104 F. rectally, as shown in chart •
Blood cultures revealed hemolytic btapi >
lococcus aureus. Multiple small Iran
fusions of citrated blood were gi' cn a
large doses of sulfanilamide were s ar
Although the temperature dropped siofti .
the patient continued to be very
and the blood cultures continued posi
for Staphylococcus aureus.

Since the sulfanilamide over a
period did not sterilize the blood st

it was discontinued. In an effort^

accomplish this sterihzatio , jg

with sulfapyridine givcn 45

pound (13.6 Kg.) child was - .

1 - ' of sulfapyridine daib

the fifth day blo °*

three days the patient had a series of chills with high tem-
perature and anorexia. Following this she doveloped pain. and
then swelling of the left leg from the knee to the ankle,
history is otherwise irrelevant.

Physical examination on admission revealed a rectal teni-
r 1042 F There were no abnormalities other than
rS* L tatock and .he .< -he k*

grains (3 Gm.)

six divided doses, on ~ "dosage

culture was negative. T w lii’H

was continued for six more
the temperature, which had bee . idty dii -
reached normal and the ‘ ducc d W
appeared. The dose was then r ^
30 grains (2 Gm.) daily or • an) .
then stopped. There '« a > . ira -

vomiting. The general con^ ^
proved rapidly in spite c (fayS .

atory infection and feve ■ 0 i(line thcraP)'

During the ^ odo , [s “!!Z y Z hot vc

isfw'on

dressings locally. Because of the anemia
was given at the end of the

for
blood tran

OI me ...

course of sulfapyn in • ^ c ar ah

ids gm-'i * _

Case 2.— E. M„ a white boy aged 11 years, week

Morris Hospital May 5, 1939, had i a t -ere i ^ &

previously, followed by a rise 111 h ante rior &!-

there was pain, swelling and redness ot

who enter

Volume 113
Number 18

SEPTICEMIA— MEYER AND AMTMAN

1641

of the right lower leg. These became more pronounced daily,
with a gradual rise in the rectal temperature to 104 F. There
was no history of recent trauma, upper respiratory infection
or furunculosis.

Physical examination revealed a rectal temperature of 103.6 F.
The child was sick and toxic. Significant abnormalities were
limited to the right lower leg. It was tense with swelling,
red and hot. There was marked tenderness, which seemed
superficial. Roentgenologic examination revealed no bone
involvement. Cellulitis of the leg was the tentative diagnosis.

Massive hot wet dressings were applied to the local lesion.
One hundred grains (6.5 Gm.) of sulfanilamide (1 grain per
pound of body weight) was given in the first twenty-four
hour period. The next day (May 6) fluctuation was evident
and the localized abscess was incised. Eight ounces (235 cc.)
of thick pus was evacuated. Culture of this pus revealed
Staphylococcus aureus. The next day (May 7) there was a
drop in the rectal temperature to 102.2 F. (chart 2) but the
boy looked very sick. Blood drawn for culture May 7 and
again May 8 revealed Staphylococcus aureus bacteremia.

On the afternoon of May 8 sulfapyridine therapy was begun.
A total of 270 grains (18 Gm.) was given by mouth in nine
divided doses the first thirty-six hours, after which the daily
dose was reduced to 135 grains (9 Gm.).

May 9 the boy complained of pain in his right elbow. Exami-
nation revealed swelling, redness and tenderness. Hot moist
dressings were applied. The local condition improved and
seventy-two hours later all the signs of inflammation had
completely subsided.

May 12, the fourth day following institution of sulfapyridine
therapy, blood drawn for culture was sterile. There was a
decided drop in temperature to 100.8 F., with marked improve-
ment in the general condition. Repeated blood cultures May 13
and 15 remained sterile. May 14 the dose of sulfapyridine was
reduced to 90 grains (6 Gm.) daily for the next three days.

The temperature dropped to normal May 15 and remained
so until May 21, when it rose to 101 F. Roentgenologic exami-
nation of the leg and elbow at this time revealed osteomyelitis
of the tibia and ulna. Sulfapyridine was again given in daily
doses of 90 grains for three days, when the temperature again
became normal. The leg improved during this period, there
was less drainage, and the arm showed no recurrence of any
signs of inflammation.

COMMENT

The effect of sulfapyridine on the local lesion is something
regarding which little is known. The lesion of the ulna in
case 2 interested us greatly. Signs of inflammation appeared
over night and disappeared completely within three days, leaving
no residue of either subjective or objective symptoms, and yet
twelve days later there was definite roentgenologic evidence of
bone destruction, which is progressing slowly and will probably
require drainage. This phenomenon may prove a very valuable
aid in the treatment of acute osteomyelitis, especially as the
recent trend seems to be toward conservative management.
Whether sulfapyridine will be of any value in reducing the
duration of osteomyelitis is as yet an open question.

We realize the pitfalls of reporting only two instances of
sterilization of the blood stream in Staphylococcus aureus bac-
teremia and claiming effectiveness for any therapeutic agent.
Unquestionably the blood stream is sterilized by normal body
defense mechanisms more often than we realize. 5 Instances
of such sterilization after the use of staphylococcus antitoxins
arc being reported in the literature more frequently. However,
the change in the clinical pictures in these cases was striking
enough to lead us to believe that sulfapyridine was instrumental
m sterilizing the blood stream. The disease is one which has
a high mortality, and any agent which might have any beneficial
effect is worthy of further investigation, especially since the
meager investigative work done so far would point to some
specific action of this drug against the staphylococcus. Proper
evaluation of the effectiveness of the drug can be made only
on a large group of cases.

1939' R ' ic,lc1 ’ H - A.: Proc. Staff Meet., Mayo Clin. 14: 138 (March 1)

TREATMENT OF FRIEDLANDER’S SEPTICEMIA BY
SULFAPYRIDINE WITH RECOVERY

Karl A. Meyer, M.D., and Leo Amtman, M.D., Chicago

Septicemia resulting from Bacillus mucosus capsulatus (Fried-
lander’s bacillus) is rare. It is in the French literature that
one finds the most frequent reports. Colombo 1 in 1917 collected
sixty cases from the world’s literature, of which twenty-five
were diagnosed during life by a positive blood culture. Caus-
sade, Joltrain and Surmont 2 collected fifteen new cases which
occurred from 1917 to 1924 and reported their own case. Since
then a case has been reported by Creyx 3 and another by
Lereboullet and Pierrot 4 in which recovery occurred. In 1924
Lereboullet and Denoyelle 5 reported two cases in children who
recovered. In 1928 Mason and Beattie 6 reported their own
fatal case, in which the portal of entry of the organism was
not determined. They reviewed the literature and made mention
of the fact that the "occurrence of septicemia from infection
with Bacillus mucosus capsulatus is not generally recognized
in Canada." Apparently up to 1927 there are only a few cases
of Friedliinder’s septicemia in which recovery has occurred.
In 1934 Baehr, Schwartzman and Greenspan 7 cited sixteen cases
of B. Friedlander bacteremia, with recovery in four. Three
of the patients who recovered had infections of the kidney and
urinary passages. The authors point out that blood invasions
from this source are often transient and that in two of the
cases the organism was recovered from the blood stream only
on the day following a urethral or ureteral chill. The other
patient who recovered bad an infection of the biliary passages.
Kolmer 8 lists Bacillus mucosus capsulatus as an organism
producing one of the rarer septicemias. He totals observations
in 282 cases of septicemia. He states that case reports dealing
with blood stream infections due to Bacillus mucosus capsulatus
are uncommon and that reports showing complete recovery
are rare. Since 1934 approximately twelve cases of this type
of septicemia have been reported in the literature. 0

From Grant Hospital and the Department of Medicine of the Uni*
versity of Illinois College of Medicine.

1. Colombe, J .: Les septicemies pncumobacillaires, Paris these, 1917,
No. 29 de ia bibliotiieque de la Faculte de medecine de Paris.

2. Caussade, G.; Joltrain, E., and Surmont, J.t Septicemie a pneumo-
bacille de Friedlander, Bull, et mem. Soc. med. d. hop, de Paris 48:
148 (Feb. 8) 1924.

3. Creyx, M.: Sur un cas de pneumobaeillemie, Compt. rend. Soc.
de biol. ©4: S96 (March 12) 1926.

4. Lereboullet, P., and Pierrot, M.: Un nouveau cas de septicemie
a pneumobacille de Friedlander terminee par la guerison, Bull, ct mem.
Soc. med. d. bop. de Paris 51:128 (Feb. 10) 1927.

5. Lereboullet, P., and Denoyelle, L. : Deux cas de septicemies
graves a pneumobacille de Friedlander terminees par la guerison. Bid], ct
mem. Soc. med. d. hop. de Paris 48 : 226 (Feb. 29) 1924.

6. Mason, E. H., and Beattie, W. W.: Septicemia Due to a Strain
of the Bacillus Mucosus Capsulatus Group in a Case of Diabetes Mellitus
Arch. Int. Med. 42: 331-337 (Sept.) 1928.

7. Baehr, George; Schwartzman, G., and Greenspan, E. B.: Role of
Bacillus Friedlander in Infections, Tr. A. Am. Physicians 4S: 353-354,

8. Kolmer, John A.: Ann. Int. Med. 8:612-631 (Nov.) 1934.

9. These cases have been reported by:

Railliet, Pcrono and Morel: Septicemia and Meningitis Due to Fried-
lander’s Pneumobacillus: Case, Bull, et mem. Soc. med. d. hon.
de Paris 50: 1693-1695 (Dec. 24) 1934. 1

Alien, B.: Otitis Cavernous Sinus Phlebitis Due to Bacillus Fried-
lander, J. Mount Sinai Hosp. 3: 169-173 (Nov.-Dee.) 1935.

Hepp, J.: Uterine Gangrene and Septicemia Due to Friedlander’s
Bacillus Following Criminal Abortion: Case, Ann. d’anat. path.
13:116-121 (Jan.) 1936.

Germain, A., and Maudet, J . : Septicopyemia Due to Friedlander's
Bacillus: Case with Initial Genito-Urinary Localization and Mul-
tiple Secondary Manifestations, Bull, et mem. Soc. med. d. lion, de
Paris 53: 1253-1259 (July 20) 1936.

Laroche, G,,_ and Brocard, H.t Septicemia Due to Friedlander’s
Pneumobacillus: Death Caused by Azotemia Following Injections of
Gonacrine (Acridine Dye) : Case. Bull, et mem. Soc. med. d. hon.
de Paris 53: 567-569 (May 3) 1937.

Brunetti, F-, Jr.: Septicopyemia from Klebsiella Pneumoniae (Fricd-
laiMer): Case, Gior. di bacteriol. e immunol. 18:91-101 (Jan.)

Pfeiffer, D. B.: Klebsiella Pneumoniae (Bacillus Mucosus Capsulatus)
Bacteremia Due to Prostatic Abscess: Case with Recovery. Ann
Surg. 106:1115-1118 (Dec.) 1937.

Bonciu, C.: Septicemia Due to Friedlander’s Bacillus with Vegetating
Ulcerative Aortic Endocarditis Causing Sudden Death (Case) Arch
Tom. de path, exptr. ct de microbiol. 10: 307-323 (Sept) 1937

Mamone, M., and Perez Fernandez J.: Postabortal Septicemia Due to
Bad us Capsulatus Friedlander Type: Case, Rev. sid. a. d. endo-
cnnol. 20:125-131 (March 15) 1937.

Brule. M.: Hillemand P„ and Gaube, R.: Septicemia Due to Fricd-

&1ri 3^a^Vch^ e ’l?3f- " Soc - "«• d ’ do

J, oSk J -&d , ii4 , 3? , iH:|«f e S5S5 i, 1 ^ F * dl5 "4er’s Bacillus:

1642

TIMING HEART MURMURS— FARF EL

.Tout. A. M. A.
Oct, 28, 1933

REPORT OF CASE

L. N„ a man aged 55, was first seen at home May 6, 1939,
with a history of a sudden onset of septic temperature of eleven
days duration. _ There were no symptoms which would point
to acute infection of the upper respiratory tract. For one
week he had a violent chill on the average of once every day,
usually in the evening but not at the same time. The chill]
winch lasted from twenty to forty-five minutes, was always
followed by a fever of 103-104 F. and profuse sweats. When
first seen at home, the patient appeared toxic with a temperature
of 103 and pulse of 100. The only positive manifestations were
diffuse dry rales and an occasional moist rale throughout the
chest, especially in the lower lobes, and slight tenderness in
the right upper quadrant of the abdomen. The spleen was
enlarged on percussion. The condition in the chest persisted
even after recovery, and this was interpreted as a chronic
bronchitis. There was no expectoration. It was observed that
the temperature between the paroxysms was almost normal.
Smears were made for malaria, but no parasites were found.
The therapeutic test with quinine was negative. X-ray exami-
nation of the sinuses and chest were negative.

May 8, at the patient s home, blood was drawn for routine
agglutination tests and beef broth was inoculated for culture.
The laboratories of the Chicago Board of Health reported

Smear from blood culture; Gram stain.

Bacillus mucosus capsulatus isolated from the broth culture
and also from the blood clot in the specimen submitted for the
agglutination tests. Smears showed a gram-negative short
thick bacillus with a definite capsule. It fermented all the
sugars except lactose. A mouse inoculated subcutaneously with
the organism was found dead the next morning. A positive
culture was obtained from the heart's blood.

The patient was removed to the hospital May 10. _ Blood
culture done on the same day showed the same organism. A
third culture May 12 after treatment was started showed only
a few colonies of the same organism after ten days incubation.

At 9 p. m. May 11, shortly after a severe chill, sulfapyridine
was started with 30 grains (2 Gm.), followed by 15 grains
(1 Gm.) everv four hours, day and night. There were no
more chills. After forty-eight hours the temperature remained
normal with the exception of a single rise to 102 on the fifth
day following institution of treatment. The drug was therefore
continued until 9 a. m. May 22. Complete blood counts and
urine examinations were done daily. There were no untoward
effects observed from the drug. The patient has remained well
to the date of this writing.

cojntE.vr

With no definite specific treatment for Friedlander’s septi-
cemia outlined in the literature, we felt that on the basis of

the recent experimental work on mice infected with pneumococci
and treated with sulfapyridine the clinical use of this in-
was justified in our case. Whitby « states that in pneutJ
coccic infections the drug acts by bringing about degenerative
changes m the capsular material of the pneumococcus. Flem-
ing u and Long, 12 unable to confirm this, did note that the
multiplication of susceptible organisms is hampered both in
vivo and in vitro following the administration of sulfapyridine
to mice or culture mediums. Long therefore suggests that
careful therapeutic trials of the effects of sulfapyridine in
Friedlander s bacillary infections seem warranted. This wc did
with presumptive success. We therefore report this as a proved
case of Bacillus mucosus capsulatus (Frfedlander’s) septicemia
with portal of entry unknown, which was treated with sulia-
pyridine and ended in recovery.

30 North Michigan Avenue — 185 North Wabash Avenue.

A METHOD OF TIMING HEART MURMURS

Bernard Farfel, M.D., Houston, Texas

It seems that many physicians have little difficulty in learning
to recognize normal heart sounds or in detecting the presence
of a cardiac murmur but often their determination of the time
of a murmur in the heart cycle is faulty, Cabot 1 states that
the commonest of all errors in diagnosis of diseases of the
heart is the misinterpretation of sj'stole for diastole.

In routine examinations, many physicians rely on the car
alone, calling on palpation or observation of the apex, carotid
or radial impulse when in doubt. That present clinical pro-
cedure is not entirely satisfactory is borne out by the frequent
errors every physician sees or makes himself. Mackenzie'
writes from his experience with recognized internists that many
doctors never acquire the ability to time murmurs. Warfield,
writing in Tice, 3 points out the possibility of mistaking a
seesaw murmur in mitral stenosis with regurgitation h> r 1
prolonged systolic murmur. It would be presumptuous to dwell
on the importance of proper timing of murmurs for physical
diagnosis.

The method I am about to describe requires none of , ! ' !C
intricate types of apparatus that have been devised. It requires
nothing that the physician does not ordinarily have at tie
bedside. My own experience with palpation coincident "i 1
auscultation has been one of difficulty in correlating the ti* 0
sensations so as accurately to time the murmurs I hear. e
that I would better be able to time the murmurs heard
I able to employ vision in conjunction with hearing, an
particularly sought some method which could be used hi a
cases. I have utilized the method to be described in
instances and have found it useful. I taught the met
several of my associates, with gratifying results.

Briefly, the following technic is employed : After I have a '
the patient’s blood pressure, I leave the cuff in place an
the mercury column at about midway between the sj ^
and diastolic blood pressure readings. This is. done so ^ •
obtain good excursions of the column with each bea . ^

listens to the normal heart, it will be found that the
excursion of the mercury column is coincident with t res ^
heart sound. In this way one has already estabhshe j
at which systole ends. Cabot 1 teaches that tlie mis a e
systole for diastole would not occur if the physician u | )£3rl
just when systole takes place. Knowing that the scc . 0 ”.j enta | |
sound and the impulse given to the mercury are ^

one should note whether the murmur in question ,nl
precedes this phenomenon, as would be true of a _s> 5 0 0 jj ,
mur, or follows it, which would be the case nil 1
murmur. __ — "

0. Whitby, Lionel: Lancet 2 : 1095 (Nov. 12) (g ,, j) !«*•

1. Fleming, Alexander: Lancet 8:7-1 Lfi>b 9), . 5:-; (ic h. HI

2. Long, Perrin H.: Sulfapyridine, J. A. M. A. 11 --” ^

1*. Cabot, R. C.: Thysica! Diagnosis, Baltimore, William V>ooi >.■

2 . Mackenzie, Sir James; Diseases of the Heart, Edinbu s

iversity Press, 1925. , „ tmvn. M<k* '**

3 . Tice, Frederick: Practice of -Medicine, Hager, ton
or Company* vol. 6, 1921.

Volume 113
K umber IS

COUNCIL ON PHARMACY AND CHEMISTRY

1643

. That the second sound is dependent on aortic tension is
pointed out by Howell, 1 who quotes Williams’ work on animals
in which he shows that the second sound disappeared as an
animal hied to death and the heart failed to throw out a suffi-
cient supply of blood to maintain aortic tension. That the
sudden thrust upward of the mercury should occur at the
moment when the second sound takes place may be at least
partially explained physiologically. Best and Taylor 4 5 describe
the rebound of the distended aortic wall at the close of systole,
causing the aortic valves to close and forcing the blood along to
the periphery as well.

It will also be observed, in using the method described, that
the period during which the mercury falls slightly, just prior
to the sudden rise, will usually coincide fairly well with the
interval between the first and second sounds, namely systole.
The technic given offers another means of timing murmurs.
This communication is forwarded in the hope that a method
that has proved useful to many of my associates and myself
may be of some aid to others.

Council on Physical Therapy

The Council on Physical Therapy has authorized publication
of the following report. Howard A. Carter, Secretary.

RAVOX HEARING AID ACCEPTABLE

Manufacturer: Zenith Radio Corporation, 6001 Dickens
Avenue, Chicago.

Description . — The Ravox Hearing Aid is supplied with power
through a cord which connects to a nominal 110 volt, 60 cycle,
alternating current electric light receptacle. On measurement
it was found that the power consumption was 20 watts. The
Ravox unit is housed in a formed sheet metal case of somewhat
irregular shape but attractive design. The weight of the unit is
5 Yi pounds and the overall dimensions are approximately 4)4
by 7 by 9 inches. A crystal type watch case receiver with head
band plugs into a pair of phone jacks at the rear of the device.
The microphone operates on the condenser principle and is sus-
pended by means of shock absorbing coil springs directly behind
a cloth covered grill located in the front face of the unit. The
amplifier has three tubes of standard make.

The amplifier is provided with a combination shut-off switch
and tone control located at the rear of the housing and a volume
control knob located at the side.

Performance Tests . — Both single frequency response tests and
speech tests (articulation and intelligibility) were made. For
the single frequency tests the Ravox unit was suspended by its
handle within a chamber which is substantially free from stand-
ing waves and excited by pure tones produced by a loud speaker
unit and oscillator. The measured
amplifications obtained with the
volume control full on and with
the tone control set for maximum
| high frequency gain are shown on
the accompanying graph. Corre-
sponding amplification determina-
tions were made with the tone
_ „ . .. control set for minimum high fre-

a\ox earmg id. quency response, and it was found
that above 2,000 cycles the amplification was reduced on the
average by approximately 15 decibels, whereas below 1,000 cycles
the gain was substantially unaltered. By direct listening it was
observed that for each test frequency the sound output was quite
Pure and substantially free from harmonics or subharmonics,
but there was present a hissing or rushing noise which inter-
fered with the test tone when the output intensity fell to about
the input intensity.

The performance of the Ravox hearing aid in transmitting
speech sounds and sentences was very good. Thus with the

4. Howell, \v. H. : Textbook of Phvsiology, Philadelphia, W. B.
launders Company, 1907.

5., Best, C. H., and Taylor, N. B. : Physiological Basis of Medical
Practice, Baltimore, William Wood & Co., 1937.

instrument adjusted for maximum high frequency response and
placed in a small room having good acoustic properties, with
observers having normal hearing in another room listening to
the output, it was found that it was necessary to reduce the
amplification approximately 45 decibels to produce a loudness
in the Ravox receiver judged to be equal to loudness of speech
when directly listened to. Under these circumstances the

Measured amplifications obtained with volume control full on and with
tone control set for maximum high frequency gain.

inherent rushing sound previously mentioned Was not objection-
able and it was found that consonant-vowel-consonant syllables
were transmitted over the Ravox with an almost perfect score.
In fact no substantial difference in score was obtained- when
one was listening alternately to the sounds directly and over
the Ravox link. Ordinary speech was likewise transmitted very
efficiently. Hence it is concluded that the significant speech
frequencies are transmitted by the Ravox hearing aid without
admixture of disturbing sounds and amplification of approxi-
mately 45 decibels.

In view of the foregoing report, the Council on Physical
Therapy voted to include the Ravox Hearing Aid in its -list of
accepted devices.

Council on Pharmacy and Chemistry

NEW AND NONOFFICIAL REMEDIES

The following additional articles have been accepted as con-
forming to the rules of tiie Council on Pharmacy and Chemistry
of the American Medical Association for admission to New and
Nonofficial Remedies. A coty of the rules on which the Council

BASES ITS ACTION WILL BE SENT ON APPLICATION.

Paul Nicholas Leech, Secretary.

ASCORBIC ACID (See New and Nonofficial Remedies,
1939, p. 499).

Ascorbic Acid-Squibb.— A brand of ascorbic acid-N. N. R.

Manufactured by E. R. Squibb & Sons, New York City. No U. S.
patent or trademark.

Tablets Ascorbic Acid-Squibb, 25 mg.: Each tablet is equivalent to
500 international units of vitamin C.

Tablets Ascorbic Acid-Squibb, 50 mg.: Each tablet Is equivalent to
1,000 international units of vitamin C.

SULFAPYRIDINE-LEDERLE (See Tiie Journal,
June 24, 1939, p. 2603).

The following dosage form lias been accepted :

Capsules Sulfapyridinc-Lcdcrlc , 0.25 Cm.

COD LIVER OIL (See New and Nonofficial Remedies
1939, p. 506).

I. V. C. Cod Liver Oil.— It has a vitamin A potency of
not less than 2,250 units (U. S. P.) per gram and a vitamin D
potency of not less than 260 units (U. S. P.) per gram.

Dosage. For adults, S cc. (2 fluidrachms) daily; for children
4 cc. (60 minims) daily. '

Prepared by the International Vitamin Corporation, New York.
L. S. patent or trademark.

No

-t r .j r-;- : . o. x . Manaarus xor coc

Lot i w! o d ^A 0n ,s rct t u,red t0 , have a vitamin A potency oi

less than 260 u^iupeTfrar Sram a " d “ D of n °>

1644

EDITORIALS

THE JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION

535 North Dearborn

Street - - - Chicago, III.

Cable Address -

* * - “Medic, Chicago"

Subscription price ....

* Eight dollars per annum in advance

Please scud in promptly notice of change of address , giving
both old and new; always state whether the change is temporary
or permanent. Such notice should mention all journals received
from this office. Important information regarding contributions

7 vill be found on second advertising page following reading matter.

SATURDAY,

OCTOBER 28, 1939

EFFECTS OF

AIRPLANE NOISE

ON

AVIATORS

Experiments have shown that prolonged stimulation
of the ear by intense sound causes cochlear degenera-
tion resulting in deafness. Bauer 1 in 1926 said that
the constant noise of high powered airplane motors
causes diminution in hearing. At first this deafness
gradually wears off after a few hours, but constant
flying without protection for the ears leads to perma-
nent impairment of hearing. Kawata 2 subjected guinea
pigs to noise for a month and on microscopic examination
found complete degeneration of the organ of Corti at
the point of transition from the basal turn to the second
coil of the cochlea.

Recently British investigators Dickson, Ewing and
Littler 3 said that noise produced by certain types of
multi-engined aircraft has been measured and found to
reach loudness levels which are injurious to human
ears. The loudness levels produced by various types
of aircraft have been measured and have shown intensi-
ties of from 110 to 135 phons. Tests carried out on
members of the Royal Air Force even after a few
hundred hours of regular flying without helmets in
enclosed cock pits showed a persistent loss of bearing
for high tones. The observations included a complete
aural examination in addition to audiometric tests. The
subjects themselves were not always aware that their
auditory acuity was impaired. This form of auditory
defect probably is progressive in character as long
as the patient continues- to fly or to tune noisy aircraft.
As the intensity and duration of the fatiguing sound
was increased, all subjects showed a succession of phe-
nomena. First there is an intensity value at C 3 , about
100 decibels above the threshold of audibility, exposure
to which for as little as two minutes leads to aural
fatigue involving subsequent depression of response.

j $au e r, J. H.: Aviation Medicine, Baltimore, Williams & Wilkins

'sSichfr Experiment^ Studfcn uber die LarmschSdi-
gungen des Gehororgans, Jap. J. M. Sc. -•. // (Sept.)I9j.

? Dickson E D. Dafciel; Ewing, A. W. G., and Littler, T.

The Effect's of Aeroplane .Vote on M

Some Preliminary Remarks. J. Laryng. & Oto!. 54: *31 (Sept.) 1 939.

Jot:*. A. M. A.
Oa. 28, 19J9

Prolongation of the fatiguing sound beyond this point or
further increase in its intensity causes greater immediate
loss of sensitivity and slower recovery, until temporary
deafness becomes chronic; still further increase in
intensity brings about cochlear degeneration. The
greatest hearing losses recorded in audiometric tests
by the British investigators of patients suffering from
traumatic deafness are almost always found in the
frequency of C 5 .

Noise in connection with flying arises from three
sources, the engine exhaust, the propeller and the wind
(slip stream). Tests were made to determine the
amount of protection of hearing provided by the stand-
ard pattern of flying helmet and other ear protectors
and also to determine what protection can be afforded
by simple ways of blocking the ear or packing the
meatus. They learned that packing the meatus with
absorbent cotton smeared with petrolatum was a quick,
safe and efficient method. Audiograms of aviators
using a helmet of the high altitude type with the ear
phones attached showed no loss for high tones. The
effect of noise on the ear seems to depend to some
extent on the relative position of the aviators in the
airplane. If the aviators sit well forward and in front
of the engines, the effect is considerably less severe
than if they sit below or between the engines. Inves-
tigation is being continued in the hope of finding still
more effective methods of protecting the ears of aviators.

CARDIAC NEUROSIS

Cardiac neurosis is especially baffling in the patient
in whom it is associated with organic hear t disease.
In a recent study of this problem, Schnur 1 has sug-
gested a procedure which may prove to be valuable
in the differentiation of the symptoms and signs of the
neurosis from those of the organic disease. The clue
precipitating cause of cardiac neurosis in a person sn
fering from heart disease, he points out, is profession.!
exaggeration of the severity of the process. Pari !S
more frequently a presenting symptom in car me
neurosis than in organic heart disease, except m core
nary thrombosis. Among other symptoms more com
mon in neurosis are weakness, sighing respiratio .
insomnia, ringing or pounding in the ears, and ain ^
ness, dizziness, nervousness, irritability and 1IS

Deep tenderness in the infra nummary area

in bis group

of patients was elicited in only 5 per cent of pri ,c
having organic heart disease, as contrasted with
cent of those suffering from neurosis alone.
superficial hyperalgesia was demonstrated in css ^
2 per cent of those with organic disease, where. ^
incidence in cardiac neurosis was 6S per cent- ^
frequent hyperalgesia suggested the intraderma i .
tion of procaine hydrochloride into the a cc e _
Immediate disappearance of hy peralgesia, ten .

1. Schnur, Sidney: Cardiac Xcurosis Associated " llh 0,31
Disease, Am. Heart J. 18:J53 (Aug.) 1939.

Volume 113
Number IS

EDITORIALS

1645

and pain resulted; also the symptoms not associated
with the precordium which had been regarded as
neurotic in origin disappeared. It was usually found
unnecessary to inject the entire hyperalgesic area. Fur-
thermore, ethyl chloride spray and, at times, saline
solution intradermally and the oral administration of
a red placebo were found equally effective. Cardiac
neurosis, be concludes, is therefore a distinct entity
with characteristics which can be recognized even in
the presence of organic heart disease by the following
criteria: an inherited or acquired predisposition to
neurosis ; a definite precipitating factor ; symptoms such
as inframammary pain and the others mentioned; infra-
mammary tenderness and hyperalgesia ; and, finally,
relief by simple procedures such as intradermal injec-
tion of small quantities of procaine hydrochloride,
together with suitable suggestion, the latter being the
more important.

Other aspects of this problem have been recently
emphasized by Professor Ryle 2 in the third Croonian
lecture delivered at the Royal College of Physicians
this year. Ryle states that there are no good grounds
for regarding simple paroxysmal tachycardia as -an
expression of cardiac disease or intoxication. Its inter-
mittence, its persistence through long years without
physical deterioration, its temperamental and other
associations, and the absence of all organic signs bring
it within the category of the neuroses. Similarly, vaso-
vagal attacks (Gowers’ syndrome) belong, he feels, in
this same group. Vasovagal attacks almost invariably
occur in persons who are simultaneously afflicted by
some slight impairment of general physical fitness and
by a chronic or recurring anxiety — thus illustrating
the combined influence of several factors which would
seem to underlie so many of the neuroses. The meno-
pause, a low-grade infection or anemia, a sudden
visceral disturbance, colonic irrigation, or a severe bout
of seasickness may serve as precipitating factors. On
this basis, Ryle suggests that some violent vasomotor
disturbance with accompanying vagal effects, manifest
especially in the occasional bradycardia, seem to afford
the best explanation of the attacks. Multiple visceral
neuroses rarely occur together in point of time. Ryle
points out. They alternate in a history or appear at
different periods in a patient’s life. In this respect
there is an essential difference between so-called allergy
and the more pronounced and specific anaphylactic
response. Therapy should involve, he believes, first and
essentially an assured diagnosis confidently stated. The
second essential is a simple and reassuring explanation
of the nature and genesis of the visceral symptoms
themselves and of their innocence so far as life and
ultimate prospects are concerned.

The study of the visceral neuroses is, Ryle concludes,
a study of men and women, of personalities and tem-
peraments, of heredity, habits and environments, and

-■ ttyle, John A.: Visceral Neuroses, Lancet 2: 407 (Aug. 19) 1939.

of peculiar biologic responses to common but often
inconspicuous stimuli. Possibly the explanation of the
visceral neuroses and of their tendency to be perpetu-
ated over long periods may invoke an inborn nervous
instability, the conditioned reflex or habit, endocrine
imbalance, and allergic sensitivity, operating severally
or in conjunction. Although with the aid of physio-
logic and pharmacologic experimentation better mea-
sures of counteraction and symptom-relief may be
found, it is Ryle’s belief that in the end the under-
standing and best protective contributions are likely to
derive largely from a clearer knowledge of the whole
man and from improved diagnostic achievement.

HUMAN REPRODUCTIVE PATTERNS

Many factors influence human reproductivity, which
in the last analysis determines world populations both
qualitatively and quantitatively. The results of long
years of study of the biologic and statistical factors
involved, interspersed with personal lines of thought
which have been provoked thereby, furnishes the sub-
ject of a recent book by Pearl . 1 Both the survival urge
and the reproductive urge have a fundamental biologic
role in influencing reproductive patterns, and there are
recognizable differences in the strength of these fac-
tors. Just as there are demonstrable differences in the
libido, there is likewise no reasonable doubt of varia-
tions between individual human beings in respect to
innate reproductive capacity, though these are extremely
difficult to measure precisely. One definitely determin-
ing factor is the limited span of reproductive life in
the human female. Less important — because it varies
less frequently and to a lesser degree — is the litter size
or frequency of multiple births. Closely related to
libido is the frequency of coitus, which, as Pearl points
out, because of the restricted period available for suc-
cessful fertilization, plays a large part iii determining
the fertility rate. This rate varies greatly with differ-
ent individuals. Another element is what Pearl calls
the pregnancy or conception rate in relation to the
extent of time during which it is biologically possible
for a woman to become pregnant. An additional factor
is that reproductive wastage which is characterized by
miscarriage or abortion, or by stillbirth. This wastage
is most difficult to determine with any degree of accu-
racy, although there is ample evidence, Pearl believes,
that reproductive wastage is a biologic factor of major
importance in differentially influencing fertility as real-
ized or expressed.

Finally — and because this factor has never been
adequately ascertained and is most difficult to determine
—the part played by contraceptive efforts in influencing
fertility is subjected by Pearl to as close analysis as cir-
cumstances would allow. The evidence available has
been marshaled in impressive fashion. Although future

r> r ' Ra rmonii: The Natural History of Population, New York,

Oxford University Press, 1939.

1040 CURRENT

additional information may lead to entirely different
conclusions, Pearl’s present views seem to be based
squarely on the evidence presented. “One consistent
broad result emerges,” lie says. “It is that if it were
not for the effect of contraceptive efforts and the prac-
tice of criminal abortion, together with correlated habits
as to postponement of marriage, there would apparently
be little or no significant differential fertility as between
economic, educational or religious classes of urban
American married couples. In the absence of these
forces the weight of the evidence as a whole is that
all these socially differentiated classes would manifest
about the same degree of fertility (with some possible
reservations regarding the lowest educational classes).
There would probably be some small residual differ-
ences, but they would not be great enough to worry
any person of a realistic, practical cast of mind.” This
conclusion, better documented than most of similar
nature, furnishes no surprise. The question whether,

COMMENT Jour. A. M. A:

Oct. 28, 1939

mothers in these same years, thus tending to keep the
latio more constant. To the biologist this would seem
to indicate that in the population of the United States,
at least, there has been no significant impairment of
innate reproductive capacity in recent years, if ever,
nor any serious alteration of average parity perform-
ance among the women in the population who actually
reproduced at all.

In general. Pearl’s analysis of the factors influencing
reproductivity seems to confirm those who believe that
the rapidly falling birth rate is a reflection of social,
economic and other extraneous factors rather than an
innate biologic phenomenon.

Current Comment

SUPREME COURT ACTS ON APPEAL
FROM PROCTOR DECISION

in essence, this differential represents a biologic phe-
nomenon with biologic purposes or whether it can and
should be altered by conscious hitman effort, Pearl
wisely leaves unanswered.

The differential rates of fertility vary not only as
between economic or social groups but also along geo-
graphic and genetic lines. It is noteworthy in this
connection, however, that the greatest percentage decline
in birth rates in the last third of a century has occurred
predominantly in those countries having the highest
previous birth rates. Likewise, the highest birth rates
are now, with few exceptions, appearing in those geo-
graphic regions having the smallest population-area
densities.

Whatever the relative importance of the factors influ-
encing reproductive patterns in this country, the main
facts are readily obtainable. Roughly, from 23 to 40
per cent of the women bearing products of conception
in 1930 were primiparas, an obviously high proportion
when viewed from the angles of race survival and popu-
lation growth. Furthermore, a definite though not now
precisely ascertainable proportion of these primiparas
will never bear any more children. It is evident, as
Pearl says, that unless a woman bears more than one
child in her lifetime she is not adequately reproducing
even herself, to say nothing of her family (self and
consort) or her strain. If in a given year a woman
produces her fourth living child, she may be regarded
as having adequately reproduced. Pearl says. When
the adequate reproducers, as so defined, were compared
with all women who actually 7 reproduced in the y 7 ears
1920 and 1930 (on a live birth basis), little difference
in the ratios of the two groups was observed. While
at first surprising, in view of the lowered birth rates
between these two periods, this can be explained, he
believes, by the drop in the percentage of women poten-
tially capable of being mothers who actually became

On October 23 the Supreme Court of the United
States indicated that it would not now pass on the suit
brought by 7 the Department of Justice charging the
American Medical Association, through various officials
and also some physicians and hospitals of the District
of Columbia, as well as other medical societies, with
conspiracy to violate the Sherman antitrust law by
activities against Group Health Association, Inc., of
Washington, D. C. The Department of Justice had
appealed directly to the Supreme Court from the deci-
sion rendered by 7 Justice Proctor of the District Court
for the District of Columbia. Attorney's for the Ameri-
can Medical Association did not oppose this attempt
by the Department of Justice.

Commenting on the decision, the Washington P° s

Sal ‘ A PROPER SETBACK

At some future date the Supreme Court may find it ^ es ' r . a ^ n
to review the government’s anti-trust case against the mcr '
Medical Association and the District Medical Society.
Department of Justice appears determined W fignt J u
Proctor’s decision to the last ditch. And the medical pro es ^
would certainly carry the dispute to the Supreme our ^
the Proctor opinion should be overruled in the ollr

Appeals.

For the present, however, the Supreme Court ' as ^
properly declined to review the case. It sees no 5f aS °" nst j.
departure from the customary judicial procedure. 0 ,j ca l
tutional issue is involved in the charges against t c

association. nti-trust

The case turns merely upon interpretation of t ie at ^
laws. The Department of Justice is attempting o
the Sherman act to provide protection for the Group _
Association against alleged restraints on the part o

ized medical profession. wcentinS

Should the Supreme Court set a precedent o n0

appeals directly from the federal district courts, " . nc( j

constitutional issue is involved, it would soon be o\cr ^
with litigation. The statute giving constitutional ease ; ' ,

of way to the highest tribunal makes it all the more ^
for the court to maintain a rigid check on other pc
review of less vital or complicated issues. _ pjvision

There are many indications that the Anti- rus t j, e

has been unduly excited over the idea of pros
medical association for alleged restraint of tra c.

Volume 113
N UMBER IS

ASSOCIATION NEWS

1647

the Supreme Court has sustained this criticism. It found
nothing in the Anti-Trust Division's petition to justify singling
out this case for special attention. If the division insists upon
clinging to its strained interpretation of the anti-trust laws, it
will at least have to rely upon the customary procedure for
final judicial clarification.

A TESTIMONIAL TO EVARTS GRAHAM

As indicated in our news columns, Dr. Evarts
Ambrose Graham, Bixby professor of surgery at Wash-
ington University School of Medicine, St. Louis, was
recently honored by the creation of a lectureship in his
name. His contributions to the knowledge of physiology
and surgery through his work on the pleura, the lung
and the biliary tract are among the noteworthy contribu-
tions of the last twenty years. Moreover, his influence,
through the accomplishments of his students, is world-
wide. The announcement of the establishment of a
Graham Lectureship to be given annually in St. Louis is
a suitable recognition of his interest in education.
Through this event Dr. Graham’s influence in the
advancement of scientific surgery will be prolonged.

POLIOMYELITIS IN THE EASTERN
COTTON RAT

Successful transmission of the Lansing strain of
poliomyelitis virus to the eastern cotton rat has been
recently reported by Armstrong 1 from the National
Institute of Health. The strain has been carried in
series through seven cotton rat transfers, and animals
of the eighth transfer had begun to develop symptoms
at the time of reporting. Paralysis of the flaccid type
developed in all. This animal is not vicious, multiplies
readily in captivity, and in view of the probable inter-
ference with the importation of monkeys during the war
may prove invaluable in continuing experimental inves-
tigations on infantile paralysis.

Association News

MEDICINE IN THE NEWS

The seventh season of broadcasting by the American Medical
Association over the facilities of the National Broadcasting
Company and affiliated stations opens Thursday November 2
at 4:30 p. m. eastern standard time (3 : 30 central standard
time, 2:30 mountain time and 1:30 Pacific time). The title
of the program will be Medicine in the News.

True to their title, the programs will consist of dramatizations
based on what is happening in the world of medicine. Each
program will include a principal news item from The Journal
or some other reputable medical source or from Hygcia. This
will be followed bj r one or more high lights on current medical
news. Each program will close with a question of the week
drawn from the question and answer correspondence of Hygcia .
A question will be asked each week and answered the following
week.

Since the program will be based on events as they proceed,
it will be impossible to announce program topics in advance,
-ach program will be developed within the week immediately
preceding its appearance and in part, perhaps, the programs will
often be developed within forty-eight hours of their broadcasting.

. V Armstrong, Charles : The Experimental Transmission of Poliomyelitis
1 ? 1< L Eastern Cotton Rat, Sigmodon Hispidus Hispidus, Pub. Health

l p - o4 :1719 (Sept. 22) 1939.

As heretofore, this is a sustaining program made possible
through the cooperation of the National Broadcasting Company.
A sustaining program brings no revenue to any radio station
or to the network. Therefore radio stations, except those owned
and operated by the National Broadcasting Company, are not
obligated to broadcast the program. State and county medical
societies should express interest in the program by letter or
personal interview with the manager of the local radio station.
Such evidence of local interest may be the deciding factor in
broadcasting the program locally.

Following is a list of the radio stations affiliated with the Blue
network of the National Broadcasting Company. This is a list
of stations to which the program is available, not a list of
stations which are certain to broadcast the program. A list of
stations announcing intention to broadcast the program will be
published in a later issue of The Journal.

Basic Blue Network

WBAL

Baltimore

WBZ

Boston

WICC

Bridgeport, Conn.

WEBR

Buffalo

WMT

Cedar Rapids, Iowa

WENR

Chicago

WLS

Chicago

WHK

Cleveland

KSO

Des Moines, Iowa

WXYZ

Detroit

WO WO

Fort Wayne, Ind.

WREN

Kansas City, Mo.

WTCN

Minneapolis

WJZ

New York

WFIL

Philadelphia

KDKA

Pittsburgh

WEAN

Providence, R. I.

WHAM

Rochester, N. Y.

WBZ A

Springfield, Mass.

KWK

St. Louis

WSYR

WMAL

Syracuse, N. Y.
Washington

Basic Blue Supplementary

WABY

Albany, N. Y.

WELL

Battle Creek, Mich,

WBCM

Bay City, Mich.

WLEU

Erie, Pa.

WFDF

Flint, Mich.

WIBM

Jackson, Mich.

WJTN

Jamestown, Vn.

WJIM

Lansing, Mich.

WNBC

New Britain, Conn.

WMFF

Plattsburg, N. Y.

WRTD

Richmond, Va.

KMA

Shenandoah, Iowa

Pacific Coast Blue Network

KECA

Los Angeles

KEX

Portland, Ore.

KFSD

San Diego, Calif.

KGO

San Francisco

KTMS

Santa Barbara, Calif.

KJR

Seattle

KGA

Spokane

WTAR Norfolk, Vn.

WCOA Pensacola, Fla.

KROC Rochester, Minn.

KELO Sioux Fnlls, Iowa

KSOO Sioux Falls, Iowa

KFAM St. Cloud, Minn.

WBOW Terre Haute, Ind.

WSPD Toledo, Ohio

KANS Wichita, Kan,

WBRE Wilkes-Barre, Pa.

WORK York, Pa.

Other Chicago Stations

WCFL

Chicago

Southeastern Group

WCSC

Charleston, S. C.

wsoc

Charlotte, N. C.

WIS

Columbia, S. C.

WFBC

Greenville, S. C.

WPTF

Raleigh, N. C.

North Mountain Group
KGHL Billings, Mont.
KIDO Boise, Idaho

KGIR Butte, Mont.

KPFA Helena, Mont.
KSEI Pocatello, Idaho
KTFI Twin Falls, Idaho

South Mountain Group

KOB

Albuquerque, N. M.

KTSM

IC1 Paso, Texas

KGHF

Pueblo, Colo.

California Valley Group

KERN

Bakersfield

KMJ

Fresno

KFBK

Sacramento

KWG

Stockton

Additional to Pacific Networks

KMED

Medford, Ore.

KTAR

Phoenix, Ariz.

KVOA

Tucson, Ariz.

Blue Southwestern Group
KGKO Dnllns-Fort Worth
KXYZ Houston, Texas

KTOIv Oklahoma City

BJuo Southern Group
WAGA Atlanta, Ga.

WJBO Baton Rouge, La.
WSGN Birmingham, Ala.
KTHS Hot Springs, Ark.
WMPS Memphis, Tenn.
WDSU New Orleans

Special Hawaiian Service
KGU Honolulu

Special Cuban Service
CMX Havana

Canadian Service
CBF Montreal

CBM Montreal

CFCF Montreal

CBL Toronto

CBK Watrous, Snsk.

Blue Mountain Group
KYOD Denver
KFEL Denver
KLO Ogden, Utah
KUTA Salt Lake City

Basic Supplementary
(Optional Red or Blue)
WSAN Allentown, Pa.
WRDO Augusta, Me.

WLBZ Bangor, Me.

WGKV Charleston, W. Vn.
WLW Cincinnati
WSAI Cincinnati
WBLK Clarksburg, W. Vn.
WCOL Columbus, Ohio
WING Dayton, Ohio
WEBC Duluth, Minn.

WGBF Evansville, Ind.
WGL Port Wayne, Ind.
WOOD Grand Rapids, Mich.
WKBO Harrisburg, Pa.
WGAL Lancaster, Pa.
WJBA Madison, Wis.

WFEA Manchester, N. II.
KYSM Mankato, Minn.

Florida Group
W.TAX Jacksonville
WLAK Lakeland
WIOD Miami
WFLA- Tampa
WSUN

Northwestern Group
KFYR Bismarck, X. D.
WDAY Fargo, N. D.

Individual Supplementary

KGXC

KFDM

WAPO

KRIS

WROL

WALA

KOAM

KGBX

KRGV

Amarillo, Texas
Beaumont, Texas
Chattanooga, Tenn.
Corpus Christ i, Texas
Knoxville, Tenn.
Mobile, Ain.

Pittsburg, ICnn.
Springfield, Mo.
Weslaco, Texas

Mid-South Group
WAVE Louisville, Ky.

WSM Na«hvill»\ Tenn.

1648

MEDICAL NEWS

Medical News

(Physicians will confer a favor by sending for

THIS DEPARTMENT ITEMS OF NEWS OF MORE OR LESS
GENERAL INTEREST: SUCH AS RELATE TO SOCIETY ACTIV-
ITIES, NEW HOSPITALS, EDUCATION AND PUBLIC HEALTH.)

CALIFORNIA

Funds for Cancer Research.— The University of California
has received §27,166 in gifts for cancer research by Ernest O.
Lawrence, Ph.D., professor of physics and director of the
radiation laboratory, it was announced October 5. The U. S.
Public Health Service gave §23,000 for cancer work under the
provisions of the National Cancer Institute Act and the Rocke-
feller Foundation gave $4,166. Other donations included $5,000
by the General Education Board, New York, for the Institute
of Child Welfare; §3,000 for research on syl vatic plague at the
Hooper Foundation by the Rosenberg Foundation; $900 to the
Institute of Child Welfare by the Josiah Macy Jr. Foundation,
and §3,750 for research by Dr. Herbert M. Evans on hor-
mones, by the Rockefeller Foundation.

Southern California Medical Association.— The one hun-
dred and first semiannual convention of the Southern California
Medical Association will be held at the Samarkand Hotel,
Santa Barbara, November 3-4. The guest speakers will be
Drs. William Edward Chamberlain, professor of radiology and
roentgenology, Temple University School of Medicine, Phila-
delphia, and Frank J. Heck, hematologist at the Mayo Clinic,
Rochester, Minn. They will discuss respectively “Pitfalls in
X-Ray Diagnosis” and “Treatment of Pernicious Anemia and
the Iron Deficiency Anemias.” Other speakers will include:

Dr. Harold E. Crowe, Los Angeles, Short Hospitalization for Fractures.

Dr. Ralph V. Byrne, Los Angeles, Surgical Concepts of Hyper-
thyroidism.

Dr. James Norman O'Neil, Los Angeles, Intraperitoneal Rupture of
the Urinary Bladder as Encountered hy the General Surgeon.

Dr. Pierre P. Viole, Los Angeles, Use of Human Convalescent Scarlet
Fever Serum in Streptococcic Infection of the Ear, Nose and Throat.

Dr. Louis E. Martin, Los Angeles, Serum Therapy versus Sulfapyridine
Therapy in Pneumonia.

Dr. William P. Thompson, Los Angeles, The Apparent Benignity of
Rheumatic Fever in Southern California.

Dr. Maurice P. Foley, Los Angeles, Present Day Concepts in the Treat-
ment of Liver Disease.

Dr. Charles H. Pettet, Los Angeles, Acute Abdominal Pain in Child-
hood.

There will be a symposium on hematology and one on intes-
tinal obstruction.

DELAWARE

Society News. — Dr. Kenneth M. Corrin discussed the inci-
dence of syphilis before the New Castle County Medical Society
in Wilmington October 17. Dr. Norman L. Cutler showed a
moving picture on ophthalmology and Drs. Oscar N. Stern and
Junius A. Giles Jr. presented a case of placenta praevia.

State Hospital Observes Anniversary. — The Delaware
State Hospital celebrated its fiftieth anniversary and dedicated
its new chapel September 28. Included among the speakers
was Dr. Edward A. Strecker, professor of psychiatry, Univer-
sity of Pennsylvania School of Medicine, Philadelphia, whose
address was entitled “Social Implications of Psychiatry.”

IDAHO

State Medical Election.— Dr. Abram M. Newton, Poca-
tello, was chosen president-elect of the Idaho State Medical
Association at the annual meeting in Boise August 23-26.
Dr Fern M. Cole, Caldwell, was installed as president and
Dr. Joseph N. Davis, Twin Falls, was elected secretary. The
1940 meeting will be held at Sun Valley.

ILLINOIS ■

Society News. — Dr. Samite 1 J. Fogelson, Chicago, addressed
the Effingham County Medical Society, Effingham, October 10
on “Treatment of Gastroduodenal Ulcerative Disease Based on

Modern Physiology.” The Kankakee County Medical Society

was addressed October 12 by Dr. Howard A. Lmdbcrg, Chi-
cago, on the treatment of pneumonia. -At a meeting of the

Fulton County Medical Sdciety in Canton October 12 Dr Leroy
H Sloan, Chicago, discussed “Neurology for the General Prac-
titioner.”- Dr Paul H. Wosika, Chicago, addressed the

Will-Grundv County Medical Society m Joliet October 6 on

“Auricular 'Fibrillation.” At a joint meeting of the Rock

Island medical and dental societies, Rock Island, October 10

Jour. A. M. A.
Oct. 28, 1$:>3

Dr. Frederick B. Moorchead, Chicago, discussed “Use of
Traction m the Management of Jaw Fractures and in
Plastic Surgery. — -Dr. Frank Deneen, Bloomington, spoke
before the Madison County Medical Society in Alton October
6 on Medical Management of Gallbladder Disease.” — It a
meeting of the Sangamon County Medical Society in Spring-
neld October 5 Dr. Irvine H. Page, Indianapolis, discussed
hypertension.- A symposium on medical economics ivas pre-

sented before the Champaign County Medical Society October
12 by Drs. Edwin S. Hamilton, Kankakee; Harold M. Camp,
Monmouth, and Calvin C. Applewhite, U. S. Public Health
Service, Chicago.

Chicago

Special Lectures. — Dr. Harry Gideon Wells, professor and
chairman of the department of pathology, School of Medicine
of the Division of Biological Sciences, University of Chicago,
will deliver the fourth Christian Fenger Lecture of the fnsti-
tute_ of Medicine of Chicago and the Chicago Pathological
Society at the Palmer House November 13. He will discuss
“A Neglected Subject, Adipose Tissue.” Birdsill Holly Broad-
bent, D.D.S., director of the Bolton Foundation, Western
Reserve University, Cleveland, will present the fourth Frank
Billings Lecture of the Thomas Lewis Gilmer Foundation at
the Palmer House November 24. The title of the lecture will
be "Clinical Significance and a Roentgenographic Method of
Measurement of Disturbances in Facial Growth.”

Dr. Whitecotton Comes to University of Chicago
Clinics.^— Dr. George Otis Whitecotton, superintendent of the
Stanford University Hospitals, San Francisco, for the last row
years, has been appointed to the same position with the Univer-
sity of Chicago Clinics. Dr. Arthur C. Bacbmeyer, director of
the clinics and associate dean of the Division of Biological
Sciences, has been acting as superintendent in addition to his
other duties since the resignation of John C. Dinsmore in 19 m.
Dr. Whitecotton will manage Billings Hospital, Bobs Roberts
Memorial Hospital for Children and the Max Epstein Chiuc,
while the supervision of Lying-In Hospital and the Home to
Destitute Crippled Children will continue under other assisMi
to Dr. Bacbmeyer. Dr. Whitecotton graduated at the Stantor
University School of Medicine in 1933.

IOWA

Fracture Clinic. — The Iowa State Medical Society udj
hold a fracture clinic at the Hotel Fort Des Homes,
Moines, November 8. The morning will be given over t
presentation of cases while the afternoon will be devot
papers by visiting speakers. ,

Pneumococcus Study Course. — The state ciepartmen
health will conduct a pneumococcus study course at tie -
hygienic laboratory’, Iowa City, October 31 -November .
course is intended primarily for laboratory workers ana
ing physicians associated with pneumonia typing __
Funds assigned to the department through the U. s ’. _ ts
Health Service make it possible to reimburse the • r S - ^

for most of the travel and other expenses incideni
course. .

Campaign Against Smallpox. — A cooperation

against smallpox is under way Jn Iowa with^ tne ^

of the committee on child health and protection o
State Medical Society, the state department of heaiin, ,
medical societies and lay organizations, according cession

nal of the Iowa Stale Medical Society. At the : cn

of the state society approval was given fo such a J t-
the recommendation of the committee on child hea ( jt, c

tection. The actual administration of the vaccine ()ie

place October 30-November 11. About seventy - ;t| CC ;

county medical societies in the state have appomte c f

to take charge of the work in their communities, jicns-

tiie societies have taken paid advertising m tnc s j l3S

papers. According to the journal, Iowa tor ma > i
ranked well at the top of the states with the Erra llpoS
the climax being reached in 1938 when 1,1/0 ca.e
were recorded. ■ „ _ . ,,

MICHIGAN re-
course in Diagnostic Rceritgenology--— Tim i ...

of Michigan Medical School, Ann Arbor, a™°%, obcr 39-
graduate course in diagnostic r oentgeno g
November 4. Topics to be considered mcMc the M
of lesions of the lungs and pleura, - exammi atu on o t ^
and great vessels, and diagnosis of diseases of uic Con(Ju;f -
soft tissues of the neck and mediastinal structures
ing the course will be Drs. Fred J. H«Igcs profo.c
genology ; Vincent C. Johnson and Js adore Lamp ,
professors, and Hobart H. Wright, mstruc

Volume 113
Number 18

MEDICAL NEWS

1649

MINNESOTA

Public Health Association Meeting. — The thirty-third
animal session of the Minnesota Public Health Association will
be held at the Nicollet Hotel, Minneapolis, November 3, with
the Hennepin County Tuberculosis Association acting as host.
At the annual Christmas Seal dinner, Dr. James D. Adamson,
professor of medicine at the University of Manitoba Faculty
of Medicine, Winnipeg, medical director of St. Boniface Sani-
torium, St. Vital, Man., and consultant in pulmonary diseases,
department of pensions and national health of Canada, will
speak on “War and Tuberculosis As We See It in Canada.”
Dr. Sidney A. Slater, Worthington, president of the Minnesota
Public Health Association, will give a memorial address hon-
oring the late Dr. Charles H. Mayo, Rochester, a former
president and later honorary president of the Minnesota Public
Health Association. Gov. Harold Stassen will speak and
greetings will be extended by Dr. Stephen H. Baxter, Min-
neapolis, president of the Hennepin County Tuberculosis Asso-
ciation. Dr. Frank J. Hirschboeck, Duluth, a member of the
state heart committee, is to be toastmaster. Distinguished
Service Christmas Seal Awards for 1938 will be presented.

MISSOURI

The Evarts Graham Lectureship.— The twentieth anni-
versary of Dr. Evarts A. Graham as Bixby professor of sur-
gery at Washington University School of Medicine, St. Louis,
was observed with two days of scientific sessions October
11-12. At a dinner, which concluded the celebration, the estab-
lishment of the Graham Lectureship was announced. It is
hoped that the first of these lectures, which will be given
annually, will be delivered in the spring. About forty-five
former pupils of Dr. Graham gathered from all parts of the
country to attend the meeting. One representative came from
Australia and others were prevented from coming by the out-
break of war. A graduate of Rush Medical College, Chicago,
class of 1907, Dr. Graham has during his career been given
many honors including the Leonard prize of the American
Roentgen Ray Society in 1925 ; a gold medal of the Radiological
Society of North America in 1925 ; a gold medal and certifi-
cate of merit of the St. Louis Medical Society in 1927, and
a gold medal of the Southern Medical Association in 1933.
He was chairman of the Section on General and Abdominal
Surgery of the American Medical Association in 1925, presi-
dent of the St. Louis Surgical Society in 1925 and of the Ameri-
can Association of Thoracic Surgeons in 1928. He has been
co-editor of the Archives of Surgery since 1920; editor of the
Journal of Thoracic Surgery since 1931 and is the author of
“Empyema Thoracis” and “Diseases of the Gallbladder and
Bile Ducts,” as well as of many articles on his specialties.

NEW JERSEY

State Society’s Clinical Conference. — The Medical
Society of New Jersey will present its second Fall Clinical
Conference November 9-10 in Jersey City with the Hudson
County Medical Society as host. Fifteen hospitals will pro-
vide material for clinics in general surgery, general medicine,
pediatrics, industrial and traumatic surgery, neurosurgery, bron-
choscopy and chest surgery, obstetrics, urology and psychiatry.
Clinics will be held in the afternoons at the Jersey City Medi-
cal Center. At a dinner at the Carteret Club Friday evening
Dr. James F. Norton, Jersey City, will be toastmaster and
Dr. Morris' Fishbein, Chicago, Editor of The Journal, will
speak on “American Medicine and the National Government.”

NEW YORK

Society News. — Dr. Konrad Birkhaug, Bergen, Norway,
former associate professor of bacteriology. University of Roch-
ester School of Medicine, addressed the Rochester Academy of
Medicine October 4 on “The Use of Sulfanilamide in Experi-
mental Tuberculosis.” Charles S. Baker, legal counsel for

the Medical Society of the District of Columbia, Washington,
D. C., addressed the Medical Society of the County of Monroe,

Rochester, October 17 on health insurance. Dr. George

Draper, New York, addressed the Medical Society of the
County of Westchester, White Plains, October 17 on “Obser-
vations from the Psvchological Panel of Persons Who Develop
Peptic Ulcer.”

New York City

Faculty Changes at Cornell. — Joseph C. Hinsey, Ph.D.,
professor and head of the department of physiology at Cornell
University Medical College, has been appointed professor and
head of the department of anatomy to succeed the late Charles
R. Stockard, Ph.D. During the present year he will also be

acting head of the department of physiology. William H. Cham-
bers, Ph.D., has been promoted to the rank of associate professor
of physiology and Kendrick Hare, Ph.D., to that of assistant pro-
fessor of physiology. Dr. Hinsey took his doctorate at Wash-
ington University, St. Louis, in 1927. He was a member of the
faculty of Northwestern University Medical School, Chicago,
from 1927 to 1929, when he was appointed associate professor
of anatomy at Stanford University School of Medicine, San
Francisco. After a year he became professor at Stanford and
remained there until his appointment to Cornell in 1936.

Society News. — Dr. Paul Reznikoff delivered a Friday
afternoon lecture before the Medical Society of the County
of Queens October 6 on “Blood Dyscrasias of Interest to the
General Practitioner.” Dr. James Alexander Miller spoke
October 20 on “Early Diagnosis of Pulmonary Tuberculosis.”

Speakers at the first fall meeting of the Medical Society

of the County of Kings October 17 were Drs. Burrill B. Crohn,
New York, on “Regional Ileitis : Medical Aspects, Surgical
Indications”; Byrl R. Kirklin, Rochester, Minn., “Bleeding
Lesions of the Intestinal Tract,” and Charles W. Mayo, Roch-
ester, Minn., “Carcinoma of the Duodenum, Jejunum and

Ileum.” Dr. Benjamin R. Shore Jr. addressed the New

York Surgical Society October 11 on “Carcinoma of the
Breast.”

OHIO

Professor Froehlich Comes to Cincinnati. — Dr. Alfred
Froehlich, former professor of pharmacology, University of
Vienna, has been appointed pharmacologist to the May Insti-
tute for Medical Research of the Jewish Hospital, Cincinnati.
Dr. Froehlich is the discoverer of the syndrome that bears
his name.

District Meeting in Cleveland. — The Fifth District of
the Ohio State Medical Association held its annual meeting
in Cleveland October 20. The guest speakers were Drs. Fred-
erick Christopher, Evanston, 111., on “Treatment of Wounds”
and “Carcinoma of the Stomach,” and Dr. Samuel A. Levine,
Boston, on “Interpretation of a Systolic Murmur” and “Prog-
nosis of Rheumatic Heart Disease.”

Postgraduate Day. — The .Summit County Medical Society
is sponsoring its eighth postgraduate day at the Mayflower
Hotel, Akron, November 8 with the following speakers : Drs.
Wilber E. Post, professor of medicine, Rush Medical College;
Charles B. Puestow, associate professor of surgery, University
of Illinois College of Medicine, and George H. Gardner, assis-
tant professor of gynecology, Northwestern University Medical
School, all of Chicago.

OREGON

Society News. — Dr. Harold L. Blosser, Portland, addressed
the Multnomah County Medical Society, Portland, October 4
on "Social and Economic Problems in Industrial Medicine.”

Dr. Roger Anderson, Seattle, addressed the Pollc-Yamhill-

Marion Counties Medical Society October 10 on “Fractures
of the Clavicle and Injuries in the Region of the Shoulder

Joint” and on “Fractures of the Leg.” Dr. Conrad A. Loeli-

ner, Salem, addressed the Lane County Medical Society Sep-
tember 17 at Cottage Grove on “Barbiturates and Hypnotics.”

PENNSYLVANIA

State Medical Election. — Dr. Francis F. Borzcll, Phila-
delphia, was chosen president-elect of the Medical Society of
the State of Pennsylvania at the annual meeting in Pittsburgh
October 2-5, and Dr. Charles H. Henninger, Pittsburgh, was
installed as president. Vice presidents elected were Drs.
Charles G. Eicher, McKees Rocks ; Ward O. Wilson, Clear-
field ; Walter J. Stein, Ardmore, and John J. Sweeney, High-
land Park. Dr. Walter F. Donaldson, Pittsburgh, was reelected
secretary. The 1940 session will be held in Philadelphia.

Philadelphia

Symposium on Pneumonia. — The Philadelphia County
Medical Society held a meeting October 11 devoted to the sub-
ject pneumonia. Dr. Wheelan D. SutlifT, assistant director,
pneumonia control division, bureau of laboratories, New York
City Department of Health, spoke on “Application of Pneumo-
coccus Bacteriology and Immunity to the Prevention and Cure
of Pneumonia.” Drs. John J. Shaw, state secretary of health,
and Dale Cook Stahle of the health department staff, Harris-
burg, discussed “Pneumonia— the Problem in Pennsylvania”;
Charles L. Brown, etiology and diagnosis; Harrison F. Flippin
chemotherapy, and Henry A. Holle, U. S. Public Health Ser-
vice, pneumonia as a national problem.

1650

MEDICAL NEWS

Pittsburgh

Annual Lecture on Diabetes. — The Renziehausen Mcmo-
rial Lecture, established in 1937 for the advancement of knowl-
edge of diabetes, will be delivered November 13 at Mellon
Institute by Dr Howard F. Root, Boston, on “Complications
of Diabetes Melhtus.”

Society News. — At a meeting of the Allegheny County
Medical Society October 17 the speakers were Drs. John W.
Stevenson on “Bicornate Uterus Associated with Pregnancy”;
Joseph W. Hampsey, “Masking of Clinical Picture of Acute
Mastoiditis During the Administration of Sulfanilamide,” and
Alfred B. Sigmann, Bridgeville, Pa., "Suppurative Appendicitis

and Its Treatment with Alcohol.” Drs. John H L Heint-

zelman and James A. Cowan Jr. addressed the Pittsburgh
Academy of Medicine October 10 on “Use of Ethyl Iodide in
Chronic Nontuberculous Pulmonary Disorders” and “Delayed
Hap in the Repair of Surface Defects” respectively.

WASHINGTON

State Medical Election.— Dr. Homer D. Dudley, Seattle,
was named president-elect of the Washington State Medical
Association at the annual meeting in August and Dr. Warren
B. Penney, Tacoma, was installed as president. Dr. James
G. Matthews, Spokane, was elected vice president and Dr.
Vernon W. Spickard, Seattle, was reelected secretary. The
1940 meeting will be in Tacoma.

WISCONSIN

State Society Award to Dr. Johnson. — The State Medi-
cal Society of Wisconsin presented its fifteenth annual Council
Award to Dr. Fred G. Johnson, Iron River, at the annual
session in Milwaukee in September. In his citation Dr. Stephen
E. Gavin, Fond du Lac, chairman of the council, observed that
Dr. Johnson has been for thirty-nine years a family physician
serving a scattered population over a large area. His services
to medicine, as cited by Dr. Gavin, include having been twice
president of a county medical society, president of the district
medical society, nine years a councilor of the state society,
seven years a preceptor of the University of Wisconsin Medical
School and a collaborator in establishing and conducting the
first tuberculosis sanatorium in Wisconsin. Dr. Johnson was
born in 1S72 and graduated from Rush Medical College, Chi-
cago, in 1900.

HAWAII

New Director of Mental Hygiene. — Dr. Edwin E.
McNiel, Honolulu, has been appointed director of the bureau
of mental hygiene and in charge of the mental hygiene clinic
under the board of health of Hawaii.

PHILIPPINE ISLANDS

Meeting at Canacao Hospital. — The U. S. Naval Hos-
pital at Canacao entertained the senior class and the faculty
of the University of the Philippines College of Medicine
August 14. Papers were presented by Lieut. Alton C. Aber-
nethy, Cavite, on “Lymphogranuloma Venereum” and Lieut.
Comdr. Charles F. Flower, Cavite, “Fracture Dressings.” Capt.
Joseph J, A. McMullin and the hospital staff were hosts. Cap-
tain McMullin is assistant adjunct professor of surgery at the
medical school in Manila.

Jovs. A. 31. .i
Oct. 28, 1911

and at the University of Pennsylvania by Drs. Eu-cne P
Pendergrass and Eliot R. Clark, Philadelphia. About 2rt)
industrial firms are affiliated with the foundation.

Dermatologists to Meet in Philadelphia.-The second
annual meeting of the American Academy of Dcrmatoloey
2™, byphilology will be held at the Bellevue-Stratford Hotel
1 luladelphia, November 6-8. The sessions will consist of sym-
posiums, courses lasting from one to four hours and round
table discussions. Dr. Cornelius P. Rhoads, New York will
be the guest speaker Monday November 6 on "Vitamin It
Complex.” Tuesday will be devoted to clinical presentations
at Jefferson Medical College of Philadelphia. There will be
symposiums on syphilis, allergy, pharmaceutical therapeutics,
physiology and chemistry of the skin. Dr. Paul A. 0'Lean,
Rochester, Minn., is president and Dr. Earl D. Osborne, Buf-
falo, secretary of the academy.

Special Society Election. — Dr. Frank R. Spencer, Boulder,
Colo., was named president-elect of the American Academy
of Ophthalmology and Otolaryngology at the annual session
in Chicago October 8-13. Dr. Spencer will succeed Dr. Frank
E. Brawley, Chicago, who becomes president January 1. Vice
presidents elected were Drs. Arthur W. Proetz, St. Louis;
Joseph F. Duane, Peoria, III., and Charles T. Porter, Boston.
Dr. William P. Wherry, Omaha, was reelected executive sec-
retary and Dr. Erling W. Hansen, Minneapolis, was made
secretary for public relations, succeeding Dr. Ralph A. Fenton,
Portland, Ore., resigned. The academy voted to sponsor a
new venture in graduate medical education. Plans were made
for the establishment of reading courses for hospital residents
and interns planning to specialize in ophthalmology and oto-
laryngology.

Changes in Status of Licensure. — The California State
Board of Medical Examiners reported the following actions
taken at its regular meeting July 10-13:

Dr. Sharon M. Atkins, Los Angeles, license restored and placed ffl
probation for five years. , .

Dr. Woodward B. Mayo, Burbank, Calif., certificate restored
placed on probation for five years. ,

Dr. Harold E. Morrison, Morro Bay, Calif., certificate restored.-
•Dr. Jesse C. Ross, Los Angeles, license restored. , , ,

Dr. Shuah Milton Mann, National City, Calif., license re voted
13 following charges of “aiding and abetting” and of illegal °P . , J
Dr. Virgil J. McCombs, Los Angeles, license revoked following
of alleged use of fictitious name and “aiding and abetting. ,

Dr. James T. Murray, Los Angeles, license revoked on cum
alleged narcotic addiction. , , „ c !

Dr. Walter M. Thorne, Fresno, Calif., license revoked on a cm rs*
alleged narcotic addiction. .. f ji™.

Dr. Donaciano Trevino, San Bernardino, . Calif., license ret o
ing bis conviction of violation of the Harrison Narcotic Act. .

Dr. James Cushing Weld, Los Angeles, license
charges of “aiding and abetting” and the use of a fictitious . • j; 3

Dr. Orel Alvin Welsh, Ventura, Calif., license rf
conviction on charges of performing an alleged illegal oper

The New York State Board of Medical Examiners reccn
reported the following' action : .

Dr. Charles I. Gordon, formerly of Brooklyn, license res 0 ‘ c

The Virginia State Board of Medical Examiners

announces

the following:

instated June 21.

GENERAL

Fellowships for Cancer Research Available.— The Finney-
Howell Research Foundation, Inc., announces that all applica-
tions for fellowships for next year must be filed in the office
of the foundation by Jan. 1, 1940. Applications received after
that date cannot be considered for 1940 awards, which will be
made the first of March. Fellowships .carrying an annual
stinend of $2,000 are awarded for the period of one year with
the possibility of renewal up to three years ; when deemed wise
by the board of directors, special grants of limited sums may
be made to support the work carried on under a fellowship.
Additional information may be obtained from the foundation,
1211 Cathedral Street, Baltimore.

Air Hygiene Meeting.— The fourth annual meeting of the
Air Hvmene Foundation will be held at the Mellon Institute,
Pittsburgh, November 14-15. Among features of the program
will be a symposium .on absenteeism in industry with Dr.
A nthnnv T Lanza New York, presiding; a forum designed
to show that” “Industrial Health Pays Double Dividends”;
reports on the foundation’s engineering research at Harvard
-University by Philip Drinker, Ch.E., Boston ; reports of medi-
cal research at Saranac Lake, N. Y-, by Dr. Leroy U. Gardner,

Dr. J. Burton Nowlin, Lynchburg, Va., license reim. - ,
More Swindlers.— A man named George W. Remic> a _
often calls himself Dr. Remick, recently represe aut hor-

a salesman for laboratory equipment firms and wit ^

ity has collected accounts owed to these hrms- . vjew

traveling in California, Arizona, Texas, Colo Equip-

Mexico, posing as a salesman for the Jones Me 0 j Los

ment Company of Chicago and the Bristow C P ^ ac | ie( l a
Angeles, among others. It is said that Rcnnc PP an
laboratory in El Paso, Texas, with the. story rc turrX'l

option on some laboratory equipment which was B . • (fat
from China. Remick informed the laboratory P >- w j,j c !i
this apparatus was held by the customs omce . j n( | uc ed
would have to be paid before it could be relea. torns 0 Bier,

the doctor to give him a check to be paid to the office

Nothing further was heard from Remick and tn 0 M.

knew nothing of the occurrence. Remick 15 ab0 . ut , V 3 j r com-
about 5 feet 9 inches tall, weighs 190 pounds, has a , j, c
plexion, light sandy hair with slight baldness an . c | o( !icj,

is said to be talkative, late to appointments, fond . r-

usually with unmatched coat and trousers. Busied

mation has been furnished by the Chicago D “iJayis
Bureau concerning a man who claimed to repre OctoBf

Company” of Indianapolis, reported in The J * r eportv|
7, page 1423. The Indianapolis Better Business ^ all

that several complaints had been received a aW j Cr.sv

from the Chicago area,, and that no fi rn L°* ’ appeared P
pany could be located in Indianapolis. II , ;„j, C (l “

? fn r -t 8 inches tall and uc cm.

He claimed that be bad w

140 pounds, it is reported.

Volume 113
Number IS

FOREIGN LETTERS

1651

out a surgical supply house in Indianapolis for “almost noth-
ing” and wanted to sell as much as possible so that he would
not have to move much stock to Chicago, where he intended
to start a business.

CANADA

Balfour Lecture at Toronto. — The fourteenth annual lec-
ture under the Donald C. Balfour Lectureship in Surgery of
the University of Toronto Faculty of Medicine, Toronto, was
delivered October 11 by Prof. George Grey Turner, London,
England, on “Transplantation of the Ureters.”

Society News. — Dr. William E. Campbell, Winnipeg, was
elected president of the Manitoba Medical Association at the
annual meeting in September. Drs. Edward D. Hudson,
Hamiota, and Hubert D. Kitchen, Winnipeg, were elected vice
presidents and Dr. Clarence W. MacCharlcs, Winnipeg,
secretary.

CORRECTION

Sigmund Freud’s Age. — The Journal, October 14, page
1494, stated that Sigmund Freud died Sept. 22, 1939, in his
eighty-third year. Dr. Freud was born May C, 1856, and was
therefore at the time of his death in his eighty-fourth year.
Dr. Freud died about 3 a. m. September 23, London time, which
would place his death before midnight New York time and,
thus figured, would make the date of death there September 22.

Government Services

Increase in Salary for CCC Physicians
Since the receipt in this office of the item entitled, “Physi-
cians Wanted for the CCC,” published in The Journal, Octo-
ber 14, page 1500, the office of the surgeon of the Eighth
Corps Area, Fort Sam Houston, Texas, has received instruc-
tions from the War Department to the effect that the salaries
of all physicians on duty with the CCC would be §3,200 per
year instead of §2,600 per year.

New Manager of Veterans Hospital
Dr. Grover C. Daniel, clinical director of the Veterans
Administration Facility, Walla Walla, Wash., has been appointed
manager effective October 1. He had been acting manager
since the recent death of Dr. Orville D. Wescott, manager.
Dr. Daniel was born in Olioville, ICy. He served in the army
medical department from September 1917 until December 1918,
and the following year graduated at Loyola University School
of Medicine, Chicago.

Examinations for Government Positions
The U. S. Civil Service Commission announces open com-
petitive examinations for the following positions : senior medi-
cal officer with a salary of §4,600 a year; medical officer,
§3,800; associate medical officer, §3,200. Applicants for the
grade of senior medical officer must qualify in aviation medi-
cine, cardiology or cancer research ; for the other positions
applicants may choose among fourteen optional branches. The
registers resulting from these examinations will be used for
filling vacancies in the U. S. Public Health Service, the Vet-
erans’ Administration, the Indian Service and the Civil Aero-
nautics Authority. Applicants must have graduated from
recognized medical schools. Those applying for the position
of senior medical officer must not have passed the fifty-third
birthday; those for medical officer the forty-fifth and those for
associate medical officer the fortieth. Dates for filing appli-
cations are as follows: November 13 if received from states
other than those in the Far West as listed; November 16 if
from Arizona, California, Colorado, Idaho, Montana, Nevada,
New Mexico, Oregon, Utah, Washington and Wyoming;
March 11, 1940, if from points in Alaska south of the Arctic
Circle; May 13, 1940, if from points in Alaska north of the
Arctic Circle. Application forms may be obtained from the
secretary of the Board of Civil Service Examiners at any
first class post office, from the U. S. Civil Service Commis-
sion, Washington, D. C., or from the U. S. Civil Service dis-
trict office in any of these cities: Atlanta, Boston, Chicago,
Cincinnati, Denver, New Orleans, New York, Philadelphia,
Seattle, St. Louis, St. Paul, San Francisco, Honolulu, Balboa
Heights, Canal Zone, and San Juan, Puerto Rico.

Foreign Letters

LONDON

(From Our Regular Correspondent)

Sept. 30, 1939.

London Hospitals in Wartime

In previous letters it has been stated that, for the treatment
of the numerous civilian casualties expected from air raids,
London has been divided into ten sectors radiating from the
center. The great hospitals are situated at the apexes of
the sectors and become casualty clearing stations, while at the
periphery-, that is in the country, are the “base hospitals” to
which the casualties will be evacuated for greater safety. The
latter are hospitals or institutions which have been converted
to this use. A description of the largest one, situated at some
distance from London, illustrates typically the gigantic prepa-
rations which have been made. The hospital normally accom-
modated 2,200 mental patients, who were transferred to other
institutions, but the malarial unit for the treatment of dementia
paralytica was maintained, so that it would be available for
the treatment of neurosyphilis. As the advanced base hospital
for St. Thomas’s and King’s College hospitals it provides 2,560
beds. The big day room has been converted into three operat-
ing rooms, each with two tables, and there are smaller operat-
ing rooms elsewhere. Adjoining the operating rooms are
resuscitation rooms, each with about twenty beds, for which
a team has been trained. The former entertainment hall is a
Red Cross dispensary.

For the treatment of the civilian casualties the hospital has
been divided into five units, which to facilitate direction have
been given different color schemes. Four of these units deal
entirely with the care of the sick and wounded. Each is con-
trolled by a surgeon on the staff of King’s College Hospital,
and his staff consists of three surgeons, one physician, two
anesthetists and a number of medical officers. The fifth unit
deals with the reception and distribution of cases and is in
charge of a physician of King’s College Hospital. Each of
the four treatment units will have one “take-in” day out of
every four and will receive the bulk of the admissions on that
day, though the other units will also be admitting, particularly
to the wards earmarked for specialist treatment.

The surgeon in charge of the unit organizes the whole of
the work and himself operates as he deems necessary. He
reports to the medical superintendent and to the physician and
surgeon respectively in charge of the medical and surgical
division. The local medical practitioners will also be employed
for sessions of two and one-half hours daily. The nurses
attached number 700 and have been drafted from London hos-
pitals. Medical students from the London hospitals have been
received and a considerable amount of instruction, including
lectures, is given. It deals with the kind of cases expected :
injuries of the head, chest and abdomen, fractures, burns,
wound infections, gas casualties and war neuroses. Even a
peranibulating museum, which goes in turn to the three hos-
pitals of the sector, has been arranged. This vast disorgani-
zation of the peacetime medical service and reorganization of
it into a wartime service has been accomplished with celerity
and efficiency.

Almost all the London consultants have been mobilized or
are on call, and most of them have ceased all other work.
But, as seems almost inevitable under the improvised condi-
tions of war, the rates of remuneration have been too crudely-
laid down. The younger men suddenly find themselves with
incomes they could not have expected for years, but the older
established ones, with heavy financial obligations, sometimes

1652

FOREIGN LETTERS

Jous. A. II. A.
Oct. 28, m

are faced with bankruptcy. A plan has been prepared to allow
senior men who wish to resume private work to exchange their
full time work for part time, so that they can continue their
private work.

Prof. G. R. Murray Is Dead
Dr. George Redmayne Murray, emeritus professor of medi-
cine in Victoria University, Manchester, and the discoverer of
the thyroid treatment of myxedema, has died. Educated at
Cambridge, he graduated with first class honors in the Natural
Science Tripos in 1886. He then went to University College
Hospital, London, where he had a brilliant career. In 1891
he was appointed pathologist to the Hospital for Sick Chil-
dren, Newcastle-upon-Tyne, and lecturer in bacteriology, Dur-
ham University College of Medicine. He made a great repu-
tation as a teacher and in 1893 was appointed professor of
comparative pathology. In 1908 he migrated to Manchester,
where he became professor of medicine. His case, which is
classic, was published in 1920 in the British Medical Journal
under the title “The Life History of the First Case of Myx-
edema Treated by Thyroid Extract."

PARIS

(From Ottr Regular Correspondent)

Sept. 20, 1939.

Medical Activities of the War

The general opinion of French medical circles is that present
war conditions ought not to interrupt the scientific labors of
the nation. The limitations placed on medical research by the
mobilization of scientific investigators and their assistants and
by the curtailment of means of action and work are perhaps
partially compensated by the study of special problems caused
by the war. Accordingly, all necessary measures have been
taken for the continuation of medical activities. The large
medical reviews will reduce their editions by about half, either
appearing once in every two times or by combining two issues
into one. The numerous meetings which were to be held
during the autumn have been postponed. However, the large
niedical societies such as the Societe medicale des hopitaux
de Paris, the Societe de medecine de Paris and the Societe
des chirurgiens de Paris have decided to meet as usual ; some
have even anticipated their regular date. The Aeademie de
medecine met September 12. Instead of the few members
usually present the attendance was almost complete. Not only
the small body that “holds the fort" during the vacations was
present but all ’who happened to be in Paris came sponta-
neously, glad to meet one another in these grave times. Many
of the academic staff were in uniform, either already assigned
to military duties or mobilized in the hospitals with which
they are associated. Some of those absent had already been
called to the front. Those past the age of military service
have for the most part been assigned to special centers.

War increases the number of cases of certain fare maladies.

It brings about an increase of wounded with numerous prac-
tical problems. It is well known what progress in surgery
resulted from the vast clinical experiences of the World War.

For that reason the Academic de chirurgie has likewise decided
to resume its meetings. Specialized medical centers will be
organized, such as the cardiologic, psychiatric, tuberculous,
syphiligraphic, tropical diseases and neurosurgery. The heads
of these centers have not been publicly named, but it is easy
to guess them by noting simply the most competent men in
each specialty. The functions of these centers will be mani-
fold. They will have to take care of patients who fall within
their specialty and seek methods of treatment best adapted to
war diseases. Once cured, these patients will be rehabilitated.

It will be necessary to determine their exact status and the
extent to which participation in military service caused or
aggravated their disease, to fix their degree of invalidism—

that is to say, the pension to which they will be eniitled-to
follow up the rehabilitated and to prepare their readjustment
to civil life so that they may be least burdensome to their
community. In short, these specialized centers will at the
same time be centers of instruction for the physicians at the
front and for the students who pursue their studies in uniform

Scientific Meetings

Hedon and Loubatieres pointed out before the Aeademie des
sciences that the quantities of hydrochloric acid exhaled and
those of oxygen utilized were normal or even somewhat beimv
normal, tested out in the type of experimental diabetes discov-
ered by Young and determined in the dog by repeated injec-
tions of hypophysial extract (anterior lobe) in the peritonea!
cavity. These quantities correspond to an expenditure oi energy
less than 2.5 kilocalories an hour. Young’s experimental dia-
betes differs, accordingly, from the one determined after com-
plete extirpation of the pancreas by the absence of a rise in
the basal metabolism. There is also a connection between
certain organic disorders, particularly of the central imtvwb
system, noted in those who occupy buildings made of rein-
forced cement. The metal framework of these buildings con-
stitutes a veritable box such as Faraday used in one of his
experiments and creates a constant vibration with the alter-
nating currents, as Denier demonstrated before the Societe
franqaise d’electrologie et dc radiologie.

Lian and Iris collaborators before the Societe frangaise
d’hematologie presented an optical method of exploring the
coagulation of the blood, based on modifications of the optical
density of the plasma in the course of its change from fibrin-
ogen to fibrin. The results are recorded by means of a graph
of a particular form which indicates the duration, the beglnmug
and the quality of the coagulation.

BERLIN

(From Our Regular Correspondent)

Sept. 6, 1935-

Reorganization of Studies in Chemistry
In the reconstruction of the medical curriculum, the rL ° ' r
ganization of the curriculum of chemical studies has ec ’
ordered. To provide uniform training in chemistry, an ssso-
ciation had been formed already before the World 1 ar )
the chemical institutes of the universities to conduct cxal111 " ^
tions and issue certificates. This preliminary examination ^
to be passed before one could proceed to work on the octo ^
thesis. Formerly, no final examination outside the docto ^
thesis existed, certifying that the student had conip
chemical program of comprehensive studies. One cov
oneself a chemist without having had a thorough train
Now, however, chemical studies have been given um or ^
No definite course of studies is prescribed for the requ ^
seven semesters. The determining factor is the e 0 rec ^
thoroughness, the attainment of which depends sole) on
aptitude and industry of the student. The gifted stu en
thus complete his studies within a shorter time than c ■„
scribed period. Success in passing the examination ccn
the chemical diploma opens the way for the doctcra can ^
The new curriculum of chemical studies divides t k s
training into two sections: (1) four semesters o I< ?° . fl a
organic, physical and physicochemical studies culmina
"preliminary" examination with diploma and (2) *
ters of. "deepened training.” In this second phase tie -
is required to select his major study whether m ^ ^
organic, general or technical chemistry. It is _ 3se _ j on gct
assumption that the complexity of chemical stu ms
permits uniform attainments in all the branches o c ^ ^
This specialized training is attested at its cone us* __
preliminary thesis leading to the diploma an is

Volume 113
Number 18

FOREIGN LETTERS

1653

quisite for admission to the main examination. Choice of
thesis material should be made with a view of continuing it
for the doctor’s degree. The “chemist with a diploma” is now
a new recognized academic degree.

Control of Malignant Tumors in Danzig
Through regulation of the Danzig senate “a labor associa-
tion for combating malignant tumors” has been organized.
This association is to establish principles for educating the
population on the prophylactic examinations to be taken at
certain intervals, especially by women, on the kinds of exami-
nations and the treatment of those afflicted. Treatment of
malignant tumors may be performed only by physicians.
Treatment by mail as well as advice offered on how to cure
oneself by means of lectures, pamphlets and so on is pro-
hibited. Physicians are required to conform strictly to the
principles established by the labor association. Physicians,
public health officials and hospitals must officially report all
cases of malignant tumors and suspected tumors within six
days. Violations are punishable by fines. Every woman 30
years of age and every man 45 years of age may have them-
selves examined once a year at the expense of the labor asso-
ciation, which in turn is reimbursed by insurance companies.

ITALY

(Prom Our Regular Correspondent)

Sept. 15, 1939.

Renal Tumors

The Accademia di Scienze Mediche of the Coneglio and
Vittorio regions at a recent meeting discussed renal tumors.
Professor Bortolozzi discussed the incidence of renal tumors.
He showed a preference for Pugliotti’s classification, which is
a modification of that of Busser and Obersimmer and is based
on morphologic histology. Professor De Gironcoli discussed
the symptoms, diagnosis and treatment of renal cancer. Pro-
fessor Opocher called attention to the importance of urologic
disorders for gynecologists. There are so many anatomic,
embryologic and physiopathologic interferences between the
urinary tract and the female internal genital organs that the
conception on the existence of a urologic branch of gynecology
is justified. The speaker discussed pyelitis and hydronephrosis
in pregnancy, and the reciprocal influence between pregnancy
and renal cancer, the coexistence of renal tumors with those of
the uterus or of the ovary, vaginal substances from renal car-
cinoma, metastases to the kidney from chorionepithelioma of
the uterus and the possible changes of sexual characters from
adrenal tumors.

Renal Complications from Blood Transfusions
Professor Papa, of Naples, in a reunion of the Societa
Napoleutana di Chirurgia, which was held recently, reported
results of clinical and experimental work on the behavior of
renal functions in blood transfusion which he carried on. He
studied the variations of azotemia, the elimination of urea and
amino acids through the urine and the possible appearance in
the urine of substances which could indicate pathologic involve-
ment after blood transfusion with compatible blood. A patient
who had repeated transfusions died from acute renal insufficiency.
The speaker found by experiments that the alterations of the
renal functions which develop from repeated blood transfusion
are due to renal alterations which can be seen during micro-
scopic studies on the kidney. The syndrome which is due to
renal blockage may develop suddenly or progressively. The
acute syndrome probably develops from spasm of the renal
arteries. The chronic syndrome probably develops from a reac-
tion of the kidney to toxic substances which" cause alterations
of the tubuli and of the glomeruli of the structure.

History of Forceps

Professor Gall of Trieste recently reviewed before the Asso-
ciazione Medica of Trieste the history of forceps, which were
invented by obstetricians of the Chamberlen family, which family
used them only when they could obtain large amounts of money
from a patient. Roonhuysen, an obstetrician from the Nether-
lands, bought the instrument from Ugo Chamberlen also with
a mercenary purpose. Later Chamberlen bought it back from
Roonhuysen. Mauriceau, a Parisian obstetrician, was accused
in the poem called "Luciniade” of having retarded the use of
forceps in France, but the accusation was false.

Policy of Authorities on Sanitation
The under secretary of state of internal affairs recently lec-
tured before a meeting of the house of representatives. He
said that improvement of the race depends on sanitation, the
problems of which cannot be solved by bureaucratic centers but
by the combined work of large groups of technicians and physi-
cians, especially municipal physicians who are well informed on
the problems of local public health. The members of the
ministry of internal affairs resolved to elevate the educational
and technical standards of officers of public health who work
in the various branches of social medicine, especially municipal
physicians who are concerned with the prevention and control
of diseases. The educational standards of midwives have been
elevated also. Administration of antidiphtheric vaccination is
compulsory.

Promotion of Assistant University Teachers
The head of the Public Education centers requested from the
members of the national board of public education the framing
of a bill which concerns assistant teachers in universities. The
bill was approved. It provides that'assistant teachers in univer-
sities who entered by winning a contest or else those who have
worked satisfactorily for five years can be either promoted to
the position of regular professors in colleges or may be appointed
to technical positions in offices of the government.

STOCKHOLM

(From a Special Correspondent)

Sept. 26, 1939.

Artificial Sunlight for Miners
What is certainly unique in Sweden, and probably in the
whole of Scandinavia, is a solarium which has been provided
by the proprietors of the Boliden mine, whose underground
workers can enjoy daylight only on Sundays and for a short
daily meal interval from the middle of September to the middle
of March. Dr. Johan Ponten, who has played an important
part in connection with this solarium, has recently issued a
report on its action since it was started in December 1937.
The room in which four large quartz lamps and four “sollux”
lamps were installed measured 5 by 6 meters and was kept at
a temperature of from 25 to 30 C. (77 to 86 F.). After chang-
ing their clothing and taking a douche or bath, the men would
sit naked in the solarium for three minutes every other day,
their eyes protected by special glasses.

Wishing to obtain objective and reliable data concerning the
effects of such infra-red and ultraviolet radiation on the miners,
Dr. Ponten carried out calcium and phosphorus analyses of
the blood on twenty-two healthy miners between the ages of
23 and 47. He found an appreciable rise in the average cal-
cium content of the serum from 9.9 mg. per hundred cubic
centimeters before the solarium was opened to 10.5, mg. in
March 193S, after the solarium had been in use for three
months. Another line of research was. to compare the mor-
bidity rates among the workers in the Boliden mine before and
after the provision of the solarium. Among the 175 under-
ground workers the sickness rate was 9.7 days per head in
1937 and S.5 in 1938. In the same period there was a rcduc-

1654

MARRIAGES

tion by 12 per cent in the frequency of “one day diseases”
and a reduction by 43 per cent of the catarrhal diseases of the
respiratory tract. A questionnaire to which anonymous answers
were invited showed that a large proportion of the men con-
sidered themselves fitter in many respects since they had
enjoyed the benefits of the solarium.

Research on Pellagra

The conviction that pellagra can be considered a foreign
disease with no practical interest for Swedes has given place
to a suspicion that pellagra may be quite common in mental
hospitals. At the Beckomberga Mental Hospital, under the
direction of Dr. S. Wohlfahrt, five well defined cases of pel-
lagra have been observed in the course of .two years. As for
the number of early or abortive forms of this disease, accurate
information is lacking, for early pellagra presents such vague
signs and symptoms that its distinction from a host of other

J<ws. A. 5!. A.
Oct. 28, 1955

ment is opening this year an institution for the teaching of
the physiology and hygiene of bodily exercises.

At first, the public was inclined to jeer at a man fanatically
devoted to the light he followed. But the medical profession
took him and his cause seriously, and the Swedish Medical
Society honored itself by electing him a member in 1831. He
seems to have been as frail of body as he was forceful ol
spirit. As a young man he was told by his doctor that he was
suffering from consumption. After his death the examination
proved this diagnosis to have been correct and showed that
death was due to malignant disease of the liver. He was sub-
ject to violent attacks of coughing and his respiration was
labored, but the vitality of his spirit dominated the frailty ol
his body throughout his life.

ill defined ailments is most difficult.

Dr. Erlaud Hindus, who has for some time paid special
attention to a twenty-six bed department for wo men patients
in the Beckomberga Hospital, has recently set himself the task
of systematically examining all new cases admitted to this
hospital for signs of defective gastric activities. He has sup-
plemented test meals with feces examinations and radiologic
examinations, and he has found achylia or hypochylia in about
91 per cent of the women patients recently admitted to the
hospital. To test his hypothesis that many of these patients
with defective gastric secretion were suffering from the begin-
nings of pellagra, he divided them into two groups as similar
as he could make them, and in both the clinical picture was
stamped by lassitude, anorexia, depression, loss of weight, sim-
ple anemia, insomnia, amenorrhea, hypesthesia, muscular weak-
ness, restlessness and anxiety or apathy. In other words, the
clinical picture was that commonly associated with the term
“gastrogenic neurasthenia." The first group was given treat-
ment as for pellagra, a stomach extract with hydrochloric acid,
extra rations of meat and eggs and, in some cases, vitamin B
preparations. The second group, which served as a control,
was given the routine treatment heretofore in vogue for such
cases in this hospital. The comparatively satisfactory response
of the patients in the first group to the special treatment given
them suggests that many, if not most, of them may have been
suffering from pellagra in a stage too early for the develop-
ment of the characteristic cutaneous changes.

The Centenary of Ling, the Father of
Swedish Gymnastics

On May 3, 1839, the death occurred of Petter Henrik Ling
at the age of 63. He was then at the head of the Central
Gymnastic Institute, honored at home and abroad. The son
of a poor clergyman, he lost his father at the age of 2 and
was brought up in most humble circumstances. He graduated
at the University of Lund and continued to study in Uppsala.
But he never qualified as a doctor. His gifts as a poet and
author were full of promise, but it was in gymnastics that he
earned a place in the history of medicine. During the century
which has passed since his death there have been countless
developments in gymnastics, yet the principles he laid down
are held to be as sound today as they were when his forceful
personality was behind them. The Central Gymnastic Insti-
tute, which he founded, has remained ever since as a school
for the teaching of gymnastics in health and disease and it
has maintained that high standard which has placed Swedish
gymnastics in so prominent a position in the world. He made
gymnastics a national movement which, beginning in die schools
and soldiers’ camps, came to inspire the whole community.
Throughout Sweden this year Ling’s memory is being paid
tribute” to, and it is no mere chance that the Swedish govern-

Marriages

Frank M. Warder, Glasgow, Ky., to Miss Irene Katherine
Randolph of Detroit Lakes, Minn., in Rushville, Ind., August «•
Warren A. Smith, Berrien Springs, Mick, to Mrs. Ruth
Cameron of Kalamazoo, in South Bend, Ind., in August.

Robert Garfield Rickert, Ann Arbor, Mich., to Miss
Miriam Irene McCausey of Highland Park, August 21.

Alexander H. Sneddon to Mrs. Wilma McLaughlin Dugan,
both of Cambridge, Ohio, in New York, August 18.

Howard Pleas Wheeler, Georgetown, Texas, to Miss
Mary Josephine Davidson of Fort Worth, August 17.

Stamatis George Velonis, Nespelem, Wash., to Miss
Helena Stuart Ross at Northampton, Mass., July «■

Hugh Alfred Watson, Queens Village, N. Y„ to Miss
Almeria Russ at Hendersonville, N. C., July 28.

John Kent Finley, Philadelphia, to Miss Margaret Slice
ban Gindhart of Ventnor, N. J., September 6.

Gf.orge W. Smeltz, Pittsburgh, to Miss Callie Waldran o
Washington, D. C., in Baltimore, August 2.

Albert J. Tanny to Miss Rose McDermott, both of A u
querque, N. M., at Santa Fe, September 5.

John Hoge Woolwine Jr., Blacksburg, Va., to Miss Frances
Wellons of South Roanoke, September 2.

John I. Rinne Jr., Anderson, Ind., to Miss Madge o
man of Marengo, at Seymour, August 31.

George Kenneth Scholl to Miss Dorothy Opheia iC ,
both of Johnson City, Tenn., August 25.

Harry Orr Veach, Los Angeles, to Miss Pauline
Chester of South Pasadena, August 13.

Terence Aloysius ICempf, Omaha, to Miss Frances
Rochford of Colon, Neb., August 26. „ .j 3

Carroll B. Shaddock Jr., Beaumont, Texas, to Miss
Martha Gaertner of Malone, July 22. _

Charles H. Mosely Jr., Monroe, La., to Miss
Jane Morley of Rayville, August 5. |(

William C. Spring Jr., Glen Ridge, N. J., to i ISS
Clark of Jefferson, Ohio, in August.

Russell B. Williams, Downsville, N. Y-, to Miss
May Keith of Salem, Va., July 27. . _

Ralph N. Redmond, Sterling, I!!., to Miss Rat lerine
of Cedar Rapids, Iowa, August 1. riaclys B

Frederick J. .Graber, Stockport, Iowa, to Mrs.

Hiatt of Toledo, September 2.

Charles Frederic Stone Jr. to Miss Haze!
both of Boston, in September.

William Curtis Stifler Jr. to Dr. Jean ■ •
both of Baltimore, July 29. PetermN

Herbert Kaplan, Collegeville, Pa., to Miss C
of Limerick, October 7. . ... n r o-.vs

Bernard P. Wolff, Atlanta, Ga., to Miss Do s
of Marietta, August 3. . rhri-'tcii-^

Ellis K. Vaubel, Dysart, Iowa, to Miss Helen
of Royal, August IS. , , f pi*-

Philip RocHF,-to Miss Susan Foulke Yocom,
delphia, August 7.

Volume 113
Number 18

DEATHS

1655

Deaths

Albert Coulson Buckley © Philadelphia; Medico-Chirur-
gical College of Philadelphia, 1897; professor of psychiatry,
University of Pennsylvania School of Medicine and the
Medico-Chirurgical College, Graduate School of Medicine,
University of Pennsylvania; associate professor of normal
histology at his alma mater, 1899-1908, and associate professor
of psychiatry, 190S-1917; member of the American Neurological
Association, American Psychiatric Association and the Associa-
tion for Research in Nervous and Mental Disease ; past president
of the Philadelphia Psychiatric Association; medical super-
intendent of the Friends Hospital ; served in various capacities
on the staffs of the Philadelphia General Hospital and the
Philadelphia Orthopedic Hospital; author of “Nursing Mental
and Nervous Diseases; aged 66; died, August 17, of pneumonia.

Ernest Charles Dickson © San Francisco; University of
Toronto Faculty of Medicine, Toronto, Ont., Canada, 1906;
professor of public health and preventive medicine, emeritus,
Stanford University School of Medicine, assistant professor of
pathology, 1910-1913, assistant professor of medicine, 1913-
1918, associate professor of medicine, 1918-1923, professor of
medicine, 1923-1926, and later professor of public health and
preventive medicine; instructor of pathology and bacteriology.
Cooper Medical College, 1908-1910; member of the Association
of American Physicians ; on the staff of the Stanford University
Hospitals ; aged 58 ; died, August 23, of cerebral hemorrhage.

Louis Daniel Englerth © Philadelphia ; Jefferson Medical
College of Philadelphia, 1914; F.R.C.S., Edinburgh, Scotland.
1919; fellow of the American College of Surgeons; served
during the World War; formerly assistant demonstrator of
clinical surgery at his alma mater; surgeon to the Frankford,
Philadelphia General, and St. Joseph’s hospitals and North-
eastern Hospital of Philadelphia; consulting surgeon to the
Grandview Hospital, Sellersville ; aged 50; died, August 16,
in the Jefferson Hospital of hypertensive cardiovascular disease.

Frank Henry Hagaman ® Jackson, Miss.; Tulane Uni-
versity of Louisiana School of Medicine, New Orleans, 1918;
president of the Central Medical Society; member of the
Southern Surgical Association and the Southeastern Surgical
Congress ; fellow of the American College of Surgeons ; served
during the World War; on the staffs of the Mississippi State
Tuberculosis Sanatorium, Sanatorium, and the Mississippi State
Charity and the Mississippi Baptist hospitals ; aged 43 ; died,
August 19, of injuries received in an automobile accident.

Willis Ellis Hartshorn © New Haven, Conn. ; University
of Minnesota Medical School, Minneapolis, 1898; clinical pro-
fessor of surgery, Yale University School of Medicine; member
of the New England Surgical Society; fellow of the American
College of Surgeons ; attending surgeon to the New Haven
Hospital; consulting surgeon to the Griffin Hospital, Derby,
Grace Hospital, New Haven, and chief of staff of the surgical
clinic, New Haven Dispensary; aged 67; died, August 4.

Joseph Francis "Ward, Brooklyn; Baltimore University
School of Medicine, 1899 ; served during the World War ; past
president of the Brooklyn Society of Internal Medicine; for
many years a member of the board of managers and also con-
sulting physician and psychiatrist of the Craig Colony, Sonyea ;
formerly chief of the diagnostic research laboratory of the Vic-
tory Memorial Hospital; aged 67; died, August 10.

Andrew Martin Gillen, Brooklyn; Long Island College
Hospital, Brooklyn, 1897 ; member of the Medical Society of
the State of New York; honorary surgeon in the police depart-
ment; chairman of the medical board and chief obstetrician at
the Shore Road Hospital ; on the staff of the Hospital of the
Holy Family and St. Mary’s Hospital ; aged 64 ; died, August
15, in the Long Island College Hospital.

William Chester Billings © Medical Director, U. S.
Public Health Service, retired, La Canada, Calif. ; Harvard
Medical School, Boston, 1894; was commissioned an assistant
surgeon in the U. S. Public Health Service, Dec. 28, 1S9S, and
'i'- a j retl ' r ed as a medical director, Oct. 1, 1933 ; aged 67 ;
died, August 16.

Flaviano E. Parodi, New York; Regia Universita degli
otudi di Genova Facolta di Medicina e Chirurgia, Italy, 1891 ;
member of the Medical Society of the State of New York;
■ellow of the American College of Surgeons; visiting surgeon
, K Columbus Hospital ; died, August 23, in the Mount
bmai Hospital.

Hugh Francis Flaherty, Hartford, Conn.; Yale University
School of Medicine, New Haven, 1907 ; member of the Connec-
ticut State Medical Society; past president of the board of
health ; aged 59 ; on the staff of St. Francis Hospital, where he
died, August 24, of arteriosclerosis and chronic nephritis.

Alice Zelia Patterson-Murphy, Flushing, N. Y. ; Boston
University School of Medicine, 1896; formerly adjunct pro-
fessor of anatomy at the New York Medical College and Hos-
pital for Women, New York; aged 64; died, August 21, in
Newton Highlands, Mass., of brain tumor.

James L. Shuler © Durant, Okla. ; Arkansas Industrial
University Medical Department, Little Rock, 1887; secretary
and past president of the Bryan County Medical Society ; medical
director of the Bryan County Hospital; aged 79; died, August
24, in Hobbs, N. M., of chronic nephrosis.

Theodore Chamberlin, Concord, Mass.; College of Physi-
cians and Surgeons, Medical Department of Columbia College,
New York, 1895; formerly district medical examiner and con-
sulting physician to the Middlesex School and the Concord
Reformatory; aged 71; died, August 8.

Jackson Joseph Ayo © Jackson, La.; Tulane University
of Louisiana School of Medicine, New Orleans, 1893; super-
intendent .of the East Louisiana State Hospital ; member of
the state board of medical examiners ; for many years parish
coroner; aged 70; died, August 18.

Charles Prevost Grayson © Philadelphia; University of
Pennsylvania Department of Medicine, Philadelphia, 1881 ;
emeritus professor of laryngology at his alma mater; member
of the American Laryngological Association; aged 79; died,
August 16, of cirrhosis of the liver.

Ellis Henry Milton, Mount Eden, Ky. ; Hospital College
of Medicine, Louisville, 1892; Southwestern Homeopathic
Medical College and Hospital, Louisville, 1898; aged 74; died,
July 17, in the King’s Daughters Hospital, Shelbyville, of an
abdominal malignant condition.

Floyd Ashley Thomas, Flemington, N. J. ; Medico-
Chirurgical College of Philadelphia, 1907; member of the
Medical Society of New Jersey; served during the World
War; member of the board of health; aged 57; died, August 9,
of coronary thrombosis.

Frank Jackman Sherman © Ballston Spa, N. Y.; Uni-
versity of Vermont College of Medicine, Burlington, 1880;
for many years health officer; aged 80; on the staff of the
Benedict Memorial Hospital, where he died, August 25, of
coronary sclerosis.

Henry Sprince © Lewiston, Maine; McGill University
Faculty of Medicine, Montreal, Que., Canada, 1923; served'
during the World War; aged 41; on the staff of the Central
Maine General Hospital, where he died, August 4, of sarcoma of
the sacrum.

Fred Barrington Sutherland, Wolfeboro, N. H. ; Cooper
Medical College, San Francisco, 1892; member of the Medical
Society of the State of New York; fellow of the American
College of Surgeons; aged 70; died, August 11, of cerebral
hemorrhage.

Nathan Easterly Hartsook © Johnson City, Tenn.; Medi-
cal College of Virginia, Richmond, 1895; past president of the
Washington County Medical Society; on the staff of the
Appalachian Hospital ; aged 70 ; died, August 10, of coronary
thrombosis.

Charles William Courville, Detroit; Detroit College of
Medicine, 1906; member of the Michigan State Medical Society;
diagnostician for the city board of health ; on the staff of the
Providence Hospital; aged 58; died, August 31, of coronary
thrombosis.

James Edward Mansfield, Oswego, N. Y.; Dartmouth
Medical School, Hanover, N. H., 1897 ; member of the Medi-
cal Society of the State of New York; for many years health
officer ; aged 69 ; on the staff of the Oswego Hospital ; died
in July.

Helmina Jeidell @ Denver; Johns Hopkins University
School of Medicine, Baltimore, 1912; member of the American
Academy of Pediatrics; aged 60; died August 10, at St. Luke’s
Hospital of postoperative ileus and chronic intestinal obstruction.

David Forrest Kirkpatrick, Lewisville, Texas; Vanderbilt
University School of Medicine, Nashville, Tenn., 1885; Medical
Department of Tulane University of Louisiana, New Orleans
1887; aged 78; died, August 20, of carcinoma of the bladder.

Clarence H. Willis © Barnesville, Ga. ; Atlanta College of
Physicians and Surgeons, 1906; past president of the Lamar
^ cd,cal Society; aged 57; died, August 15, at the
Middle Georgia Hospital, Macon, of cerebral hemorrhage

1656

DEATHS

Jour. A. M. A.
Oct. 28, m

Charles Miner Miller Jr. ® Olive View, Calif.; Univer-
s , Uy ,?, f P, lttsbur £ h School of Medicine, 1928; served during
the World War; on the staff of the Olive View Sanatorium;
aged 45 ,* died, August 27, of a self-inflicted bullet wound.

Harold Cintra Cox, New York ; University of Virginia
Department of Medicine, Charlottesville, 1921; member of the
Medical Society of the State of New York; aged 44; on the
staff of the French Hospital, where he died, August 25.

John Harrison Timberman, Chillicothe, Mo.; St. Louis
University School of Medicine, 1906; member of the Missouri
State Medical Association ; served during the World War ;
aged 62 ; died, August 22, of cerebral hemorrhage.

Janies Gregory Marron, Lincoln, Neb.; Bellevue Hospital
Medical College, New York, 1887; member of the Nebraska
State Medical Association; veteran of the Spanish-American
War; aged 75; died, August 19, of cardiac infarction.

Percival Walter Darrah, Leavenworth, Kan.; University
of Pennsylvania Department of Medicine, Philadelphia, 1898;
member of the Kansas Medical Society ; on the associate staff
of St. John’s Hospital ; aged 67 ; died in August.

William a Bailey, Louisville, Ky.; University of Louis-
ville Medical Department, 1888; member of the Kentucky State
Medical Association; aged 76; died, August 4, in the Jewish
-Hospital of cerebral hemorrhage.

James Samuel Hyde, Fall River, Mass.; Columbia Uni-
versity College of Physicians and Surgeons, New York, 190’;
aged 65 ; died, August 9, in the Union Hospital of diabetes
melhtus and bronchopneumonia.

August Omer Truelove, Fort Wayne, Ind. ; Indiana Uni-
versity School of Medicine, Indianapolis, 1915; served du ring
the World War ; aged 57 ; died, August 7, in St. Joseph's
Hospital of pernicious anemia.

Charles Pusey McCracken, Colorado Springs, Colo.;
University of Arkansas School of Medicine, Little Rock, 1918;
member of the Colorado State Medical Society; aged 45; died,
August 21, of myocarditis.

William L. Turner, Springfield, Mo.; Barnes Medical
College, St. Louis, 1906; member of the Missouri State Medical
Association ; aged 68 ; died, August 30, in a local hospital of
injuries received in a fall.

Loren Wilder © Chicago; Rush Medical College, Chicago,
1901.; fellow of the American College of Surgeons; chief of the
surgical staff of the Edgewater Hospital ; aged 66 ; died, August
19, of cerebral hemorrhage and arteriosclerosis.

Fred Farley Carpenter, Pella, Iowa; Drake University
Medical Department, Des Moines, 1897 ; member of the Iowa
State Medical Society; veteran of the Spanish-American War;
aged 69 ; died, August 6, of coronary occlusion.

John Wesley Page © Jackson, Mich.; University of Pitts-
burgh School of Medicine, 1914; aged 59; on the staffs of the
Jackson Clinic and the W. A. Foote Memorial Hospital, where
he died, August 22, of coronary occlusion.

Allen C. Holliday, Athens, Ga. ; University of Georgia
Medical Department, Augusta, 1884; member of the Medical
Association of Georgia ; for many years member of the board
of education ; aged 75 ; died, August 20.

Emil Otto Jellinek, San Francisco; Medizinische Fakultiit
der Universitat Wien, Austria, 1892 ; served during the World
War; formerly on the staff of the Mount Zion Hospital; aged
73; died, July 22, of coronary occlusion.

Isaac Sherman Clark, Long Beach, Calif.; Keokuk (Iowa)
Medical College, 1898; member of the California Medical
Association; aged 66; died, August 3, in St. Luke’s Hospital,
Spokane, Wash., of coronary thrombosis.

Jacob Heckmann © New York; Hessische Ludwigs-
Universitat Medizinische Fakultiit, Giessen, Hesse, Germany,
1896 ; on the staff of the Misericordia Hospital ; aged 68 ;
died, August 13, of coronary thrombosis.

Jefferies Buck © Baltimore; University of Pennsylvania
Department of Medicine, Philadelphia, 1895; aged 68; died,
August 14, in the Union Memorial Hospital of arteriosclerosis
and hypertensive cardiovascular disease.

Stanley B. Dickinson, Portland, Ore. ; College of Physi-
cians and Surgeons, School of Medicine of the University of
Illinois, 1897; aged 68; died, July 22, in the Veterans Admin-
istration Facility of coronary sclerosis.

George Adelbert Emard © Mansfield, Mass.; Tufts Col-
lege Medical School, Boston, 1918; for many years on the staff
of the Sturdy Memorial Hospital, North Attleboro; aged 56;
died, August 3, of cerebral hemorrhage.

Charles C. Ross © Clarion, Pa. ; University of Pennsylvania
Department of Medicine, Philadelphia, 1891; secretary of the
Clarion County Medical Society; county health officer; aged
72 ; died, August 5, of heart disease.

Haynes Watts Brownfield, Anthony, Kan.; Hospital Col-
lege of Medicine, Louisville, Ky., 1901 ; member of the Kansas
Medical Society ; aged 59 ; died, August 2, of Buerger s dis-
ease and carcinoma of the bladder.

Burkert Clark © Hamilton, Ohio; Miami Medical College,
Cincinnati, 1901; served during the World War; aged 65;
died, August 25, in the Veterans Administration facility,
Dayton, of cerebral arteriosclerosis.

George Thomas Laman, Cave City, Ark. (licensed in
Arkansas in 1904); for many years member of the school
board ; member of the Arkansas Medical Societ} , aged 57,
died, August 8, of angina pectoris.

Cyrille Phedora Verdon, Granby Que., Canada ; Lava!
TTniversitv Faculty of Medicine, Quebec, 189o; Laval Uni-
^sity Medical Faculty, Montreal, 1896; aged 66; died, July
24, of carcinoma of the esophagus.

Clovis Hiram Robinson, Crane, Texas; Tulane Univer-
sity of Louisiana School of Medicine, New Orleans, 193/;
member of the State Medical Association of Texas; aged -8;
died, July 22, of nephritis.

Harry Thompson Liggett, Louisville, Ky.; Kentucky
School of Medicine, Louisville, 1905; served during the no™
War; aged 64; died, August 17, in St. Joseph’s Infirmary ot
staphylococcic septicemia.

William Coleman Rountree, Fort Worth, Texas; Uni-
versity of Tennessee Medical Department, Naslrville, l°«i
aged 69 ; died, August 2, of hypertensive heart disease, nephritis
and cerebral hemorrhage.

Samuel Augustus Sturm, Pittsburgh; Western Penns}l|
vania Medical College, Pittsburgh, 1895; member of the Ale ■
Society of the State of Pennsylvania; aged 78; died, Augus ,
of carcinoma of the nose.

Arthur Lavoie, Sillery, Que., Canada; M.B., Laval ™.
versify Medical Faculty, Montreal, 1886, and L.M., 'n ;
M.D., Laval University Faculty of Medicine, Quebec,
aged 75; died in August.

Joseph Alexander McCready, Greenwich, Ohio; e '“ £
Hospital Medical College, New York, 1875; member o ,
Medical Society of the State of Pennsylvania; aged V >
August IS, of senility.

Homer Bowen, Walterboro, S. C. ; University of
Medical Department, -Augusta, 1911; member of tn J
Carolina Medical Association; aged 52; died, Augu
cerebral hemorrhage. . •

Everett Dayton Knight ® Anderson, Ind.; 0 n

versify School of Medicine, Indianapolis, 19-5 > . e 0 [

the staff of St. John’s Hospital, where he died, Aug™ ■
cerebral hemorrhage. _ ce

S. W. Williams, Gassaway, Tenn. (licensed in Tenr
in 1910); formerly bank president and member o r™ f
of education of Cannon County ; aged 58 ; died, A g
coronary embolism. Af^dical

Raymond Fox Roller © Altamont, Kan. ; Kansd ■
College, Medical Department of Washburn Colleg , cffe .
1913; at one time mayor; aged 55; died, August ,
bral hemorrhage. _ _ i cf j cr ;on

Eugene Rischelle Delong, Geigertown, . j c j; r2 |

Medical College of Philadelphia, 1891; member ^ ?/,

Society of the State of Pennsylvania; aged 07, ’

of heart disease. , - t , 0 { Jlli-

Carl Frederick C. Kramer, Chicago;
nois College of Medicine, Chicago, 1909; age
3 r ears on the staff of the Belmont Hospita , »

of heart disease. , Medical

Napoleon B. Houser, Charlotte, N C YfflVtlie Good
School, Raleigh, 1891; formerly on the stott cer ebral

Samaritan Hospita! ; aged 69 ; died, August - ,
hemorrhage. r; ,| jj„j v tr-

. Paul Clark Gilson, San Leandro, Calffi : Mcu ^
sity Faculty of Medicine, Montreal, Que., Ca ‘ ’ j cs tata 1
29; died, July 10, of an overdose of sleeping c.p
accidentally. _, . \\*cst trrl

Ellis Brown Rhodes © East Cleveland, . 3?( ,\

Reserve University Medical Department, Cun » arc ; r .crr:
66; died, August 7, at his home m Shaker Hcigm
of the colon.

Volume 113
Number IS

DEATHS

1657

Irving Jerome Bleivveiss, Cleveland ; The School of Medi-
cine of the Division of Biological Sciences, _ University of
Chicago, 1933; aged 33; died, August 30, in Chicago of cardio-
renal disease.

Robert J. Gauldin, Dallas, Texas ; St. Louis College of
Physicians and Surgeons, 1900; member of the State Medical
Association of Texas; aged 69; died, August 5, of intestinal
Obstruction.

David Joseph Hetrick, Harrisburg, Pa. ; Jefferson Medical
College of Philadelphia, 1897 ; member of the Medical Society
of the State of Pennsylvania; aged 67; died, July 11, of coronary
occlusion.

George Wilkinson, Jersey City, N. J. ; Bellevue Hospital
Medical College, New York, 1882; member of the Medical
Society of New Jersey; aged 77; died, August 17, of arterio-
sclerosis.

Rupert William Ford, Otcgo, N. Y. ; Albany (N. Y.)
Medical College, 1S99; member of the Medical Society of the
State of New York; aged 65; died, August 17, of angina
pectoris.

William Colfax Roberts, Owatonna, Minn. ; University of
Michigan Homeopathic Medical School, Ann Arbor, 1899; aged
70; died, August 25, of coronary thrombosis and chronic myo-
carditis.

Howard Conover, Barnegat, N. J.; Hahnemann Medical
College and Hospital of Philadelphia, 1905; member of the
board of health ; aged 61 ; died, August 13, of cardiac insuffi-
ciency.

James H. Fargher © La Porte, Ind. ; Chicago Homeo-
pathic Medical College, 1903; on the staff of the Holy Family
Hospital; aged 64; died, August 6, of coronary thrombosis.

Minnie Agnes Hinch Conley, Wilmette, 111. ; Northwest-
ern University Woman’s Medical School, Chicago, 1901 ; aged
64; died, August 31, of chronic myocarditis and arteriosclerosis.

Annette B. Fiske Pomeroy, Pontiac, Mich. ; Michigan
College of Medicine and Surgery, Detroit, 1901 ; aged 77 ; died,
August 26, in Stoney Point, of myocarditis and arteriosclerosis.

Heinrich Vogel, New York; Albcrtus-Universitiit Mcdi-
2 inische Fakultat, Konigsberg, Prussia, 1896; aged. 64; died,
July 19, in Washington, D. C., of carcinoma of the sigmoid.

D. E. Bridgefarmer, McKinney, Texas (licensed in Texas
under the Act of 1907) ; aged SO ; died, July 22, of cerebral
hemorrhage, hypertensive heart disease and arteriosclerosis.

C. Hector Sexton, Dunn, N. C. ; University of Maryland
School of Medicine, Baltimore, 1890; aged 83; died, August
30, in the Good Hope Hospital, Erwin, of coronary sclerosis.

Stephen A. Cunningham, Marietta, Ohio; Medical College
of Ohio, Cincinnati, 1890 ; member of the Ohio State Medical
Association; aged 71; died, August 14, of heart disease.

Claude Ely Simons, San Diego, Calif.; Hering Medical
College, Chicago, 1902 ; aged 58 ; died, August 19, in San
Francisco of coronary thrombosis and arteriosclerosis.

G. Howard Wilson, Dalton City, 111. ; National Normal
University College of Medicine, Lebanon, Ohio, 1896; aged
67 ; died, August 31, of amyotrophic lateral sclerosis.

Albert Lafayette Foster, Corryton, Tenn. ; National Uni-
versity Medical Department, Washington, D. C., 1897 ; for
many years postmaster; aged 74; died in August.

Reuben L. Hust, Albuquerque, N. M. ; Vanderbilt Univer-
sity School of Medicine, Nashville, Tenn., 1899 ; aged 69; died,
August 19, of cerebral hemorrhage and leukemi .

William M. Edgerton, Minneapolis ; University of Minne-
sota College of Medicine and Surgery, Minneapolis, 1896;
aged 69 ; died, August 4, of coronary sclerosis.

Robert Joseph Carey, North Brookfield, Mass.; Yale Uni-
versity School of Medicine, New Haven, Conn., 1928; aged 36;
died, August 20, in Boylston of tuberculosis.

George W. Antoine, Houston, Texas ; Meharry Medical
College, Nashville, Tenn., 1906; served during the World War;
aged 60; died, August 17, of heart disease.

Frank William Hewes, Groton, Conti.; University of
Vermont College of Medicine, Burlington, 1894; aged 72; died,
August IS, of carcinoma of the intestine.

George Henry Littlefield, Boston ; University of Michigan
-"Tartmcnt 0 f RIedicine and Surgery, Ann Arbor, 1878; aged
41 : died, August 18, in the City Hospital.

John O. Briscoe, Weslaco, Texas; Missouri Medical Col-
lege, St. Louis, 1887; aged 79; died, July 24, in Mission of
complications following a fractured hip.

William Yancey White, Center, Ala.; Vanderbilt Uni-
School of Medicine, Nashville, Tenn., 1SS7; aged 7S;
med, August 11, of coronary occlusion.

Walter Odesly House, Tarboro, N. C. ; Medical College
of Virginia, Richmond, 1927 ; aged 41 ; was killed, August 22,
near Nashville in an airplane accident.

Jesse Howard Hutten, Omaha; Howard University College
of Medicine, Washington, D. C., 1898; aged 68; died, August
11, in Los Angeles of heart disease.

David Henry Braden, Wooster, Ohio; Homeopathic Hos-
pital College, Cleveland, 1895; aged 71; died, August 13, of
carcinoma of the liver and rectum.

Ben C. Crisler, Aberdeen, Miss.; College of Physicians
and Surgeons, Memphis, Tenn., 1907; aged 52; died, August
10, of poisoning by carbolic acid, self administered.

Gilbert Leroy Pray, Lake City, Iowa ; State University of
Iowa College of Medicine, Iowa City, 1897 ; aged 63; died,
August 19, of bronchopneumonia.

Orley Haven Van Eman © El Centro, Calif.; College of
Medical Evangelists, Los Angeles, 1924; aged 40; died, August
24, of a self-inflicted bullet wound.

Sylvester Sutton Hamilton, Punxsutawney, Pa. ; Columbus
(Ohio) Medical College, 1878; aged 86; died, August 2, of a
fractured hip received in a fall.

Wen Galaway Cutts, Pittsburgh; Detroit College of Medi-
cine, 1909; aged 66; died, July 10, in St. Francis Hospital
of carcinoma of the prostate.

John August Rolfs, Aplington, Iowa; Drake University
College of Medicine, Des Moines, 1904; aged 70; died, August
29, of coronary occlusion.

James Harry Hagan, Lake Forest, 111.; Drake University
Medical Department, Des Moines, 1890; also a pharmacist;
aged 76; died, August 27.

Floyd B. Moore, Fairhope, Ala.; Chicago Medical College,
1889 ; aged 71 ; died, August 5, of chronic myocarditis and
arteriosclerosis.

Alexander A. Friedel, Memphis, Tenn.; Jefferson Medical
College of Philadelphia, 1887; aged 79; died, August 1, of
arteriosclerosis.

Burt Omen Jerrel, Oskaloosa, Iowa; Chicago Homeo-
pathic Medical College, 1894; aged 70; died, August 17, of coro-
nary occlusion.

Joseph Lafayette Minton, Hartman, Ark.; Missouri Medi-
cal College, St. Louis, 1880; aged 85; died, August 7, of per-
nicious anemia.

Timothy A. Daly © Chicago; Northwestern University
Medical School, Chicago, 1897; aged 65; died, August 16, of
heart disease.

Edgar Merryman Parlett, San Francisco; Baltimore Medi-
cal College, 1902; aged 59; died, August 21, of a self-inflicted
bullet wound.

Abraham B. Deany, Winchester, Ky. ; Meharry Medical
College, Nashville, Tenn., 1903; aged 62; died, August 13, of
myocarditis.

Leonidas M. Jones, Harrison, Mich.; Detroit Homeo-
pathic College, 1906; aged 63; died, August 28, of coronary
thrombosis.

John William Wills, Wellston, Ohio; Kentucky School of
Medicine, Louisville, 1890; aged 76; died, August 14, of
pneumonia.

■ Davis H. Westfall, Polk, Neb.; John A. Creighton Medical
College, Omaha, 1902; aged 64; died, August 11, of coronary
occlusion.

Lewis Mendelsohn ® Jersey City, N. J. ; Baltimore Medi-
cal College, 1901; aged 66; died, August 26, of pulmonary
embolism.

Henry A. Smith, Sumner, Miss.; Missouri Medical Col-
lege, St. Louis, 1879; aged 81; died, August 1, of coronary
occlusion.

Edward Bower Flavien, New Haven, Ind.; Toledo Medi-
cal College, 1898; aged 63; died, August 27, of carcinoma of
the lung.

David Finley Brown, Hudgins, Va.; Cleveland University
of Medicine and Surgery, 1897; aged 82; died, August 15, of
senility.

Henry G. Stemen, Lebanon, Ohio; Medical College of Fort
Wayne, Ind., 187S; aged 88; died, August 16, of myocarditis.

ilenry KODert Hay, Wiarton, Ont., Canada; Victoria Uni-
versity Medical Department, Coburg, 1887; died, August 21.

William John Beatty, Keewatin, Out., Canada; Trinity
Medical College, Toronto, 1896; died, August 23.

Robert EHce Calhoun, Tulsa, Okla. ; Barnes Medical Col-
lege, St. Louis, 1898; aged 70; died in August.

165S

BUREAU OF INVESTIGATION

Bureau of Investigation

THE

UNIVERSAL

TION

HEALTH

FRAUD

FOUNDA-

Post Office Closes Mails to F. L. Gailey
and Z. Dominguez

Florence L. Gailey, a 70 year old woman, allegedly the widow
of a physician who died in 1926, together with 73 year old
Zefcrino Dominguez, carried on from Los Angeles a rather
elaborate piece of mail-order quackery under the trade styles
Universal Health Foundation,

Goode Products Company and
Good Products Company. Mrs.

Gailey was president and Mr.

Dominguez was vice president
of the concern.

The information that follows
is based in part on material in
the files of the Bureau of In-
vestigation of the American
Medical Association and, more
largely, on the statements made
by Judge Vincent M. Miles,

Solicitor for the Post Office
Department, in his memorandum
to the Postmaster General rec-
ommending the issuance of a
fraud order. Mrs. Gailey and
Dominguez sold through the
mails (1) a device called the
“Miracle Exerciser,” (2) a book
entitled “Secrets of How to
Live 150 Years” and (3) certain
nostrums called, respectively,

“Miracle Hemovida Tablets,"

“Miracle Digestall Tablets” and
“Si-Nease Miracle Antiseptic.”

The business was started in 1931

under the name “The Miracle Exerciser Company,” which was
changed in 1935 to “Universal Health Foundation.” No physi-
cians, pharmacists or chemists were connected with the enter-
prise, and the nostrums, book and “exerciser” were purchased
from other sources.

Mrs. Gailey is said to have told the Post Office officials that
she had learned all she knew about the human system from her
husband. She declared that she originated the Miracle Exer-
ciser, which, according to the advertising, would prevent not
only “senility and loss of sex power” but also “prolapses in all
the vital organs” and would, in addition, “stimulate circulation
in the scalp” and aid “in all heart disturbances." The Miracle
Exerciser consisted of two spiral springs, each with a handle
at one end while the other ends were connected by a metal
plate or bar. The user was supposed- to lie supine with the
feet on the bar and a handle in each band; the bar was to be
pushed with the feet and the handles pulled with the bands.
One variation in its use was for the user to lie with head hang-
ing over the side of the bed for the alleged purpose of causing
greater blood circulation in the head. The mischievous possi-
bilities of such recommendation in cases of elderly people with
sclerotic vascular systems may be imagined.

The nostrum “Hemovida” was said by the Gailey-Dominguez
concern to be “based on the Nobel Prize Award of 1935” —
whatever that might mean. The tablets were reported to con-
tain seaweed (kelp), alfalfa, legume starch, cornstarch, chloro-
phyll, some animal matter (allegedly liver extract) and small
amounts of iron, phosphorus, magnesium, sulfur, sodmm and
notassium. The “Miracle Digestall Tablets’ were essentially
of the same composition as Hemovida except that they contamed

Jous. A. M. A.

Oct. 28, !9j3

no animal matter. The advertising led the public to believe that
Hemovida would “produce more healthy red blood cells,” vvoifd
“raise, the defenses of the. body," “increase vitality” and cert
pernicious anemia. The Digestall tablets were claimed to make
it possible for oldsters to “retain your youthful appearance
throughout the entire span of life.” “Si-Nease Miracle Anti-
septic” was a mixture of mineral oil and olive oil in which there
was 1 per cent epliedrine, ethyl aminobenzoate, carbolic aril,
menthol, camphor, eucalyptus and oil of thyme. Government
tests were said to show that the stuff had "very weak inhibitory
effects upon germs tested in vitro.”

The only evidence offered by Gailey-Dominguez was state-
ments from two alleged physicians respecting the claims made
by the company. Only one of these statements was sworn and
neither was supported by any evidence to show the qualifications
of the writers or to show in fact whether those who made them
were physicians. The statements were held to be incompetent
as medical evidence and their incompetence was even admitted'
by the attorney for the Universal Health Foundation! Judge
Miles expressed the opinion that "some of these alleged doctors’
statements appear ridiculous on their face."

Even more preposterous, however, is the claim appearing
under the name of F. L. Gailey on the cover of an advertis-
ing leaflet, shown (reduced) on this page. The claim reads as
follows :

The World’s Most Eminent Authority Diet-
etics And On Brain Degeneration— caused thru
injurious upright posture of the human body.

After the hearing in Washington Judge Miles, on going mto
the matter in detail, declared that the evidence showed that t > e
scheme was a fraudulent one and he recommended that t e
Postmaster Genera! issue a fraud order closing the mails to
the concern. On Feb. 16, 1939, the mails were closed to
Universal Health Foundation, Good Products Company, 0IXL
Products Company, F. L. Gailey, president, Zeferino Doming^,
vice president, Z. Cortez, secretary, John Clark, assistant stcr
tary, and their officers and agents as such.

MISBRANDED “PATENT MEDICINES”

Abstracts of Notices of Judgment Issued by ^' e ^ 0
and Drug Administration of the United Sta es
Department of Agriculture
[Editorial Note. — The abstracts that follow are g ''f%
the briefest possible form: (1) the name of the t }, e

the name of the manufacturer, shipper or consigner, ^

composition; (4) the type of nostrum; (5) the reason ^

charge of misbranding, and (6) the. date of issu f\ ^
the Notice of Judgment — which is considerably later
date of the seizure of the product and somewhat la cr
conclusion of the case by the Food and Drug Adminis

Gelding Skin Remidin. — International Stock Food Co.. , an ^ ? r ‘ plyeW
Medicine Co., Minneapolis. Composition: Chiefly a * < -° ‘ • r t5 effective
and small amounts of ethyl acetate and mercuric chi lonm c * b3T \^i

ness as a cure for eczema, rash, scabies, plant poison - ctc , f v.-'
itch, ringworm, itching “piles,” parasitic diseases,
fraudulently represented.— DV. I. 29253; December 19SS.1

Ingersoll's Gall-Stone Pills, Gall Stone Remerfy and^^j^ phw .;

-G.'A. Ingersoll Remedy Co., Milwaukee Compos tiw Vpian’t " df ^

" °* e * tr £ c „,^ nc3r.scf.

jihthalein (0.64 grain in each), small amounts c v *tcm u*-

a salicylate and menthol; Gall Stone Remedy an > - 0 j; v e oil. ^

liquid medicine containing essentially a .j er5 one

sugar and water, cinnamon — —

baking soda and sodium tartrate, and the other, a tfe3 ({ n g Po-
tions made for the effectiveness of these nost^m^ n^rttber

flavored; and two pow

ic acid.
n treai

[N. T 29268; December

conditions were declared fraudulent.— ------ n C

-Washington Herk in l, ‘°\

Nature's Herb Tablets.'

Composition: Plant material, including “'o'- - rmn 3113 ',. 7 ' 1

liver, kidney, rheumatic an d stomach (ed.-f- >

catarrh, nervous diseases, etc., was fraudulently rev
29255; December 1938.]

Volume 113
Number 18

CORRESPONDENCE

1659

Correspondence

POLIOMYELITIS AND TONSILLECTOMY

To the Editor: — Dr, H. G. Langworthy (The Journal,
September 9, p. 1052) believes that we are unduly overwrought
over the relationship of poliomyelitis and the removal of tonsils
and adenoids. He states:

Considering that operations for tonsillectomy and adenectomy number
possibly one fourth of all major operations that are performed yearly in
the country and under all sorts of varying conditions and circumstances,
one could well promote almost any idea, however untrue or remote, by
citing the occurrence of a few sporadic cases. The removal of adenoids
and tonsils, when necessary, is so important in the welfare of children
that attempts to raise doubts and issues not clearly proved is to do great
harm rather than good. Because a few cases of poliomyelitis occurring
in summertime may have appeared after any operation, whatever that
operation might accidentally have been, is no reason whatever to raise
doubt and fear. If there is an epidemic of poliomyelitis in one’s own
community, any wise physician under these exceptional circumstances
should easily recognize what is the best procedure to adopt. The summer-
time during the long vacation period is a good time for the removal of
tonsils and adenoids in school children and should be consistently
encouraged.

It is fairly well established by now, from the experimental,
epidemiologic and clinical points of view, that the nasopharynx
constitutes the portal of entry for the poliomyelitis virus. Any
tissue injury present as a result of operation on the tonsils and
adenoids, in the presence of a poliomyelitis epidemic, would tend
to increase the susceptibility to the virus.

Silverman (Acute Poliomyelitis in Syracuse, N. Y., Am. J.
Vis. Child. 41:829 [April] 1931) reported five cases of infan-
tile poliomyelitis following tonsillectomies and adenoidectomies
(Fischer, A. E., and Stillerman, Maxwell : Acute Anterior
Poliomyelitis in New York, 1935 [A Review of 686 Cases],
Am. J. Dis. Child. 54:9S4 [Nov.] 1937).

That a seasonal variation exists, one must remember that the
peak of poliomyelitis not infrequently corresponds to the heavy
pollen concentration during late August and September months
(Felderman, Leon: Acute Anterior Poliomyelitis with Special
Reference to Its Rhinological Aspect, Laryngoscope 48:802
[Nov.] 1938).

It is a mistake to advise parents that the summer is tire ideal

time for tonsil and adenoid surgery. As a matter of fact, the

cooler months of the year offer the child a more auspicious time

without undue risks. „ _ , r -i j t ■ •

Leon Felderman, M.D., Philadelphia.

PRIMARY TUBERCULOSIS IN ADULTS

To the Editor : — As I have been especially interested in pri-
mary tuberculosis in adults for several years and recently pub-
lished an article on the subject, together witli Hedvall (Malmros,
Haqvin, and Hedvall, Erik: Studien fiber die Entstehung und
Entwicklung der Lungentuberkulose mit besonderer Berfick-
sichtigung des Verlaufs der tuberkulosen Erstinfektion des
Jugendlichen und Erwachsenen, Tuberkulose-Bibliothek No. 68,
Leipzig, Johann Ambrosius Barth, 1938; reviewed in The
Journal, Dec. 17, 1938, p. 2331), may I be allowed to make a
lew comments in connection with the editorial entitled “Primary
Tuberculosis in Adults” in The Journal, July 8, page 146.
It concerns the following statement: “Primary infection in
adults, other things being equal, appears to be ... no
more grave than in children” and in addition the following
points from page 147, taken from the article of Myers and his
co-workers :

The first infection type of tuberculosis, as observed in this group of
adults, has resulted in no significant symptoms or abnormal physical signs
throughout the entire course of development. Indeed, he states, the lesions
m the majority of their cases would not have been known to exist had it
not been for periodic tuberculin tests, and the making of roentgenograms of
the positive reactors. It apparently makes no difference at what time of
life the first infection with tubercle bacilli occurs with reference to the
average type of tuberculosis in human beings.

In order to understand the importance of primary tuberculosis
in adults, it is surely essential to study in detail cases in which
tlie tuberculin reaction in adults has changed from negative to
positive and to check up on them by frequent roentgenograms
during the years immediately following. In our work Hedvall
and I have given a report of 151 such cases of primary tuber-
culosis in adults. Of these, 104 showed no symptoms besides
the positive tuberculin reaction. Of the other forty-seven cases,
a primary complex or merely enlarged hilus glands could be
shown roentgenologically in twenty-one cases. In these cases
there usually appeared in connection witli the infection general
symptoms such as fever, symptoms of influenza, increased sedi-
mentation rate and, in women very often, erythema nodosum.
In some cases pleurisy developed after an interval of a few
months and in others actual pulmonary tuberculosis resulting
from “subprimary initial lesions” in the supraclavicular region.
In some of the cases the first sign of tuberculous infection was
an exudative pleurisy. The primary infection can also first
appear as acute miliary tuberculosis. In all these different forms
of primary tuberculosis in adults there generally appeared in
connection with the infection, as in children, more or less pro-
nounced general symptoms for which the persons concerned
sought medical aid because of feeling ill. Again, in other cases
(fourteen) actual tuberculosis of the lungs gradually developed
without any general symptoms and often with a normal sedi-
mentation rate. Changes in the lungs were discovered here
only by means of systematic roentgen supervision. The first
detectable lesions were in the form of “subprimary initial lesions”
— diffuse, cloudlike spots of different size, often multiple, and
in the majority of cases situated in the supraclavicular region
or in the first intercostal space. In a considerable number
of cases the initial apical lesions were the first manifestation of
a progressive type of pulmonary tuberculosis. The conditions
found in those cases in which the tuberculin reaction was posi-
tive at the time of the first examination corresponded well with
those in the aforementioned group of cases. A subclavicular
infiltrate of the Assmann type was only rarely found to be the
earliest lesion.

As is evident from the foregoing, primary tuberculosis in
adults can appear in different forms. In some cases the infec-
tion gives pronounced general symptoms; then enlarged hilus
glands are most often found, and sometimes a typical primary
complex. In many cases, however, progressive tuberculosis of
the lungs develops in close connection with the infection (already
after a few months) without the person concerned feeling ill.
It may be of great interest to know of this form of primary
tuberculosis in adults, for it can be discovered only by systematic
roentgen examinations. It is possible, and perhaps likely, that
it is just this form of tuberculosis which is the cause of the
high morbidity and mortality in tuberculosis of the lungs in
persons between the ages of 20 and 30. In any case, one must
probably count on the fact that primary infection in adults is
more grave than in- children, for among children, as is well
known, one finds progressive tuberculosis of the lungs rather
seldom. From the point of view of national economy it might
be more important to sacrifice work and money in examining
young adults rather than children of school age. As far as I
can understand, there has been as yet but slight advantage from
all mass examinations (x-ray) of children. On the contrary,
one might be able to expect better results from tuberculin and
roentgen examinations (with frequent supervision) of young
adults.

Lastly, may I draw attention to a little typographic error on
page 146. In the report of Heimbeck’s examination it says “The
highest morbidity was in the nurses who were positive at the
time of admission.” I presume that the word should have been
negative.

Haqvin Malmros, M.D., Orebro, Sweden.

1660

QUERIES AND MINOR NOTES

Jons. A. 51. A.
Oct. 28, 1911

Queries and Minor Notes

The answers here ruBLisiiEu have been prepared by competent

AUTHORITIES. TlIEY DO NOT, HOWEVER, REPRESENT THE OPINIONS OF
ANY OFFICIAL BODIES UNLESS SPECIFICALLY STATED IN THE RF.PLY.

Anonymous communications and queries on postal cards will not

BE NOTICED. EVERY LETTER MUST CONTAIN THE WRITER’S NAME AND
ADDRESS, BUT THESE WILL BE OMITTED ON REQUEST.

NIGHT BLINDNESS AND VITAMIN DEFICIENCY

To the editor: — One of my patients, a man about 50 years old, has com-
plained of painful symptoms apparently associated with the use of his
eyes in reading. He has worn glasses for many years but none of the
ophthalmologists to whom I have sent him have found any disease con-
dition in his eyes or elsewhere and his general health is good. The
trouble is diagnosed as being of entirely muscular origin. After reading
rather close material but under approved conditions of illumination, the
patient feels a general strain or dilatation around the eyes; this leads
to a general headache seeming to center in the middle of the head,
with slight fever and some blurring of sight, restlessness and nausea that
may climax in vomiting. He has developed aversion to night driving
of his motor car to an unusual degree. Can you advise me whether
or not any relation has been proved between night blindness and
vitamin deficiency and, if so, what treatment of this condition has
proved most successful? Do you feel that an analogous vitamin deficiency
could possibly be connected with the symptoms that have developed in
this patient? M.D., Massachusetts.

Answer. — Vitamin A deficiency of the retina is one of the
many causes of night blindness. If the patient is suffering
from night blindness arising only from the lack of provitamin
or vitamin A in the food and has no disease which prevents
the vitamin A from reaching his healthy retina in sufficient
quantity, there is reason to believe he can be cured of his night
blindness by taking daily from 5,000 to 10,000 international
units of vitamin A by mouth. His aversion to night driving
perhaps may be relieved by this treatment, but it is doubtful
whether his other symptoms are related to vitamin A defi-
ciency. It is possible but not probable that vitamin Bi defi-
ciency may be related to these symptoms.

BONE CHANGES IN SYPHILIS

To the Editor:—’ Thewlis, in his book "Preclinical Medicine" in the chapter
on svphilis quotes extensively from Bainbndge's paper Diagnosing the
Undiagnosed Lues," which maintains that in the absence of the ordinary
signs of syphilis, including a negative serologic reaction, syphilis can
be diagnosed by the finding of peculiar indentations visible in the bones
of the 9 hands, indentations which apparently need special radmlogic
• he detected. I have been unable to find mention of this

experienc . i; t erature with the exception of the sources

ciUdTand I should like to know whether these observations and con-
clusions have been confirmed or not. .

Francesco Ronchese, M.D., Providence, R. I.

Answer —Apparently Thewlis takes his opinions entirely

v?

importance is realized. statement is provided

Suss'd A*,, l* °‘

the hands were indicative of sypl luhUc mfeem ^ ^ faoth
Characteristic changes in f, een recognized

congenital and a . cq -“ ,r ®« standard textbooks. The comments
and are described m all J to ^bri*te however, are the only

of Riley and S t ™ th p^ticu af Se of ’ roentgenologic change
references to this parTicuia ' v , f significance that
that h-e been unearthed L and -^sjerhaps cts^ ^

so modern and Diagn osis of the Extremities and

£nT NeWVrk, Paul B. Hoeber, 1939) does not mention

them.

THYROXINE IN HYPERTHYROIDISM

To the Editor: — What Is the present status of the treatment of hypcithf*
roldism with thyroid extract as described by McClendon and Rice in the
Proceedings of the Society for' Experimental Biology and Medicine Ur
March 1939? How can prolonged feeding of thyroxine or thyroid extract
produce thyroid atrophy, as stated by Elmer in his book "Iodine Metub*
ofism" (New York, Oxford Press, 1938)?

R. L GorrcH, M,D., Clarion, lo»o.

Answer. — All that McClendon and Rice (Proc. Soc. Exfcr.
Biol. & Med. 40:379 [March] 1939) showed, was that the
administration of 2 grains (0.13 Gm.) of desiccated thyroid
daily to five women with toxic adenoma and eleven patients
with exophthalmic goiter did not affect the basal metabolic
rate significantly. Probably this means that at high lewis d
metabolism relatively large amounts are required to affect the
rate. The article by McClendon and Rice does not demonstrate
that desiccated thyroid has any value in the treatment of hyper-
thyroidism. It has been tried many times in the past m this
condition on the assumption that the secretion o the thyroid
was defective and that therefore, in spite of the high metal-
lism, an actual hypothyroid state existed. As a result ot care-
ful observation, it appears that desiccated thyroid is I'M™"
and not beneficial in the management of patients with Ufl*

^Profonged feeding of thyroxine or desiccated thyroid
ably produces thyroid atrophy by decreasing t e
the thyroid gland so that a resting state develops. In asm i
manner testosterone propionate may inhibit the func
testis to the point of hypospermia.

recurrent massive pleural effibion

tho Editor: — Kindly suggest the monogement of duro tion, in w
iffusion on the right side of the chest, of over Y ^ insidious erf
ibese woman at the menopausal age. The onset h n0 |1SS ,!

lyspneo and slight cough are the only tm ,m cl the

veight and the blood pressure is low. wos negetire. The

Hood is negative. X-ray examination of the ch t^^ os «s

Trow colored fluid removed wos 0 lum0 , by pM'«

juinea pig inoculation. There wos no evidence o ^ the
>r x-roy exomination. The chest was opp str0 „ colored M

lyspneo and each time more than 2 or 3 t >“ or ' cell!

:ontaining pus cells and i ** red b oo d a I t ™ e ™ hmh t he h itory
.spiraled. She is being treated for ,u ^ rc h fluid as poss'h |e “

rnd roentgenograms are negative. Should d a sma || amount

amoved when excessive dyspnea is > '“ l1 f0 atjSorb sponlonreusb
laid be removed, or should the fluid be , thc pleurol

f it will? is the injection of air or of eh emicols, into ^ ^ „„
ifter removal of fluid of any value. M n New

veek or two before producing excessive dyspne . M.D.,

BK or IWO uciwis, # -

NSWER.— In this case the problem
on the etiologic diagnosis of the P'eur y as (u bcr-
1 such a diagnosis is made, treatment o d ^ 1()e ca <e5
is is the correct attitude, since 80 per « lolI5 unless
eurisy with effusion are to be c011 . cases sijow*

itely proved otherwise. Thirty per cen C(1 when

tubercle bacillus, a percen age wluch is fes are

fluid is cultured on special mediums or t

. 1 ... .s.r/'A.

IU1U 15 * ,

yarding the question as to how ^ ^'^'js^ugg'esteti t|»j
ler in gradual stages or complete j , | et] - orl and flat
>uid be removed in gradual .stages Pj (liat a ir has

uid should be replaced by air. It is r (hc procedure
:inct therapeutic value and that ‘J

aid in diagnosis. Ao chemicals s following

order to make an etiologic diagnosis v ac
ms may be of value: (« > n >“ h f c 3 parcncl.)^
ially to differentiate the bronchograp a cur tam

;es, which are difficult to obtain t 8 ^ effus ion oi
or the thickened pleura assooated tn ^ y 0 p S j,

standing; (b) bronchoscop.c esamurtti^^^ mal ,g-

coscopy for nodules on the plcur » jj s an J cxa m

(*) section of the sputum °r mal.gnan t cNis^ ^
n of the stomach contents for th - nc 3 ,:1

rally, the sputum should be examined as
tomach washings should be repeated^ wou!(i not h:
is necessary to remember that .tumo c , ca(l l>.

in the fluid unless the tumor '"vadedffie P fe ^ ^
rtunately, the specific gravity of ^ dala g iv cn. ^

Ho whole, and basing an op ,. { tumor Witl' w 'i

rather suggestive of a tnahgna i, ic ;ilus

whole, and basing an op* 111 minor wiu* 1 " ' ,

The at fluid S f S Siv°e fo^thc tuberefc

S d think ma!i?Mnt gro '' vlh '

Volume 113
Number IS

QUERIES AND MINOR NOTES

1661

TUBERCULOUS WOUND INFECTION AFTER
NEPHRECTOMY

To the Editor: — A man aged 44 was operated on six months ago and had
a right tuberculous kidney removed. After six weeks the wound broke
open and has remained so ever since. I used irrigations of "mercresin"
solution, ultraviolet rays, calcium orally and large doses of super 0
vitamin. There has been little or no improvement during the last six
months. The Wassermann reaction is negative and x-ray examination of
the chest is negative. I have been advised that tuberculin might be of
some value. Kindly advise me whether you feel that it is worth a trial
and as to the method of use. Victor P. Dalo, M.D., Louisville, Ky.

Answer. — It is evident tliat the patient lias a widespread
tuberculous infection of his wound. The reason of this occur-
rence in an occasional case has been the subject of much specu-
lation. Among the theories advanced are the following : 1.

The wound becomes infected from the ureteral stump. 2. Some
of the perirenal fat that has been left behind harbors tubercle
bacilli and, following surgical trauma, breaks down, and so
the wound becomes infected. 3. A short time ago a new
theory was advanced to the effect that these wounds become
infected by the blood stream.

As far as treatment is concerned, there arc two schools of
thought — the one is medical and the other is surgical. The
adherents of the medical point of view in the management of
tuberculous wounds advise plenty of rest in bed, lots of sun-
shine or the use of ultraviolet rays, cod liver oil and the like;
in other words, a general program of management such as one
employs in any case of tuberculosis. The treatment of the
wound consists of dry dressings and the occasional applica-
tions of Peruvian balsam. Under this sort of a program most
of these wounds heal, although it takes a long time.

The surgical school believes in closing the wounds by opera-
tion, removing the tuberculous tissue by means of a dull curet
and suturing the wound with silver wire. While healing may
be slow under the medical program, the wound generally heals.
It is to be remembered that after operation the wound may
again become infected and break down.

The use of tuberculin is not advised. It might be advisable
to try dressings of cod liver oil.

ATROPINE AND ITS DERIVATIVES

To the Editor: — 1. Would you please inform me whether any of the newer
atropine preparations, such as novatropine and syntropan, have advantages
over the time-honored extract and tincture of belladonna and atropine
sulfate? 2. Will the administration of the extract of belladonna, one-
fourth grain three times a day, ar of atropine sulfate, Viso grain three
times a day, produce therapeutic effects on the gastrointestinal tract
equal to those obtained by the usual increasing doses of tincture of
belladonna? 3. Does the extract of belladonna have any advantage over
atropine sulfate? It seems more usually prescribed when capsules or pills
are desired, especially in combination with other drugs.

M.D., New York.

Answer. — The synthetic substitutes for atropine have been
prepared to overcome the side actions which limit the use of
atropine in full dosage. These undesirable side actions of
atropine which occur when atropine is used in full therapeutic
dosage over a period of time include extensive drying of the
mucous membranes and skin, a persistent mydriasis, a rapid
heart due to the action on the vagus, and a continual desire
to micturate. Larger doses may produce more serious mani-
festations and restlessness. Also in persons over the age of
30 and in those with a tendency to an increased intra-ocular
tension the tendency of atropine to increase this condition must
not be disregarded. Novatropine and syntropan are both
included in New and Nonofficial Remedies for 1939.

Atropine or belladonna is frequently used over an extended
period in the treatment of gastrointestinal conditions to reduce
spasm of the smooth muscle and also to reduce the secretion
of hydrochloric acid in the stomach. The newer synthetics,
such as those mentioned, will reduce spasm of the smooth
muscle, but there is some question as to whether they will
inhibit the secretion of hydrochloric acid to the same degree
as ail equivalent amount of atropine.

1. If relief of spasm of the smooth muscle is desired over a
period of time, the synthetics will control this with a minimum
degree of the undesirable side actions mentioned.

2. Since the extract of belladonna is a 400 per cent prepa-
ration (i. e. 1 Gm. of the extract contains the active principles

I Gm. of the crude drug) and since belladonna leaves con-
tain not less than 0.3 per cent of mydriatic alkaloids, one-
tourth grain (0,016 Gm.) of the extract contains 0.0002 Gm.
Uauo grain) of the total alkaloids. If equivalent quantities of

the tincture which is a 10 per cent preparation are used, equal
effect on the gastrointestinal tract will be produced.

3. Belladonna contains eight or more alkaloids. They all
have practically the same action on smooth muscle, but some
are hypnotic and some stimulating to the cerebral cortex. They
are present in the extract in the proportion that they occur
in the plant. The activity is due mainly' to atropine and
hyoscyamine. The latter alkaloid is equivalent to atropine in
its central effect. If rather large doses of belladonna are to
be used over a period of time, the extract might be more
desirable than atropine sulfate, owing to the lessened mental
effect of the extract when given in equivalent amounts.

INDUSTRIAL DERMATITIS

To the Edtior : — I am seeking information as to the cause of a dermatitis,
apparently of occupational origin. With a negative history for any
similar condition previous to 1938, the patient broke out with a macula-
papular rash confined chiefly to the ventral surfaces of the forearms,
which persisted until the middle of April (having started in January);
he began this particular work, i. e., as a laborer in a creamery, July 1,
1937, the work consisting chiefly of sterilizing and cleaning equipment.
Some of the lesions became pustular and for these he received inocula-
tions with beneficial results. He was free from any recurrence until March
15, 1939, when the condition returned and has persisted since. The itch-
ing coming on during the night is most distressing, and from his scratching
some pustular lesions develop. The materials used in his work arc as
follows; (1) a preparation called Pep-Tex, which is a milk-stone remover
made by the Diversey Corporation, Chicago; (2) Diversol, a chlorine prep-
aration made by this firm; (3) a boiler compound for cleaning the boilers;
(4) a copper polish, which is a reddish powder, and (5) chlorine. It is
with this group of things that I hope you will be able to help me, by
suggesting causes of such a dermatitis as we have in this instance.

R. S. Quackenbush, M.D., Goshen, N. Y.

Answer. — All the substances that the patient uses are poten-
tial cutaneous irritants. Pep-Tex contains strong alkalis, such
as trisodium phosphate, and sodium silicate mixed with sodium
chromate. It will irritate the skin if allowed to remain on it
for any length of time. It will also enter cuts and abrasions
to form chronic ulcers. In addition to this the sodium chromate
may also act as a cutaneous sensitizer.

Diversol is also strongly alkaline and in addition contains
sodium hypochlorite, which may itself be a cutaneous irritant.

Boiler compounds are also strongly alkaline, containing such
substances as sodium hydroxide, sodium carbonate, trisodium
phosphate and sodium fluoride, all of which will irritate the
normal skin.

Copper polishes may contain crude sodium carbonate, oxalic
acid, oleic acid, quartz or silica. The color may be due to
paris red or to iron oxide. The sodium carbonate and the oxalic
acid are powerful irritants of the skin.

Chlorine can also irritate the skin.

It is advisable that the treatment in this case consist only in
the application of mild lotions or ointments, such as boric acid
or calamine, and the wearing of long rubber gloves while
working to prevent further contact with any of the irritants.

EPHEDRINE IN RHINOLOGY

To the Editor : — I have been asked to get an opinion as to the use of
ephedrine in the treatment of various nasal conditions. The company
making this inquiry states that there seems to be some doubt in the
minds of the medical profession as to the wisdom of using ephedrine in
the treatment of various nasal conditions. M.D., North Carolina.

Answer. — Ephedrine and its salts are drugs of choice for
local use in the nose in cases in which the pharmacologic effect
of a vasoconstrictor is desired. Thus it is used in acute rhinitis,
acute sinusitis and the like. As shown by Proctz and others,
ephedrine in weak solutions, from 1 to 3 per cent, has no
deleterious effects on ciliary action. In accord with present day
thought, ephedrine is best used in physiologic solution of sodium
chloride rather than in an oily preparation. It is also well used
in weak dilutions, from 0.25 to 0.5 per cent, in the displacement
method of treatment as advocated by Proetz.

Although ephedrine is perhaps one of the more important
drugs in the treatment of acute and subacute nasal conditions,
it must be used with caution in chronic nasal disease. Thus,
for example, in vasomotor rhinitis and perennial nasal allergy,
in which there is chronic nasal obstruction and the need for
relief is constant, ephedrine should be used with caution, for it,
as do similar drugs, may act as a sensitizing agent when used
indiscriminately. A transient vasoconstriction is followed in
many instances by a prolonged vasoparalysis ; sneezing, a watery
discharge and itching become prominent complaints, and the
original disease is much aggravated and prolonged by the very
medication intended to relieve it.

1662

QUERIES AND MINOR NOTES

Jobs, A. 51 ,1
Ocr. 28, JSjj

DISGUISING TASTE OF SULFATES

To the Editor : — Please lei me know who!
sulfate as to taste.

powder is best used to disguise
F. W. Cobar, M.D., Milwaukee.

Answer. — The question as to disguising sulfate is rather
general and indefinite, as it does not specify a particular one.
It is not the sulfate but rather the specific radical attached that
needs disguising.

As to disguising sulfates in the dry form : Magnesium sulfate
is least unpalatable in the form of the effervescent salt of mag-
nesium sulfate N. F. VI. Sodium sulfate may also be made
into effervescent form. Either is perhaps best taken in ice
cold lemonade. Tablets of codeine sulfate, quinine sulfate and
strychnine sulfate are official in N. F. VI and can be easily
swallowed without having the patient experience the bitter taste.
The sulfates that need not be given in too large dosage may
be dispensed in capsule form.

As to disguising sulfate in liquid form: Codeine sulfate and
strychnine sulfate may be well disguised by the use of com-
pound syrup of eriodictyon N. F. VI. Ephedrine sulfate may
be prescribed in cherry syrup and is official in N. F. VI under
the title “syrup of ephedrine sulfate.”

In both cases the effects gradually pass off. The mydrbtb
action may persist two weeks and the mental or psychic spr.n-
frequenT” ° nSer ' IdiosJ ' Jlcrasy t0 tlle ^donna group is quite

In the case described it is extremely improbable that the
symptoms of acute belladonna poisoning could persist alter a
year. The rapid pulse and the occasional measles-like rash
point to an unstable vasomotor system. The drug could net
now be active on the vagus, and the rash is certainly not fa
(o any retained atropine. It is more probable that the patient
is of the nervous type and is susceptible to suggestion. If the
can be really convinced that there is no longer any retention
of the drug her symptoms may disappear.

MAGNETS FOR REMOVAL OF OCULAR FOREIGN mil

To the Editor :— Will you kindly furnish me with some infownotion repoi
i'ng magnets for removal of intra~ocular foreign bodies? Are the iiw
pensive magnets now advertised by reputable instrument houses stfidt
tory for this work? These work on alternating current with no lectiin
and, I believe, cost less than $15. ^.0. Atabama.

SMOKING ACETTLSAUCmC ACID WITH TOBACCO

To the Editor:— For the past nine years l have been jail physician and
during that time it has been frequently called to my attention that cer-
tain inmates were in the habit of crushing tablets of ocetylsalicylic acid
and putting the powder in tobacco and smoking the mixture. Can you
tell me what the effect of the mixture would be from a single smoke and
what would be the effect of the continuous use of acetylsalicylic acid
in this way? M.O., District of Columbia.

Answer. — A search of the literature lias failed to reveal any
reports on the effects of inhaling the vapors of acetylsalicylic
acid in tobacco smoke. When this drug is mixed with tobacco
and smoked as described, several products would be formed
and inhaled. Some of the acetylsalicylic acid would probably
be volatilized and inhaled as the unchanged acetylsalicylic acid.
There would be some salicylic acid and acetic acid inhaled and
absorbed and also some other disintegration products of the
drug. These substances sensitize the mucous membranes of
the respiratory tract and in this way would enhance the effects
of the tobacco itself. In addition, the inhalation of the vapors
of acetylsalicylic acid would have the usual effect of this drug
but to a much greater degree, because of the avenue of entrance
into the body. The inhalation of salicylic acid vapors in suf-
ficient amounts produces a nervous exaltation and a cerebral
inhibition somewhat resembling that produced by alcohol. This
is followed by depression.

It is difficult to say just what the effect of a single smoke
would be. The effect of the continuous use of acetylsalicylic
acid in this way would vary, just as the continued use in the
ordinary way produces different effects in different persons. In
addition to the physiologic effect produced by smoking acetyl-
salicylic acid, the psychic effect in these individuals must not be
disregarded.

ATROPINE POISONING

To the Editor : — A patient took an overdose of bellodonno about one year
ago and still complains of some of the symptoms of acute atropine poison-
ing. Is it possible for her to have a persistence of these symptoms

after such a period of time? My pharmacology textbook states that

atropine is fully eliminated in thirty-six hours in the urine. Is is possible
that some of the belladonna has become stored somewhere in the body?
Her pulse has been 100 or over ever since the poisoning. She breaks

out with a measles-like rash over the back every now and then. She

has lost her sense of smell. M.D., California.

Answer.— The size of the overdose of belladonna is not given,
so that it is difficult to predict the possible effects. Doses of
belladonna, of both the tincture and the fluidextract in amounts
up to ten times the U. S. P. doses, have been administered over
a period of time without any harmful effects persisting after
the drug was stopped. . , ,

Atropine, to which the effects of belladonna are mainly due,
is rapidly absorbed by mucous membranes and the intestine.

If atropine is given in ascending dosage to animals over a period
of time the drug may be stored in their flesh for several days
and this flesh may produce atropine intoxication in other animals
- ■ — It disappears rapidly

Answer. — The value of a magnet in the removal of inlri
ocular foreign bodies depends on the strength and extent of ti
magnetic fieid. The more powerful the magnet, the simpler
the extraction and the less trauma does the eye suffer. Ft
fairly superficial foreign bodies or for such as are located i
the anterior chamber and can be removed through a simpl
keratome incision, the simpler and hence weaker magnets suffici
But for the foreign bodies that have penetrated deeply a™*
a result of time may be tightly embedded in ocular tissues, tti
most powerful magnet is none too strong. A comparison o
the relative value of magnets is not available, but the Wb
satisfactory of all the magnets on the market is the one tna
was devised a few years ago by Dr. Walter B. Lancaster o
Boston.

PERSISTENT PAIN FROM SYPHILITIC PERIOSTITIS .
To the Editor : — Kindly advise mo how to control poin^

■ secondary

syphilitic periostitis that hos apparently been resistant to onalytic, I' 1 ..

Answer. — The persistence of the pain in

ment. A woman aged 27, without a history ot initial or 1 -— — •> .j i(

complained of pain in both shins at night. X-ray examination
was negative; serologic examination of the blood wos posi i .
spinal fluid was normal. During the past year she nos » Jljmirt
tions of mapharsen and of neoarsphenomine, sixty inicctia
and large doses of potassium iodide. The pain ana ,c " , j| 5t |

tibia, clavicles and calvarium have never been relieved co p j
studies showed a slight hypochromic anemia but no 9
dyscrasio. Serologic examination of the blood is still pos^

. the tibia, cl 3 '’'*’

and calvarium following the amount of treatment
patient has been given and the negative x-ray ex
would suggest some factor other than syphilis as ,.
the difficulty. As a rule the “night pains” of ffg*
pear readily following several injections of an ar ^ c " , f j ve a
ration, but occasionally patients with osseous syp ” WEl .
more pronounced benefit from the intramuscular u eJ[ p|j.
curial preparation. If further search reveals no . 5 0 f
nation for the discomfort, a course of tiveny conjure
mercuric succinimide, one-sixth grain (0.01
tion with large doses of potassium iodide, un
three times a day, should be tried.

up

ROENTGEN THERAPY IN BONE

Editor:— May I hove a brief stotement of the pr «« t n,» fw»<

theropy for bone end joint tubercuiosu, especiol » f/ y.

To the Editor:-
gen

and the ulna?

Arnold Backaf,

oit#

Answer. — Tuberculosis affecting P 10 ?

responds well to roentgen treatment but, li „ chronic

esses in general, the response is usually , tmen t, tul* f '

inflammations that are amenable to roentge ^ j,,. dosej

culous lesions of bones and joints arc c dose, art

corresponding to about three fourths ot an , a j s of tb ftS
the treatment should be repeated regularly may Y

or four weeks. At first (if sinuses are present; } „ 3gc dfey
increased drainage for a short time; later j v( , ,

f it is consumed in sufficient quantities. It disappears rapidly increased uramage 7! ' sJx t0 twelve

from the blood and is excreted, mostly unchanged, entirely by lsh . es f ^^’:,f v nd i 0 1 " £ Sing may take place (Desja^-,

the urine, mainly within thirty-six hours In acute, atropine and^ occasionally .longer, R h 1 ^ Ra y ys on Tttbe rcdw» I

noisomnsr the effects are felt m an hour or less, while in slower . •* . . , r 34.719 (Oct l 1935)-

poisoning the full effect may not develop for one or two days, esses, Wisconsin M. J. 34.719 [OctJ ^

Volume 113
Number IS

• EXAMINATION AND LICENSURE

Medical Examinations and Licensure

COMING EXAMINATIONS

NATIONAL BOARD OF MEDICAL EXAMINERS
SPECIAL BOARDS

Examination of the National Board of Medical Examiners and Special
Boards were published in The Journal, October 21, page 1588.

STATE AND TERRITORIAL BOARDS

Alabama: Montgomery, June 18-20. Sec., Dr. J. N. Baker, 5 1 9
Dexter Ave., Montgomery.

Arizona: Basic Science. Tucson, Dec. 19. Sec., Dr. Robert L.
Nugent, University of Arizona, Tucson.

Arkansas: Medical (Rcaular). Little Rock, Nov. 9-10. Sec., Dr.
D. L. Owens, Harrison. Medical (Eclectic). Little Rock, Nov. 9-10.
Sec., Dr. Clarence H. Young, 1415 Main St., Little Rock.

California: Oral examination (required when reciprocity application
is based on a state certificate or license issued ten or more years before
filing application in California), San Francisco, Nov. 15. Sec., Dr.
Charles B. Pinkham, 420 State Office Bldg., Sacramento.

Connecticut: Medical (Regular). Examination. Hartford, Nov.

14-15. Endorsement . Hartford, Nov. 2S. Sec., Dr. Thomas P % Murdock,
147 W. Main St., Meriden. Medical (Homeopathic). Derby, Nov. 14-15.
Sec., Dr. Joseph H. Evans, 1488 Chapel St., New Haven.

Delawarf: Examination. Dover, July 9-11. Reciprocity. Dover, July
16. Sec., Medical Council of Delaware, Dr. Joseph S. McDaniel, 229 S.
State St., Dover.

Florida: Jacksonville, Nov. 13*14. Sec., Dr. William M. Rowlett,
Box 786, Tampa.

Indiana: Indianapolis, June 18-20. Sec., Board of Medical Registra-
tion and Examination, Dr. J. W. Bowers, 301 State House, Indianapolis.

Kansas: Topeka, Dec. 12-13. Sec., Board of Medical Registration
and Examination, Dr. J. F. Hassig, 905 N. 7th St., Kansas City.

Kentucky: Louisville, Dec. 5-7. Sec., State Board of Health, Dr.
A. T. McCormack, 620 S. Third St., Louisville.

Maine: Portland. Nov. 14-15. Sec., Board of Registration of Medi-
cine, Dr. Adam P. Leighton, 192 State St., Portland.

Maryland: Regular. Baltimore, Dec. 12-15. Sec., Dr. John T.
O’Mara, 1215 Cathedral St., Baltimore. Homeopathic. Baltimore, Dec.
12-13. Sec., Dr. John A. Evans, 612 W. 40th St., Baltimore.

Massachusetts: Boston, Nov. 14-16. Sec., Board of Registration in
Medicine, Dr. Stephen Rushmore, 413-F State House, Boston.

Mississippi: Reciprocity. Jackson, December. Asst. Sec., State

Board of Health, Dr. R. N. Whitfield, Jackson.

Nebraska: Lincoln, Nov. 24*25. Dir., Bureau of Examining Boards,
Mrs. Clark Perkins, 1009 State Capitol Bldg., Lincoln.

Nevada: Written examination and reciprocity with oral examination.
Carson City, Nov. 6. Sec., Dr. John E. Worden, 311 W. Robinson St.,
Carson City.

New Hampshire: Concord, March 14-15. Sec., Dr. T. P. Burroughs,
State House, Concord.

North Carolina: Reciprocity and Endorsement. Raleigh, Dec. 11.
Sec., Dr. W, D. James, Hamlet.

North Dakota: Grand Forks, Jan. 2-5. Sec., Dr. G- M. Williamson,
4'A S. Third St., Grand Forks.

Ohio: Columbus, Dec. 5-7. Sec., Dr. H. M. Platter, 21 W. Broad
St., Columbus.

Oklahoma: Basic Science. Oklahoma City, Nov. 6. Sec. of State,
Hon. C. C. Childress, State Capitol, Oklahoma City. Medical. Okla-
homa City, Dec. 13. Sec., Dr. James D. Osborn, Jr., Frederick.

Oregon: Basic Science. Portland, Feb. 24. _ Sec., State Board of
Higher Education, Mr. Charles D. Byrne, University of Oregon, Eugene.

Pennsylvania: Philadelphia, January. Dir., Bureau of Professional
Licensing, Dr. James A. Newpher, Department of Public Instruction,
358 Education Bldg., Harrisburg.

South Carolina: Columbia, Nov. 14. Sec., Dr. A. Earle Boozer,
505 Saluda Ave., Columbia.

SouTn Dakota: Pierre, Jan. 16-17. Dir., Medical Licensure, Dr.
G. J. Van Heuvelen, State Board of Health, Pierre.

Texas: Austin, Nov. 20-22. Sec., Dr. T. J. Crowe, 918-19-20 Mercan-
tile Bldg., Dallas.

Vermont: Burlington, Feb. 13-15. Sec., Board of Medical Registra-
tion, Dr, W. Scott Nay, Underhill.

t- VlR< ? INIA: Richmond, Dec. 13. Sec., Dr. J. W. Preston, 30 Yi
Franklm Road, Roanoke.

West Virginia: Fairmont, Nov. 6-8. Sec., Public Health Council,
Dr, Arthur E. McClue, State Capitol, Charleston.

Wisconsin: Basic Science, Milwaukee, Dec. 2. Sec., Professor
Robert N. Bauer, 3414 W. Wisconsin Ave., Milwaukee. Medico/. Madi-
son, Jan. 9-11. Sec., Dr. E. C. Murphy, 314 E. Grand Ave., Eau Claire.

Tennessee June Examination
Dr. H. W. Qualls, secretary, Tennessee State Board of
Medical Examiners, reports the written examination held at
Knoxville, Memphis and Nashville, June 15-16, 1939. The
examination covered ten subjects and included 100 questions.
An average of 75 per cent was required to pass. One hundred
and eighteen candidates were examined, all of whom passed.
The following schools were represented:

School

Georgetown University Sc

H «7 o rd Q R n ' V A rsity Colic*
87.9, 89.2, (1938) 88.4
Harvard Medical School.,

Wo-mx ocnooi oi ineaicine

85.1, S5.5, 85-6, 85.7, 85.8, 86.3,
87.1, 87.2 87.6, 87.7, 89.6

Year

Per

Grad.

Cent

(1937)

86.1

(1937)

83.8,

(1939)

84.6

(1938)

82.6,

(1937)

85.2

1663

Jefferson Medical College of Philadelphia..... (1938) 86.4

University of Pennsylvania School of Medicine (1939) 86.5

Meharry Medical College (1939) 85,

85.6, 85.8, 86, 86, 86.2, 86.3, 86.5, 86.6, S6.6, 86.8,

86.8, 87, 87.1, 87.3, 87.4, 87.4, 87.5, 87.6, 87.7, 8 7.8,

87.9, 88.1, 88.2, 8S.4, 89, 89.2, 89.3, 89.8, 91.6

University of Tennessee College of Medicine (1937) 8S.7,

(1939) 84.2, 84.5, 85, 85.3, 85.3, 85.7, 85.9, 85.9,

86.9, 88, 88, 88, 8S, SS.2, SS.7, 88.8, 89, 89.1,

89.4, 89.4, 90.7, 91.5, 93.5

Vandeibilt University School of Medicine (1931) 85.8,

(1939) 82.3, 82.6, 83.9, 84.3, 84.3, 85.2, S5.3, 85.5,

85.8, S5.9, 86, 86.1, 86.2, 86.3, S6.4, 86.7, S7, 87,

87, 87.1, 87.1, 87.3, S7.5, 87.7, 87.7, 87.9, 87.9, 88,

88.1, 88.2, S8.6, 88.6, 88.7, 89.3, S9.9, 90, 90.4, 91.8,

92.3

McGill University Faculty of Medicine (1937) 94.3

Thirteen physicians were licensed by endorsement from March
14 through July 18. The following schools were represented:

School

LICENSED BY ENDORSEMENT

Year Endorsement
Grad. of

University of Arkansas School of Medicine... (1936) Arkansas

George Washington University School of Medicine (l927)Dist. Colum.

University of Georgia School of Medicine..... (1936) Georgia

College of Physicians and Surgeons of Chicago (1912) Indiana

University of Illinois College of Medicine (1930) Mississippi

Louisiana State University School of Medicine (1939) Louisiana

Tulane University of Louisiana School of Medicine. . (1936, 2) Louisiana

University of Maryland School of Medicine and Col-
lege of Physicians and Surgeons (1937) Maryland

University of Michigan Medical School (1933) Michigan

Jefferson Medical College of Philadelphia (1934) Penna.

University of Pennsylvania School of Medicine (1936) Penna.

Medical College of the State of South Carolina (1937) S. Carolina

North Dakota July Report

Dr. G. M. Williamson, secretary, North Dakota State Board
of Medical Examiners, reports the oral and written examination
held at Grand Forks, July 4-7, 1939. The examination covered
twelve subjects and included ninety questions. An average of
75 per cent was required to pass. Nine candidates were exam-
ined, all of whom passed. One physician was licensed by reci-
procity and two physicians were licensed by endorsement. The
following schools were represented :

School PASSED

Northwestern University Medical School. .. (1938

Harvard Medical Scho n1

University of Minneso " •

University of Oregon '!• ' .* - ' .

Univ. of Western Ontario Medical School. . (1936) 75.4,

McGill University Faculty of Medicine

Regia Universita di Napoli Facolta di Medicina
Chirurgia

Year

Ter

Grad.

Cent

, (1939)

81.3*

.(1935)

85.2

.(1936)

80.8

(1938)

79.2

(1938)

78.4

.(1936)

80.S

€

,(1936)

80.1

School LICENSED bv reciprocity

Loyola University School of Medicine (1926)

Reciprocity

with

Illinois

g c k 0o j LICENSED BY ENDORSEMENT Grad ^ n ^° r ^ ment

College of Medical Evangelists (1928)N. B. M. Ex.

Harvard Medical School (1929)N. B. M. Ex.

* This applicant has received the M.B. degree and will receive the M.D.
degree on completion of internship.

Minnesota June Report

Dr. Julian F. Du Bois, secretary, Minnesota State Board of
Medical Examiners, reports the written, oral and practical
examination held at Minneapolis, June 20-22, 1939. The exami-
nation covered twelve subjects and included sixty written ques-
tions. An average of 75 per cent was required to pass. Fifty-six
candidates were examined, all of whom passed. Four physicians
were licensed by reciprocity and two physicians were licensed
by endorsement. The following schools were represented:

School . passed Grad.

Emory University School of Medicine (1937)

Loyola University- School of Medicine (1939)

Northwestern University Medical School. . .(1936) 86.5,' (1938)

Rush Medical College (1936) 85.3, (1938)

State University of Iowa College of Medicine (1938)

University of Michigan Medical School (1937)

University of Minnesota Medical School (1938)

85/ 86.2/ 87/ 87.1, 88/ 89.6/ (1939) 82.2. 83 4
83.5 84.2/ 84.5/ 85, 85.1/ 83.1, 85.5/ 86/ 86, StkS
$6.6/ 86.6, 87.1/ 87.1/ 87.1, 87.3/ 87.5/ 87 5 *

88.L 88.3/ 88.3/ 88.3, 89/ 89.1, 89.2, 90.5, 9 l.’l/

Washington^ University School of Medicine (1937)

Cornell University Medical College * (1935)

University of Oregon Medical School !*.!!**.!** *(1938)

University of Pennsylvania School of Medicine. ..*"(1936)

Per

Cent

85.1
89.6

91.2
87.3, 88.6

89

87.2
84.4,

88.1

89.1

86.4

90

1664

BOOK NOTICES

Marquette University School of Medicine (1939) 85 1 87 89 6

University of Wisconsin Medical School. .. (1936) 88.1, (1938)' ' 83*5

University of Manitoba Faculty of Medicine (1935) 85.6

School licensed by RECIPROCITY ^ ea T Reciprocity

OLUUOI Grad. W ltll

State University of Iowa College of Medicine. . (1932), (1936) Iowa

Johns Hopkins University School of Medicine (1928) Louisiana

University of Minnesota Medical School (1938) Washington

School licensed by endorsement Grad

Northwestern University Medical School... (1939)N. B. M. Ex.

New York University College of Medicine (1936)N. b! m! Ex!

. * Tll ,' s applicant has received the M.B. degree and will receive the
ALU, degree on completion of internship.

Book Notices

Menstrual Disorders: Pathology, Diagnosis and Treatment. By c.
Frederic Ftuhmann, B.A., M.D., C.M., Associate Frofessor of Obstetrics
and Gynecology, Stanford University School of Medicine, San Francisco,
California. Cloth. Price, JS. Pj>. 329, with 119 illustrations. Phila-
delphia & London : W. B. Saunders Companj’, 1939.

This excellent monograph is ineptly named, since the first
152 pages deal with the processes of normal menstruation ; viz.,
the morphologic changes, the physiology and the mechanism of
the hormonal controls of the menstrual process. The opening
chapter is a splendid historical review of the concepts of men-
struation. The morphologic changes and the histopathology are
excellently written and particularly well illustrated. The com-
plicated pictures of the hormonal control of menstruation are
presented clearly and simply and the references to the literature
and bibliography are almost all inclusive. The latter half of
the book deals with the pathology of menstruation rather ade-
quately in the light of our present knowledge. It leaves some-
thing to be desired, however, in its style, there being considerable
overlapping and repetition. These remarks should not detract
from the value of the work and the appeal which it should have
for the practitioner of medicine. It is by far the best discussion
of this problem for the general practitioner that is available
today.

Report on Cardiazol Treatment and on the Present Application of
Hypoglycajmic Shock Treatment in Schizophrenia. By W. Rees Thomas,
M.D.. F.B.C.F., D.P.M., Medical Senior Commissioner of the Board of
Control, and Isabel G. H. Wilson, M.D.. M.R.C.P., D.F.M., Medical Com-
missioner of the Board of Control. Board of Control (England and
Wales). Paper. Price, 30 cents. Pp. TO. New York: British Library
of Information; London: His Majesty’s Stationery Office, 1038.

This is a remarkable book which contains a wealth of accurate
data, gathered from dependable and well known authors, a book
which bears the backing for accuracy of the English board of
control.

The authors tried to be objective as far as is humanly pos-
sible and to refrain from personal prejudice. Matter of fact
objection is raised to taking very much from the literature of
the originators for granted and neglecting to point to the differ-
ences which are obvious in the “history" of the development
of the treatment as well as the theory. The technic and the
results from various authors are stated as completely and effi-
ciently as possible. It seems sometimes that the description of
the rather simple technic of the shock produced through metrazoi
alone is too detailed and elaborately stated. With the same
extreme accuracy, the authors describe the technic of the shock
produced through insulin treatment, although they had already
done so in their first publication. The many variations and
possibilities are described and the experiences of the authors
are freely mentioned. A wealth of reports from the literature
and experiences are presented in such a manner that one inter-
ested in a particular question can easily find the details. The
book is certainly helpful to any one who needs advice in some
particular difficulty.

In the enumerating of the complications and dangers winch
occur with the use of metrazoi alone, the authors are rather
too short. They did not cover the numerous publications in
America about this subject. In neglecting these and in bringing
in just the statement from Meduna, they have made the danger
of this treatment appear in an entirely different light from that
in which we see it in this country. In reporting the results o
treatment by metrazoi alone and by insulin alone, they display
^“ shortcomings. It seems rather strange that the authors,

Jour. A. Jt. A.

On. 23 , isa

reporting about American results, neglected the firs! laid
reports, for example the official statistics from the Mental
Hygiene Department of the state of New York, published by
Superintendent Ross, and used rather the information about the
American materia! given them by Dr. Meduna. They shotM
not have chosen this volunteered information just because it
was more accessible. Availability is not sufficient to secure
preciseness.

In such a book one expects to find first hand reports to
results. ^ By neglecting them the authors create an impression
concerning the experience in America, especially with metal
treatment, entirely opposite to the real situation. The fact tint
the authors preferred to take their statistics for this courtly
from hearsay instead of using the original official reports fret
the state of New York, covering a great number of cases
spoils the good record of this book. If they had done it properly
it would have shown, as reflected now from the literature an
as Sake! pointed out long ago, that the epileptic fit is valiaY
as symptomatically used by himself but does not lave val
importance for a permanent cure.

Annual Reprint of the Reports of the Council on Pharmaty ami Mw
istry of the American Medical Association for 1938 with the C ammrtk
That Have Appeared in The Journal. Cloth. Price, M. Pk l!i
Chicago: American Medical Association. 1939.

This volume tells why the Council on Pharmacy and Chemistry
has rejected or why it has not yet accepted tire products con-
sidered in a given year. In addition it may contain authoritative
monographs on the current status of such pharmacologic or
therapeutic questions as may have been raised in the course of
the Council's deliberations. The last named category is repre-
sented in the current volume by the report on the omission from
N. N. R. of all creosote and guaiacol compounds. After exten-
sive consideration of the literature and of data furnished by t e
pharmaceutic firms whose products stood accepted, the Couno
came to the conclusion that the oral use of such preparations or
action on the respiratory passages could be defended only <®
empirical grounds and that, therefore, they are not a necessarj
part of the modern therapeutic armamentarium. .

Another status report in this volume is that on the use
colloidal sulfur in the treatment of chronic arthritis. After co
sidering the referee's exhaustive report of the literature, ;
Council concluded that claims for the use of colloidal u .
the treatment of chronic arthritis are at present umvarra
and cannot be recognized until satisfactory evidence, is a ' .
able with regard to the following factors : the determina 10
the types of cases in which it may be used with a fair expee ,,
of benefit ; the determination of the chief contraindica '° n ;
determination of the optimal dosage; the determin atmn
best form in which sulfur is to be used, whether as toe
sulfur, as ordinary sulfur administered orally or as co 01
fur for intramuscular or intravenous injection, g u jf.

Among the preliminary reports in this volume, ^

apyridine, which carries a special article by Dr. c
Long, a Council member who has been much con ^ er .f (ef jfc;
the work on this drug, is perhaps of greatest interes . ^

Food and Drug Administration had released the drug - 0 ,. ;
use of physicians early in 1939, the Council j| cce P <j jj
brands for inclusion in New and Nonofficial lieme
connection with the published descriptions ksuedano ,

report (The Journal, May 6, 1939, p. 1850) tasw (h
questionnaire sent to men who had been pronune
experimental use of the drug. This report, no dou , '
in the next volume of reprinted Council reports.

,ouin.u nearirj

The ’status report on Immune Globulin (Human)
in this volume is another example of the P r °e e .wripfi 01
tioned. It appeared in connection with the pub ts ou t>!ifhed
of accepted brands and followed a preliminary rep
in 3935. The longer period of abeyance in wmen
was held is noteworthy. . jnicrcd

The Council’s continuous and, at present, i folloivk?

in matters of drug nomenclature is attested 5 onjin ft;
reports appearing in this volume : Nonpropne } . an-pbc"

Benzedrine and Benzedrine Sulfate (ampbetani jarr')-

sulfate); Sulfapyridinc (the nonpropneWQ
_ of nomenclature were involved > Extra d

reports of omission or rejection: Abbott s A- * »- F~
with Cod Liver Oil and Viostero! Omitted from

amine
Questions

Volume 113
Number 18

BOOK NOTICES

1665

(unwarranted implied claim for effect of vitamin B complex com-
ponent) ; Nupercainal-"Ciba” Not Acceptable for N. N. R.
(false implications concerning actual relationship to the accepted
Nupercaine) ; Quinoliv Not Acceptable for N. N. R. (coined
proprietary name for unoriginal mixture) ; Sedormid Not
Acceptable for N. N. R. (therapeutically suggestive name) ;
Fru-T-Lax Not Acceptable for N. N. R. (misleading and
inadequately descriptive name). Of course, other objectionable
features were concerned in the reasons for rejection but the
question of nomenclature was given much weight in each con-
sideration.

• Attention should be called to the excellent status report on
Ergonovine prepared for the Council by Dr. Ralph G. Smith. It
will be recalled that Ergonovine is the nonproprietary name
adopted by the Council for the new ergot alkaloid which had
been given various names by various investigators. Dr. Smith’s
article is a compendious study of the new drug and its relation to
ergot therapy. The Council’s name, Ergonovine, appears to be
in the process of being generally adopted.

Methodon der Virusforschung. Von Prof. Dr. Henrlque da Itochn-
Llmn, Dlrektor des Staatl. Blologlsclien Instltuts, Sao Paulo, Dr. Jos6
Reis und Dr. Karl SUbersclimidt. Dlcse Abhnndlung erschetnt zugletcli
ala Lleferung 4S0 In Abt. XII, Tell 2 des Abderhaldenschen Hnndbuchs
der blologischen Arbeltsraethoden. Cloth. Price, 24. GO marks. Pp. 384,
with 54 Illustrations. Berlin & Vienna : Urban & Schwarzenberg, 1039.

This volume has an attractive format and contains excellent
subject and author indexes. Almost half the text describes the
technics of investigations of plant viruses ; the remainder gives
most of the procedures involved in studies on viruses derived
from man and the lower animals, including those of the
rickettsial diseases and pleuropneumonia bovum. At the end
of each section are numerous references which add definite value.
Of the authors, da Rocha-Lima has the respect and esteem of
his colleagues for his original contributions to the subject of
rickettsiae, particularly those associated with typhus fever, and
Reis has studied avian and virus pathology. Silberschmidt is
engaged in investigations on plant viruses, especially the study
of the immunologic reactions of plants to infection. Within
the last eleven years a number of comprehensive treatises deal-
ing with the general aspects of viral agents and the diseases
induced by them have been presented to the public. From
the first, issued under the editorship of Rivers and of the
British Medical Research Council, to those recently published
under the direction of Levaditi and of Doerr, methods were
described therein only as part of the subjects dealt with.
In the present book a special contribution for the advanced
student and investigator on virus technology is achieved for
the first time. It is to be regretted that its contents are limited.
With such limitation, omissions of certain established technics
can occur. In the section on inclusion bodies, micro-incineration
and the important subject of inclusions produced by nonviral
materials are not considered ; nor is mentioned, in the section
on preparation of materials for animal inoculation, the value
of broth as a diluent and suspending fluid or the use of centrifu-
gation for clearing material from concurrent bacteria. Not all
the routes of animal inoculation are given. Nor, in the section
on determination of size, is the fact stressed that two important
considerations are involved in obtaining correct end points:
(1) infectivity of the virus in question and (2) its concentration.
It would have been desirable, furthermore, to offer centrifuga-
tion as a means for recovering virus from neutral serum-virus
mixtures and to give explicit procedures of serum-virus pro-
tection tests. However, the difficulty should be recognized of
preparing a work such as this, on a subject which is so ener-
getically studied, with such great progress. Although other
omissions than those mentioned occur, the description of technics
in the study of plant viruses, of ultrafiltration, of inclusion
bodies and of tissue and embryonated egg cultivation are
superior. What is stated in the text (including illustrations)
has apparently been taken from original articles — a fact of
utmost importance in creating a solid book. Descriptions of
many of the most modern developments are included, such as
purification of viruses by ultracentrifugation, stream double
refraction, the Muench law, the electronmicroscope and light
reactions. The present volume should prove of value to pliyto-
patliologists who are investigating viruses and should be useful
in supplementing existing books on these agents.

William Alanson White: The Autobiography of a Purpose. By Wil-
liam A. White, M.D., A.M., Sc.D. With an introduction by Bay Lyman
Wilbur. Clotli. Price, $3. Pp. 293, with portrait. Garden City, New
York : Doubleday, Doran & Company, Inc., 1933.

This is a stimulating and inspiring book which succeeds in
being true to its subtitle, “The Autobiography of a Purpose”.
It is written in the first person with engaging candor and frank-
ness. The author has apparently succeeded in taking an
objective attitude toward his life, his personality and his pur-
pose. There is no egotism in it nor any self deprecation.

After a preface and introduction in which he gives his reasons
for writing the book, he divides his material into three parts.
In the first of these he deals with the origin and early expres-
sions of his purpose in life, including chapters on his first
fifteen years, his college life, medical school and internship, the
beginning of his career in psychiatry at the New York State
Hospital at Binghamton and the beginning of his work at St.
Elizabeth’s Hospital, Washington. Part two deals with the
building of St. Elizabeth’s Hospital, the development of person-
nel, factors in administration, liis correspondence, consultations,
extramural activities, medicolegal experience and teaching. In
this part are found chapters on the development of modern
knowledge about dementia paralytica and the first use of malaria
therapy in the United States. The closing chapter in this part
deals with patients he knew and whom he designates character-
istically as his friends.

Throughout the book one sees evidence of what must have
been the chief characteristic of the author’s personality, namely
an insatiable interest in human beings and a broad and catholic
sympathy for all mankind. His chapter on correspondence
shows this universal human sympathy ; he never failed to answer
letters even from persons of obviously unsound mind. His
medicolegal experience is characterized by a constant refusal,
after one unsatisfactory incident, to testify for the prosecution
on the ground that a doctor’s business is to salvage human life
and never to assist in its condemnation.

What may be regarded as the key to his life and to his
philosophy is found near the end of the book (page 2S4) in his
statement that "ideas are quite as real as chairs and tables and
very often at least, if not always, very much more important.”
He places great emphasis on the modern psychiatric conception
of the idea of the totality of the individual as opposed to dis-
tinctions between body and mind and he believes that the next
great step forward in medicine will be along the line of further
acceptance and development and the practical application of this
concept.

The book is a valuable contribution both to professional and
to popular literature in the field of mental hygiene and psychiatry.
No layman can read it without a better understanding of the
phenomena of mental disease and a broader and deeper sympathy
with those unfortunates commonly known as “crazy people.”
No doctor can read it without being a better clinician and a
wiser physician.

Die Grundlagen unserer Emahrung und unseres Stoffwcchsels. Von
Emil Abderhalden, o. 6 Professor der Physiologic und der physlologlschen
Cliemle an der Martin Luther-Unlversltat llalle a. S. Fourth edition.
Paper. Price, 6 marks. Pp. 193. Berlin : Julius Springer, 1939.

This is an interesting account of the relation between plant
and animal nutrition, the nature of the inorganic and organic
nutrients, the chemical changes which occur in the intermediary
metabolism of individual nutrients, the deficiency diseases, the
nutritional significance of the milling of cereals, and the energy
requirements of man for work. The author’s well known
facility as a writer insures an entertaining style. The brevity
of the volume necessitated a superficial treatment of the great
number of facts mentioned. There is no bibliography. Although
the preface is dated January 1939, the book gives the impression
that it was written at least two years ago and also that the
author is not familiar with recent American researches in nutri-
tion. For example, manganese is mentioned as occurring in
the body and nothing is said of its physiologic role, which
represents the major discovery of practical importance in poultry
production in recent years. There is no mention of the anemia
due to cobalt deficiency. Nicotinic acid in relation to pellagra
is not mentioned. There are available in English several more
timely books on nutrition.

J.UUO

BOOK NOTICES

The Diagnosis and Treatment of Disoases of the Thyroid. By James
H. Means, M.D., Jackson Professor of Clinical Medicine, Harvard Uni-
versity, and Edward P. Richardson, M.D., John Homans Professor of
Surgery, Harvard University, Boston. (Itoprlnted from Oxford Mono-
graphs on Diagnosis and Treatment.) Cloth. Price, $5. Pp. 357, with
1938 1UStratl ° nS ^" C "' Yor,; ' Toron t° & London : Ox-ford University Press,

_ This volume is a series of monographs, each covering a par-
ticular phase of thyroid disease and each complete in itself.
From the nature of this compilation there is much overlapping
and repetition of material. As a whole, the book has given in
an interesting manner a true description of goiter throughout
the ages. The historical side of goiter and the part that each
man has played in the development of our present knowledge is
given in detail. The monograph on exophthalmic goiter is
thorough. Every theory of the cause is described and criticized ;
every diagnostic measure is explained and evaluated; a rational
understanding of the probable causes and principles of treatment
is achieved. Detailed case histories of hospital patients, cover-
ing twenty-three years, are given to contrast the diagnosis and
treatment at different periods. The book gives little space to
cretinism and congenital hypothyroidism, which in some sections
of the country arc of greater importance than is indicated. These
monographs were copyrighted in 1929 and few references to
work done in the past ten years have been added.

Ober die Wirkung von Erhiihung der Korpcrtemperatur auf den Kreis-
lauf: Experlmentelle Untersuchungen iiber die Kreislaufverhaltnisse bei
Erwarmung von Kaninchen mit besonderer BerUcksichtigung der Blut-
druckregulation. Inauguraldissertation. Von Itunar Brennlng, Paper.
Pp. 147, with 37 illustrations; Appendix, pp. 47. Uppsala: Almqvist &
Wikseiis Boktryckcri-A.-B., 1938.

This monograph reports numerous animal experiments, largely
with rabbits, on the relationships and mechanisms of circulatory
changes associated with elevated body temperatures. There are
included many graphs and tabulations. The citations in the
literature are more international than is usual with continental

Jon. A. 51. A.
Oct. 28, 19J1

the student is instructed to adjust Endo’s medium to fa 7.1
but the method of making such an adjustment is omitted, in
the chapter on germicides there are a number of rather broad
statements concerning some of the commercial preparations,
such ^ as lysol is one of the most valuable disinfectants known”
and “hexylresorcinol, a compound related chemically to phenol,
and marketed in a mixture called S. T. 37, is an effective dis-
infectant.” Phenol coefficients are omitted for all germiddes
mentioned, as are also the various methods of testing the
efficiency of germicides.

Studien fiber hereditiire, multipte Epiphysenstorungen. Av Seved nib-
bing. Akademlsk avhandllne, for vlnuande av medicine DoMorssraJ,
Upsala. Paper. Pp. 107, with 94 illustrations. Helsingfors, 1937.

The introduction contains a review of the literature of pri-
mary disturbances of ossification. This is detailed, covering
general conditions such as achondroplasia and cretinism, to
localized aseptic necroses, osteochondritis dissecans, osteochon-
dritis deformans coxa (coxa plana) and kyphosis dorsalis juve-
nilis. The material of the study consists of hereditary anomalies,
and the author describes the occurrence of congenital anomalies
in six members of a large family. These anomalies are
thoroughly studied and elaborately described. They involve
multiple joint epiphyses, but especially the metacarpophalangeal
articulations, knees, hips and vertebral bodies. The x-ray
appearances, which he divides into two principal types, namely
anatomic variations and anomalies on the one band and destruc-
tive lesions similar to the osseous aseptic necroses on the other,
are most elaborately presented. There are unfortunately no
microscopic investigations to correlate with the clinical an
x-ray studies. As a monograph on a rather circumscribed su
ject, built on a comparatively small clinical material, the boo"
is carefully and painstakingly compiled and an interesting con
tribution to the rather dark field of primary epiphysial grown
disturbances.

publications. Brenning seems to have evolved a rather complex
and quite theoretical concept anent the mechanisms involved.
The experimental data do not by any means prove his con-
tentions; they merely suggest that his may be one of several
possible theories to cover the facts. The factual portion of the
work represents extensive and painstakingly careful studies.
The monograph will'be of special interest chiefly to investigators
in the physiology of the circulation and thermoregulation. The
clinical applications of the contentions are as yet remote.

Zur Epidemiologic der Kinderlahmung : Einc statlstische Analyse. Von
Birger Jonsson. Acta Medicn Scandinavica, Supplemcntum XCY1II.
Paper. Pp. 193, with 13 illustrations. Stockliolm ; Esselte Aktiebolng,
1938.

This book contains an analysis of one epidemic of poliomyelitis
which occurred during the years 1935-1937. They had 266 cases
of paralysis, sixty-two abortive cases and 129 suspects. No
epidemics bad occurred in this area previous to 1935. Jonsson
considers that the maximum of dissemination of poliomyelitis
lies between the maximum of the intestinal diseases typhoid and
dysentery on the one hand and contact diseases such as diph-
theria and scarlet fever on the other hand. It was found that
the disease did not follow the waterways but was most common
in areas with the most crowded population.

Medical Microbiology. By Kenneth L. Burdon, Fli.B., Sc.M., Ph.D.,
Assistant Professor of Immunology and Bacteriology. Louisiana State
University School of Medicine, New Orleans. Cloth. Price, S4.50. Pp.
703 with 120 illustrations. New York: Macmillan Company, 1939.

This book is a revision and enlargement of the Textbook on
Bacteriology by the same author. It was apparently written
to suit the requirements of the author in his own classroom.
Part 1 is devoted to the historical aspects and other phases of
general bacteriology; part 11 gives brief instructions for labora-
tory routine; part in presents sources and modes of infection,
with brief instructions for procedures in the operating room
and the home; part iv deals with the microbiology of some of
the more important communicable diseases. Five appendixes
contain instructions for the preparation of culture mediums and
stains and procedures for immunologic tests. W ithout doubt
the book is satisfactory to the needs of the author, but the
brevity of description in some cases is unfortunate. For instance,

Pulmonary Tuberculosis: A Synopsis. By Jacob Segal, M.D., *2?S

rutmonary lupercuiosis: A synopsis. 1 sy jucu u Y - rfc

clan in Charge of Fordham Hospital Tuberculosis Clinic, b ..
Foreword by the late Pol N. Coryllos, M.D., F.A.C.S. Cloth. 1 'niford
Pp. 150, with 21 illustrations. New York, Toronto & London.

University Press, 1939.

This is a brief presentation on pulmonary tuberculosis,
contains numerous illustrations, mostly prepared iroin *
films of the chest. Approximately half a page is devote
first infection type of tuberculosis and the remainder 0 |C
to reinfection clinical forms of the disease. Various pi
the examination for tuberculosis, such as the tu er *i u 'under
symptoms, physical signs and x-ray films, are outline ■ ^

treatment such subjects as hygienic regimen, ires 1 a ,
drugs and physical therapy are briefly discussed. ,c
of collapse therapy .includes artificial pneumothorax, oe ^
pneumonolysis, phrenicectomy and thoracoplasty. n M era ble
mately ten pages prevention is discussed, and c0 eJ 0 f
emphasis is placed on predisposing or contributing Rouses,
tuberculosis, such as living in poorly ventilated an a

Heart Patients: Their Study and Care. By s - »»•

Sc.D. Cloth. Price, $2. Pp. 160. Philadelphia: Lea A ^

The author states that the purpose of this volume H J P leac l,-
with clarity and precision all that is useful in t ic j n ,j ic
ings on impairment of the heart and all tliat is ^ ira , e _ !rt Jliis
maze of modern methods in investigation of t ® history
book is divided into twenty-two chapters dealing " * r ornl s of
and physical examination and the more impor a ( j, e

cardiac disability. Chapters are also devote 0 3t i c nts
heart patient rather than treating the heart, w m Jfany o1 '
wish to know and selecting nurses for heart P a ie , yeetivt-
the chapters fall far short of meeting the au > j nt por-
Moreover, there are a number of statements per a' ^ Two

tant subjects to which serious objections ma> ( / ie first

examples will suffice. The first of these a PP|| 57 ; ‘‘In
paragraph pertaining to electrocardiograph), 0 ~ cncc , wl»k
either indicting a heart or in establishing > 5 weigh 5
the patient furnishes testimony and the j 5 .- s , couf t of h r ; !
evidence, the case must be brought to trial in r( j; 0 g r 3plt>' ■’
appeal— cardiography (electrocardiography,)- . ; s 0 f ficM 1
also the court of last resort in a differential ding

Volume 113
Number 18

BOOK NOTICES

1 667

conditions.” The second appears on page 119 in a discussion
of the athlete’s heart: “From a circulatory standpoint competi-
tive athletics should absolutely be interdicted at schools and
colleges. Struggles for supremacy are crippling to the hearts
of youth.”

Hereditary and Environmental Factors in the Causation of Manic-
Depressive Psychoses and Dementia Praecox. By Horatio M. Pollock,
Director of Mental Hygiene Statistics, New York State Department of
Mental Hygiene, Benjamin Malzberg, Senior Statistician, New York State
Department of Mental Hygiene, and Raymond G. Puller, Director of
Research, New York State Committee on Mental Hygiene of the State
Charities Aid Association. Cloth. Price, $2.50. Pp. 473. Uttca, New
York: State Hospitals Press, 1939.

This volume represents a study of the prehospital history of
patients with manic-depressive psychoses and dementia praecox
admitted for the first time to the Utica State Hospital in 1928,
1929 and 1930. There are eight chapters : the first deals with
a review of studies of the inheritance of mental disease, the
second with family stock of manic-depressive patients, the third
with the query “Do mendelian laws apply to the inheritance of
manic-depressive psychoses?" the fourth with family stock of
dementia praecox patients, the fifth with comparative studies
of the prevalence of mental disease among relatives of patients
and among the general population, and the sixth and seventh
chapters with environmental factors in both manic-depressive
psychoses and dementia praecox. The eighth chapter contains
a summary and conclusions. There is an excellent bibliography
and index. One finds in this book a reasonable discussion of
these two most important and common mental diseases. Many
of the controversial questions are not answered by the authors,
but they plead for more research so that in the end there may
be an adequate conception of the causative factors in mental
disease.

Elektrodiagnostik. Yon Dr. B. Neousslklne und Dr. D. Abramowitsch.
Cloth. Price, 12 Swiss francs. Pp. 242, with 30 illustrations. Berne:
Medizlnischcr Verlag Hans Huber, 1939.

This is a thorough discussion of eletrodiagnosis. It is written
in simple, clear and concise German. There are six chapters
and one appendix with thirty illustrations. The first chapter
deals with the principles of galvanic and faradic currents. The
second part discusses the methods of electrical testing with both
currents and chronaxia. The third and fourth chapters list the
results of the electrical tests. Normal and pathologic chronaxia
values are given for all muscles as well as the variabilities in
complete or partial lesions of nerves. The fifth part deals with
the use of electricity in examining sensation and sense organs,
as the optic, vestibular and acoustic nerves. The sixth chapter
discusses testing of the vegetative nervous system and the spinal
reflexes. The appendix includes a brief consideration of the
impedance angle, psychogalvanic reflex, electrocardiography,
electromyography and electro-encephalography. The book is
highly recommended to all neurologists, physiologists and physi-
cal therapists.

Intracranial Tumors of Infancy and Childhood. By Perclval Bailey,
Douglas N. Buchanan and Paul C. Bucy. Cloth. Price, $5. Pp. 598,
with lie illustrations including 23 plates. Chicago : University of
Chicago Press, 1939.

This is a needed and desirable monograph. It is the result
of a study of an unselected series of 100 consecutive cases from
infancy to the sixteenth birthday. All the cases were verified
either by study of specimens removed at operation or at
necropsy. It consists of fifteen chapters, a bibliography of 483
references, an author and subject index and excellent illustra-
tions of gross specimens, ventriculographic studies and patients.
Ependymomas, malignant and benign tumors of the cerebellum,
gliomas of the brain stem, optic cbiasm and hypothalamus,
tumors of the cerebral hemispheres, craniopharyngiomas, tumors
°f the pineal body and miscellaneous tumors are discussed in
detail. There are chapters on general pathology, symptomatol-
ogy, differential diagnosis and technic and the results of treat-
ment. There are excellent microscopic sections of the various
tumors. The book should be read by every neurologist, neuro-
surgeon and neuropathologist because it will prove to be an
excellent reference. It contains so much valuable information,
suggestions and points that studying it is the only way to
uppreciatc it.

Blood Group Tests as Evidence of Non-Paternity in Illegitimacy Cases.
By Clyde E. Keeler, B.S., M.A., M.S., Instructor in the Howe Laboratory
of the Harvard Medical School, Boston. Paper. No pagination. Boston :
Robert C. True, Massachusetts Society for the Prevention of Cruelty to
Children, 1939.

In this small pamphlet the principles underlying the applica-
tion of the Landsteiner blood groups and M-N types in dis-
puted parentage are outlined briefly and in elementary fashion.
This will serve as an easy introduction to the subject. Unfor-
tunately there are a number of mistakes. Thus the author
seems to have the impression that the transfusion of blood from
an individual of type M into an individual belonging to type N
may give rise to iso-antibodies for M, so that subsequent trans-
fusion of type M blood may be dangerous. Actually the forma-
tion of immune antibodies for M or N lias never been observed,
despite the fact that hundreds of thousands of transfusions are
given every year.

Chronic Arthritis. By Robert T. Monroe, A.B., M.D., Associate in
Medicine, Harvard University, Boston. Edited by Henry A. Christian,
A.M., M.D., LL.D., Hersey Professor of the Theory and Practice of
Physic, Harvard University, Boston. [Reprinted from Oxford Loose-
Leaf Medicine.] Cloth. Price, $2. Pp. 84. New York, London &
Toronto : Oxford University Press, 1939.

The author of this small volume is an internist, and his book
reveals a good sound fundamental knowledge of arthritis.
Scientific presentation with adherence to facts and absence of
enthusiasm and fads in therapy make this volume exceptionally
valuable. Nothing new is added and nothing is omitted. It is
written in a concise style and no useless material burdens the
reader. Chronic arthritis is divided into three types, atrophic,
hypertrophic and periarticular. These arc discussed separately
from the point of view of etiology, pathology, diagnosis and
treatment. Here chronic arthritis is presented in complete form,
and the student and physician will find the answers to their
problems if they can be answered.

Man and His Health: A Guide to Medical and Public Health Exhibits
at the New York World’s Fair 1939, Together with Information on the
Conservation of Health and the Preservation of Life. Published for the
American Museum of Health, Inc. Boards. Price, 50 cents. Pp. 90,
with Illustrations. New York: Exposition Pub’ns., Inc., 1939.

This is a brief description, with illustrations, of the exhibits
in the Hall of Medicine and Public Health at the New York
World’s Fair. In the Hall of Man is presented a large amount
of material on anatomy and physiology from the Oberlander
Trust. In the Hall of Medical Science there are twenty-eight
exhibits, presented by various scientific and commercial organiza-
tions. Brief mention is made of health exhibits found in other
parts of the fair, such as the Federal Building and various state
and foreign buildings.

A Textbook of Clinical Neurology with an Introduction to the History
of Neurology. By Israel S. Weclisler, M.D., Frofessor of Clinical
Neurology, Columbia University, New York. Fourth edition. Cloth.
Price, $7. Pp. 844, with 162 illustrations. Philadelphia & London:
W. B. Saunders Company, 1939.

This edition contains many additions as well as an introduc-
tion to the history of neurology. The latter is a valuable
adjunct. Neuritis is regarded as a neuropathy, in a rewritten
chapter. The olfactory tests of Elsberg, the carotid sinus syn-'
drome, petrositis, the premotor syndrome and electro-encepha-
lography are included in this edition. There are five parts, on
method of examination, the spinal cord, the peripheral nerves,
the brain and the neuroses. This book is highly recommended
to students and general practitioners.

Pye’s Surgical Handicraft: A Manual of Surgical Manipulations,
Minor Surgery, and Other Matters Connected with the Work of House
Surgeons and of Surgical Dressers. Edited by Hamilton Bailey, F.R.C.S.,
Surgeon, Royal Northern Hospital, London. Eleventh edition. Cloth.
Price, $0. Bp. 512, with 302 illustrations. Baltimore: William Wood
& Company, 1939.

The author has brought down to date one of the most com-
plete single volumes on general surgery and has presented it
as a guide to bouse surgeons. Each subject is dealt with in a
concise but thorough manner which makes it enjoyable. The
chapter on pulmonary complications is especially* well presented.
Each procedure discussed in a given technic is presented in
detail, so that one unfamiliar with the technic can easily* folloyv
the steps.

1668

BUREAU OF LEGAL MEDICINE AND . LEGISLATION

jovt. a. a.

On. 28, W;

Bureau of Legal Medicine
and Legislation

MEDICOLEGAL ABSTRACTS

Medical Practice Acts: Indorsement of Licenses of
Foreign Licentiates; Board’s Right to Require Exami-
nation of All Foreign Applicants. — The Education Law of
New York authorizes the board of regents to indorse a license
issued by a legally constituted board of examiners in any other
state or country on satisfactory evidence that the requirements
for the issuance of such license were “substantially the equiva-
lent” of the requirements in force in New York when such
license was issued and that the applicant has been in the lawful
and reputable practice of his profession for a period of not
less than five years prior to his making application for such
indorsement. When the evidence presented is not satisfyingly
sufficient to warrant the indorsement of such license, the board
is authorized to require that the candidate for indorsement
shall pass such subjects of the licensing examination specified
by statute or regents’ rule as should be required of the candi-
date to establish his worthiness to receive such indorsement.

Sept. 21, 1936, the Board of Regents of New York adopted
the following rule :

‘That on applications filed after October 15, 1936, no license issued by
a legally constituted board of examiners in any foreign country shall be
indorsed pursuant to the provisions of Section 51 of the Education Law,
unless the applicant shall pass the licensing examination prescribed by
law or Regents rule.”

The petitioners in these cases had licenses authorizing them
to practice medicine in Germany. In 1937 they applied for
and passed in the state of New York the examination in Eng-
lish required of foreign applicants. Both then applied for
admission to the January 1938 medical licensing examination,
one petitioner reserving any rights he might possess under the
New York laws regulating. the practice of medicine, but both
failed to pass the examination. The petitioners then applied to
the board of regents for an indorsement of their German licenses,
the board denied the request and the petitioners, in a proceed-
ing instituted in the supreme court of New York, special term,
Albany County, sought to compel the board to act favorably
on their applications. They contended that the board’s rule,
promulgated in 1936 and requiring examinations of all foreign
applicants, was invalid because the law required an examina-
tion of a foreign licentiate only when the evidence of his
qualifications was not satisfyingly sufficient and that the evi-
dence of their qualification was sufficient to entitle them to an
indorsement of their German licenses.

In the opinion of the court, the rule adopted by the board,
however well intentioned, directly contravened the statute. The
latter authorizes the indorsement of a foreign license on proof
of substantially equivalent requirements and a specified period
of practice in the foreign country. The rule permits of no
such indorsement but requires every foreign applicant to stand
examination. In this respect the board transcended its power ;
it may not legally set a standard more restrictive than the
statute. The exhibits submitted by the petitioners, the court
thought, gave prima facie force to their contention that their
qualifications were sufficient and an order was issued directing
the trial of the issue as to whether the petitioners had actually
produced evidence satisfyingly sufficient to entitle them to
indorsement of their licenses. From this order the board
appealed to the supreme court of New York, appellate division,
third department.

As viewed by the appellate division, the sole issue to be
determined was not whether the board had exceeded its powers
in promulgating the rule in question but whether or not the
action of the board in denying the petitioners’ applications for
indorsements of their foreign licenses was arbitrary, unfair, or
capricious. The record before the court did not convince it
that the board had rejected the petitioners’ applications because
of the rule adopted in 1936 but because it had appraised the

evidence of qualifications submitted by the petitioners and hi
found it wanting. The obvious purpose of the statute, \h
court said, was to permit the board to indorse a license issued
by the licensing board of another state or country in those
cases in which the applicant is unable to meet the letter d
the requirements of the New York statute but possesses essen-
tially the same or equivalent qualifications. The power granted
to the board is a limited one, remedial in its nature, and mast
be exercised with caution and with due regard to the statutes
regulating the practice of medicine in New York. The board
may not through the exercise of the power granted by the
law indiscriminately indorse foreign medical licenses. Before
it may legally indorse such a license it should be satisfied that
the applicant has met substantially all requirements, li it errs
at all, it should be on the side of the protection of the public
from unworthy' and inefficient practitioners.

The burden of proving his qualifications is on the applicant.
He must not only prove that he graduated from certain insti-
tutions but he must also prove to the satisfaction of the board
that these institutions are substantially the equivalent ol the
New York schools. He must not only prove that he has a
foreign license but he must also prove to the satisfaction ot
the board that the requirements for that license were substan-
tially the same as in New York. The petitioners failed to
offer such proof. In the Erlanger petition, it was asserted that
he began the study' of medicine in 1912 and continued it at
various German universities until October 1914. It was alleged
that he continued his studies after the war and received 1»>
diploma and German medical license in July 1922. In the Leu
petition, it was alleged that at the beginning of the b°r.
War he had completed sufficient medical courses in German
universities to serve as an assistant physician and that her' 1
serve as such in various hospitals until the end oi the war m
that he received his medical license on June 10, 1919.
of the institutions from which the petitioners graduate , ■-
court pointed out, had ever been registered by the boarior
by the department of education as maintaining proper me lta
standards. In neither petition was there any allegation
the German standards at the time the petitioners receive 1
licenses were substantially the same as those existing i"
state of New York. There was no proof whatever as ®
equality of the German institutions, including faculty i -^
of courses of study, curriculum or equipment.. There «
proof that the petitioners ever passed an examination or
licenses as required in New York. What little eu en , c .. ^
was before the board, in the opinion of the court, < ^

that the standard of the German schools was lower
standards in New York and that the requirements tor ^
man license were far from being essentially the same a

in New York. . ,-;iri,ir.;

The petitioners asserted that many other German PL
had been admitted to practice medicine m New l (he
board since 1917 by indorsement of their certi 5* jj ie board
court thought this point to be without merit. ' cC ,r.-
may have done in the past was immaterial , t JC c0
:erned only with its action in the cases before 1 . co yrt

To sustain the contention of the P etll ’ oner ’ ^ car

jbserved, would mean that any foreigner w o ^ jorei?"
anguage and who has been licensed to pr ac 1 _• j 0 { fiic

country and who actually practiced there for a P fl( ^
rears could, on the moment of his arrna a practice b’- !

fork, demand the issuance of a license to him t i ^ ^
irofession in the state. The legislature. nc> purse:

ntention. Our own citizens, the court pom f ^ good clu f ‘
l rigorous course of study and supply c ' 1 ,i ie petitioner'
icter in order to practice medicine and yet, ■ ^ (o practice
vere correct, any foreigner who was sta tc of V"

nedicine in his native land could come was r -

fork and be immune from such requirements- tll3t the

rk and be immune from such requiremims- t!iat to-

e slighest bit of proof before the court t ^*1 ac-
tion of the board of regents constituted

unlawful ar

tion of the board of regents constituieu |rJa i cos-

bitrary exercise of power. The orders ‘ ^ pcl ; t ion*
reefing the trial of the issue as to whet! - n

educed evidence satisfyingly sufficient to come
itute were therefore reversed.

Volume 113
Number 18

BUREAU OF LEGAL MEDICINE AND LEGISLATION

1669

Petitioner Levi then appealed to the Court of Appeals of
New York, which in a memorandum decision affirmed the
judgment of the appellate division. — Levi v. Regents of the
University of State of New York ct at.; Erlangcr v. Same,
8 N. Y. S. (2d) 19; 10 N. Y. S. (2d) 1013; 22 N. E. (2d)
ITS.

Narcotic Drug Act (Illinois) : Information Must Allege
Marihuana Is Cannabis Within Meaning of Statute;
Court Will Not Take Judicial Notice of Its Composi-
tion. — The defendant was convicted in the municipal court of
Chicago on an information charging the unlawful possession
of a habit-forming drug; to wit, marihuana. The conviction
was upheld by the appellate court for the first district and the
defendant thereupon appealed to the Supreme Court of Illinois.
In the trial court, in the appellate court and in the Supreme
Court the defendant contended that the information under which
she was convicted failed to charge any criminal offense.

The narcotic drug act of Illinois, 193S, III. Rev. Stat. 1937,
Ch. 38, makes it unlawful for any person to possess any narcotic
drug except as authorized by the act. It defines the term
"narcotic drugs” as including cannabis. The term “cannabis”
is defined so as to include "the following substances under
whatever names they may be designated : (a) The dried flower-
ing or fruiting tops of the pistillate plant Cannabis Sativa L.,
[Linne] from which the resin has not been extracted, (b) the
resin extracted from such tops, and (a) every compound, manu-
facture, salt, derivative, mixture, or preparation of such resin,
or of such tops from which the resin has not been extracted.”
The act makes no specific reference to “marihuana.” The
prosecution claimed, however, that the word "marihuana” is
defined in all standard dictionaries as a narcotic drug of the
cannabis family, that it is so well known that the court should
take judicial notice of its meaning and that marihuana is there-
fore included in the narcotic drug act of 1935.

It is to be observed, commented the court, that while the word
"marihuana” was included in the narcotic drug act of 1931, it
is not in the act of 1935 under which this prosecution was
brought. The narcotic drugs embraced in the act of 1935 are
specifically defined in it. Even if it is conceded that marihuana
is Cannabis sativa L., it is obvious that, if the possession of mari-
huana constitutes an offense under the act, it must be charged
that the marihuana alleged to have been unlawfully possessed
was from the dried flowering or fruiting tops of the plant named
in the act and that the resin had not been extracted. The
possession of marihuana is not a criminal offense unless it is of
the specific quality and kind defined in the statute. No charge
that the marihuana possessed by the defendant in this case was
of that specific quality and kind is contained in the information.
The information, therefore, did not charge the defendant with
any offense known to the law.

The judgment of the courts below were reversed by the
Supreme Court and the cause remanded with directions to pro-
ceed in accordance with this decision. — People v. Sowed (III.),
IS N. E. (2d) 176.

Dental Practice Acts; Validity of Provisions Authoriz-
ing Revocation of License for Advertising. — The New
Jersey dental practice act authorizes the revocation of the license
of any dentist who advertises in any manner his product or
the price or charge to be made or the character or durability
of his works or products. On proof that Levine had trans-
gressed the statute in this respect the New Jersey State Board
of Registration and Examination in Dentistry revoked his
license to practice dentistry. Levine then instituted certiorari
proceedings before the supreme court of New Jersey. He con-
tended that the provision of the dental practice act just cited
is an improper exercise of the police power of the state and is
unconstitutional ; that it erects a wall of silence behind which
monopoly and high prices could flourish, and that the advertise-
ment that he had published respecting the prices charged by
bun for dental work and the character and durability of his
''Qrk was true, and, finally, that the provision referred to inter-
teres with his right of free speech in the conduct of his business.

On the authority of Scmlcr v. Oregon State Board of Dental
Examiners, 294 U. S. 60S, 55 S. Ct. 570, 79 L. Ed. 10S6, in
"Inch the Supreme Court of the United States upheld the con-
stitutionality of a provision of the Oregon dental practice act

authorizing the revocation of the license of a dentist for adver-
tising prices for professional services, the supreme court of
New Jersey thought that it was clear that the legislature in
authorizing the revocation or suspension for this sort of adver-
tising adopted a measure necessary to protect the public from
the wiles and artifices of the charlatan. The truth or falsity
of the dentist’s assertions, said the court, is of no importance.
It is possible that everything that a dentist may say in an adver-
tisement is the literal truth, but if this sort of advertising affords
the unscrupulous practitioner an opportunity to practice a decep-
tion on his patients, then there is reason why the legislature
should authorize the suspension or revocation of the licenses of
those who so advertise. The issue before the state board in
suspending Levine’s license on the charges made was simply
whether he had resorted to the prohibited practices, and it was
not necessary for it to investigate the truth or falsity of his
advertisements, since they admittedly offended against the legis-
lative concept of proper dental practice. To urge that an indi-
vidual licensed by the state to practice a skilled profession may
not be precluded by the state from advertising the price to be
charged for his work and the durability thereof is tantamount
to urging that the state may not make regulations which will
preclude charlatans from enticing the public to their offices by
arts which are likely to deceive, and that those engaged in
practicing a profession requiring skill and knowledge may not
be required to conform to a standard of practice which the people
by their representatives deem necessary for their protection.

The supreme court, accordingly, in effect, affirmed the order
of the board revoking Levine's license. — Levine v. State Board
of Registration and Examination in Dentistry (N. }.), 1 A.
(2d) 876.

Evidence: Admissibility of Expert Testimony Based
on Statements Made by Patient to Expert.— On Sept. 24,
1933, the plaintiff jumped from a speeding automobile, fell on a
concrete pavement and was knocked unconscious. Twenty-eight
days later, on October 22, she was riding as a passenger in the
defendant company’s street car when it was struck by a train.
She sued the defendant company to recover damages for injuries
which she claimed she sustained as a result of the street car
accident. From a judgment in favor of the plaintiff, the com-
pany appealed to the Supreme Court of Missouri, division No. 1.

An expert medical witness for the plaintiff testified that,
based on his own examination and on the history of the case
as given to him by the plaintiff, the disturbance of function of
the plaintiff’s bladder which he found at the time of his exami-
nation of the plaintiff in June 1934 was due to a spinal con-
cussion which she had received at the time of the street car
accident. The witness admitted that, while he had been told
by the plaintiff of the prior automobile accident, he had not
been informed that after that accident she had remained in a
hospital for ten days because of her injuries, that her reflexes
were sluggish, that she complained of pain in her abdomen and
that she had paralysis of her bladder necessitating catheteriza-
tion. He stated that from the history which he had obtained
from the plaintiff it was his understanding that she had recovered
from the injuries she received in the automobile accident and
was well when the street car accident occurred.

The testimony of this witness, the Supreme Court held, was
not competent evidence and should not have been admitted. It
was based on the history of the physical condition of the plaintiff
as told to the witness by the plaintiff herself. The plaintiff did
not confine her statements to her physical complaints and ail-
ments as of the time of the examination by the witness. She
informed him of her alleged recovery from previous injuries
which she had sustained, but she did not reveal the physical
injuries and complaints she suffered as the result of that acci-
dent. A medical expert witness, said the court, may give in
evidence his opinion of the condition of a patient based on his
examination of the patient or on the patient’s statements as to
present symptoms or physical condition or on both such exami-
nation and statements. He may not, however, base his opinion
on the patient’s statements as to past physical condition. The
admission in evidence by the trial court of the medical expert
witness’s testimony was reversible error. The judgment of
the trial court was reversed and the case remanded for a new
trial.— Berry v. Kansas City Public Sendee Co. (Mo.) 121
S. IK (2d) 825.

1670

SOCIETY PROCEEDINGS

Jovi. A. Jt. A.
Oct. 28, 1933

Workmen’s Compensation Acts: Compensability of
Cerebral Thrombosis Due to Exertion. — The claimant,
Uditsky, while engaged in grinding and beveling glass in the
shop of the defendant, Krakovitz, exerted himself to prevent a
slipping heavy piece of glass from falling. As lie did so he
experienced a sensation “like a fire” in his head and over his
face and also numbness of his left hand. Thereafter he was
unable to work. Later his left hand and the left side of his
body became paralyzed. His condition was diagnosed as poly-
cythaemia vera (a condition characterized by an increase in the
number of red blood corpuscles) and cerebral thrombosis with
hemiplegia. He filed a claim with the workmen's compensation
board for compensation under the workmen’s compensation act
of Pennsylvania. The board denied him compensation for
permanent total disability but awarded him compensation for
the loss of the use of his left arm. From a judgment of the
court of common pleas No. 6, Philadelphia County, affirming
the board’s award, the defendant appealed to the superior court
of Pennsylvania.

The claimant’s claim, said the superior court, was supported
by the testimony of two physicians that his condition had been
caused by the extreme effort he exerted in saving the slipping
glass from falling. In the judgment of the court, therefore, the
evidence justified the finding of the workmen’s compensation
board, on which it based its award that the claimant’s condition
resulted from an accident in the course of his employment.
Accordingly, the judgment of the court of common pleas uphold-
ing the board’s award was affirmed. — Uditsky v. Krakovitz
(Pa.), 2 A. (2d) 525.

Evidence: Testimony of X-Ray Technician in Inter-
preting Roentgenograms Admissible. — In a personal injury
suit a witness was shown to be in charge of the x-ray and
laboratory department of a certain hospital “as an x-ray tech-
nician who reads and interprets x-rays for the medical staff of
that institution” and to have had fifteen years of experience in
reading and interpreting roentgenograms. The trial court then
permitted the witness to testify that certain roentgenograms
disclosed fractures of the vertebrae of the subject but refused
to permit the witness “to express an opinion as to whether the
fractures were due to trauma or injury.” On an appeal to the
Supreme Court of Mississippi, division B, it was contended that
the testimony of this witness was not competent because he
was not a physician and surgeon and because he had never taken
a course in anatomy. The witness, said the Supreme Court,
was competent to testify as to what the roentgenograms dis-
closed because his training and experience should have qualified
him so to testify. The fact that a witness is a physician and
surgeon would not be the best test of competency in this regard,
since it is conceded that many medical practitioners are unable
to read and interpret roentgenograms. The experience of an
x-ray technician in observing the effect of known fractures, as
reflected in the pictures thereof, over a period of years, should
peculiarly qualify him to state the facts thereby disclosed,
although he would not be competent to express an opinion as
to what caused the condition showed. — Aponaug Mfg. Co. v.
Carroll (Miss.), 184 So. 63.

Medical Practice Acts: Chiropractic as the Practice
of Medicine.— A complaint was filed in the city magistrates’
court of New York, tenth district, Borough of Brooklyn, charg-
ing that Zinke, an unlicensed chiropractor, unlawfully engaged
in the practice of medicine and unlawfully used a designation
tending to imply or designate himself as a practitioner of medi-
cine. The chiropractor moved for a dismissal of the complaint,
contending that it did not charge that he held himself out to
be able to diagnose, treat, operate or prescribe for any human
disease, pain, injury, deformity or physical condition.

The court found, however, that there was directly and by
inference a holding out by the defendant that he was able to
perform one or more of the prohibited acts. He displayed
certificates bearing his name as a “Doctor of Chiropractic” and
signs bearing his name as a “chiropractor.’ He also caused
himself to be listed in the telephone directory as a chiropractor.
These signs and certificates, the court pointed out, were pre-
sumptive evidence of a holding out within the meaning of the

medical practice act. The titles "Doctor” and "chiropractor’
carried with them definite implication that the possessor of to:
titles was able to treat bodily conditions. Furthermore, the
setup of the defendant’s office, attendant, dressing rooms and
split-back robes, neurocalometer and articulated table, constituted
equipment of one who uses it as preliminary to and in the actual
treatment of physical conditions. When the defendant took the
histories of his patients and subsequently treated them and
accepted compensation, there arose an inference of a holding out

Furthermore, the court continued, the defendant diagnosed.
His history taking, examination with the use of a neurocalometer
and bis statements as to the causes of conditions of his patients
showed that he made a determination which he deemed sufficient
for the purpose of treatment. The term diagnosis, in modem
terminology, is a “sizing up” or a comprehending of the physical
or mental status of a patient. It is the conclusion itself rather
than the procedures on which the conclusion is based which
constitutes a diagnosis per se. No particular language need be
used and no disease need be mentioned, for the diagnostician
may make or draw his conclusion in his own way. The defen-
dant also undertook and offered to treat. The definition of the
practice of medicine in New York states that the treatment may
be by “any means or method.” The defendant’s method was by
manipulation of the spine.

The court expressed itself as not concerned with whether
chiropractic treatments are beneficial or injurious. The only
question for determination was whether the facts stated in the
complaint showed that the defendant had violated the law. The
court was of the opinion that they did and the motion to dis-
miss the complaint was overruled. — People v. Zinke (TV. i-h
7 N. Y. S. (2d) 941.

Life Insurance: Admissibility of Hospital Records in
Evidence. — A Pennsylvania statute prohibits physicians jj®
divulging in civil cases communications made to them by “
patients which tend to blacken the character of the patient,
an action on a life insurance policy, the superior court of e
sylvania held that hospital records, showing that the msn
had been treated for chronic alcoholism and delirium trem i
were not inadmissible under this statute. The proscrip w
restricted to "communications" made by the patient to t ic P ■
cian which tend “to blacken his character.” It does no »
to information obtained by the physician from his IF .
examination. In the judgment of the court, the evidence o ^
to was either not a “communication” made by a P** 1 * , (fi
physician or it did not tend to “blacken” the patient s c
— Soltaniuk v. Metropolitan Life Ins. Co. (Pa.) 1 A - '

Society Proceedings

COMING MEETINGS Cl ,

American Academy of Pediatrics, Cincinnati, November ^

Clifford G. Grulee, 636 Church Street Evanston, in., Df Fa0 ] )I.
American Society of Anesthetists, Los Angeles, V
Wood, 745 Fifth Ave., New York, Secretary. 21-24. V u

Vmerican Society of Tropical Medicine, Memphis, X ■»

E. Harold Hinman, Wilson Dam, Ala., Secretary. as C jy, »

^ 2-4.° Ci Dr” W. °I\ te Mengertf n U^verslty S Hospitals, I«-» f

:entrai eti Society for Clinical Research, Chicago, Nov 3 4.

Thompson, 4932 Maryland Ave., St. Louis, Secretarj^^^^ r^a.
nter-State Postgraduate Medical Association of St..

Oct. 30-Nov. 3. Dr. W. B. Peck, 27 East Stephens
111., Managing Director. w „. th Laboratories JL.:

lew York State Association ofPublic Health^ Av e.. ^
Nov. 3. Miss Mary B. Kirkbride, New Scotian ^

'acific et Coast Society of Obstetrics and Gynecolosy. S« r ' u p r ;

Nov. 8-11. Dr. T. Floyd Bell. 400 29th St., Oakland, „ £ V
ladiological Society of North America, At! c vr * 3CU se, N. V*.

Donald S. Childs, 607 Medical Arts r^ditions,

ociety for the Study of Asthma and All York, Seer }

Decf 9. Dr. W. C. Spain, 116 East 5 3d St., New ^ j„. G

outhern Medical Association,, Memphis, Tcnm, n
Loranz, Empire Bldg., Birmingham, Ala., Si ecrci p r . £. .

outhern Surgical Association, Augusta, G c ,( ._ \r. :

Ochsncr, 1430 Tulanc Ave., New Orleans Secrete _ ? ]K Dr.
outhwestem Medical Association, El Fa.o, p a!0 , Texar, - ■ ;j y

Spearman, 3003 First National Bank Bldg., El r ArJanaS , M*
ri-States Medical Society of Texas. Louisiana T « J5 ,

.„.„cs Medical Society of T«as, Lomsiana a ,, seen

reicas, Nov. 8-9. Dr. Robert K. Womack, ^ Pr . A I.er

astern Surgical Association, Los Angeles, D - Sccrct ary-
Montgomery, 122 South Mich, son Blvd., Chicago,

Volume 113
Number 18

CURRENT MEDICAL LITERATURE

1 671

Current Medical Literature

AMERICAN

The Association library lends periodicals to members of the Association
and to individual subscribers in continental United States and Canada
for a period of three days. Three journals may be borrowed at a time.
Periodicals are available from 1 929 to date. Requests for issues of
earlier date cannot be filled. Requests should be accompanied by

stamps to cover postage (6 cents if one and 18 cents if three periodicals
are requested). Periodicals published by the American Medical Asso-
ciation are not available for lending but may be supplied on purchase

order. Reprints as a rule are the property of authors and can be

obtained for permanent possession only from them.

Titles marked with an asterisk (*) are abstracted below.

American Journal of Cancer, New York

30 : 527-700 (Aug.) 1939

•Blue Nevus (Jadassohn-Tieche) : Its Distinction from Ordinary Moles
and Malignant Melanomas. H. Montgomery and J. E. Kabler,

Rochester, Minn. — p. 527.

Neoplasm Studies: VI. Granulocytic Accumulation Following In Vivo
Roentgen Irradiation of Mouse Sarcoma 180. C. G. Grand, New
York.— p. 540.

Observations on Rats Treated with Sex Hormones, Estrin and Testos-
terone. C. S. McEuen, Montreal. — p. 551.

Pulmonary Asbestosis: V. Report of Bronchial Carcinoma and
Epithelial Metaplasia. K. M. Lynch and W. A. Smith, Charleston,
S. C.— p. 567.

Early Carcinoma of Ampulla of Vater. J. Foldes and F. W. Heyer,
Nanticoke, Pa. — p. 574.

Transferable Liver Neoplasm (C198) Arising in Female Mouse of
Leaden Strain. A. M. Cloudman, Bar Harbor, Maine. — p. 578.
Cytology of Tumor Cell in Rous Chicken Sarcoma. M. Levine, New
York. — p. 581.

Respiratory Changes in Vitro in Normal and Malignant Tissues Follow-
ing Irradiation. Anna Goldfeder, New York. — p. 603.

Sterol Metabolism in Tumor Mice. F. L. Breusch, Szeged, Hungary. —
p. 609.

Blue Nevus, Moles and Melanomas. — Montgomery and
Kahter state that the blue nevus has been confused with the
Mongolian spot. The latter is usually a solitary plaque from
2 to 12 cm. in diameter occurring on the back, usually near
the sacrum. It may be brown rather than blue. It is seen
most frequently in the Mongolian race but also occurs in the
Caucasian. The pigmented area is poorly defined; it is not
elevated or indurated. It is usually present at birth and, as a
rule, disappears within the first few years. Occasionally mul-
tiple plaques are seen scattered over the body and solitary
Mongolian spots have been described elsewhere than on the
back. The cells in the Mongolian spot are histologically nearly
identical in appearance with the blue nevus cells but are rela-
tively few in number and occur singly rather than in clumps
or in masses. There is no disturbance in the normal archi-
tecture of the connective tissue and elastic tissue fibers. The
blue nevus occurring in infancy or early childhood also must
be differentiated from ordinary pigmented nevi, dermatofibroma
with hemorrhage (histiocytoma), small deeply situated heman-
gioma and finally malignant melanoma. The blue to blue-gray
usually distinguishes the blue nevus, on clinical grounds alone,
from the ordinary brown to brownish-black pigmented nevus.
In typical cases the nevus cells in the two conditions present
entirely different morphologic features. Dermatofibroma is
occasionally blue, especially when deposits of hemosiderin are
to be found histologically. A few chromatophores laden with
pigment may be seen, but no elongated fusiform melanoblasts
(blue nevus cells) are present. A small deep hemangioma
may be blue, but it is soft to palpation and blood is obtained
oil puncture of the lesion. In a few cases blue nevus may
simulate the steel blue color of an early malignant melano-
epithelioma in which radiating lines of pigment in the lym-
phatics have not yet developed. A wide surgical excision is
indicated in these cases. The histologic picture is confusing
only when the cells of melano-epithelioma elongate into spindle
shaped cells frequently containing much pigment. These cells,
however, also have an increased amount of cytoplasm and their
nuclei are hyperchromatic and frequently contain mitotic figures,
three characters which are not seen in blue nevus cells. It is
the authors’ belief that if blue nevi are looked for they will
be found much more frequently than the literature would indi-
cate. Blue nevus rarely shows malignant change. When this
occurs it would seem to be that of a relatively slow-growing

melanosarcoma. Like ordinary pigmented nevi, the blue nevus
usually runs a benign course and there is no need for surgical
excision unless for cosmetic purposes or when the lesion is
situated in an area exposed to repeated trauma, friction or
irritation.

American Journal of Psychiatry, New York

9G: 1-254 (July) 1939. Partial Index
*Age of Onset of Epilepsy: Differences Between Deteriorated and Non-
deteriorated Patients. H. A. Paskind and M. Brown, Chicago. — p. 59.
•Frequency of Seizures in Epilepsy: Differences Between Deteriorated
and Nondeteriorated Patients. H. A. Paskind and M. Brown,
Chicago. — p. 65.

Cell Minerals in Amaurotic Idiocy, Tuberculous Sclerosis and Related
Conditions, Studied by Micro-Incineration and Spectroscopy: Examples
of Degenerative and of Neoplastic Cell Disease. L. Alexander and
A. Myerson, Boston. — p. 77.

Psychogenic Factors in Asthma. T. M. French, Chicago. — p. 87.

Cerebral Damage in Hypoglycemia: Review. A. B. Baker, Minneapolis.
— p. 109.

Psychiatric Disorders in Fifty School Teachers. J. H. Wall, White
Plains, N. Y. — p. 137.

Life Situation Tests as Aids in Psychiatric Prognosis. A. A. Low, H. D.

Singer and Catherine L. McCorry, Chicago. — p. 147.

Convulsive States with Evidence of Brain Hemiatrophy. L. Casamajor
and R. W. Laidlaw, New York.— p. 165.

Involuntary Eye Movements as Criterion of Depth of Insulin Coma.

H. Brill and R. F. Binzley, Brentwood, N. Y. — p. 177.

Anomalies and Dangers in Metrazol Therapy of Schizophrenia. L. E.

Geeslin and H. Cleckley, Augusta, Ga. — p. 183.

Metrazol Shock Treatment: Pharmacologic and Biochemical Studies.
F. C. Redlich, Independence, Iowa. — p. 193.

Seizures in Deteriorated and Nondeteriorated Epilepsy.
— Paskind and Brown report studies on the age of onset of the
epilepsy in a group of nondeteriorated, well adjusted, non-
psychotic nonfeeblemindcd extramural persons with epilepsy.
Their material consists of the records of 368 adult nondeterio-
rated patients with epilepsy. In order to allow sufficient time
for deterioration to occur, no patient was accepted for this study
unless seizures were present for at least six years. Patients
with defective mental development and with focal signs of
neurologic disorder were not accepted for this study. A com-
parison of the age of onset of these nondeteriorated patients
with that of institutional, deteriorated patients revealed that:
1. Fewer nondeteriorated patients have the onset before 5 years
of age. 2. Fewer nondeteriorated patients have the onset before
10 years of age. 3. More nondeteriorated patients have the
onset after 20 years of age. 4. More nondeteriorated patients
have the onset after 40 years of age. It is concluded that
deteriorated patients with epilepsy differ from the nondeterio-
rated ones in that there is a tendency to later onset in the non-
deteriorated patients. The material which the authors used for
the studies on the frequency of seizures consists of the records
of 317 adult nondeteriorated extramural patients with epilepsy.
No patient was accepted for this study unless he had had seizures
for at least six years. Patients with defective mental develop-
ment and with focal signs of neurologic disorder were not
accepted for this study. The seizures studied were of patients
who had had no treatment or only inadequate, irregular treat-
ment. Comparing the frequency of major seizures in their series
of nondeteriorated patients with the frequency of such seizures
in deteriorated institutional patients, the authors say that in
their series 5.7 per cent had grand mal seizures at intervals of
less than a day. This ratio is much smaller than that given in
other reports, in which comparative figures vary between 10.9
and 20.4 per cent. In 14.5 per cent of the present series of
patients, major seizures occurred at intervals of a week or less.
This figure again contrasts markedly with other reports in
which the comparative figures vary between 18.3 and 56 per
cent. In 52.1 per cent of the patients of the present scries
grand mal seizures occurred at intervals of one month or less.
Comparative figures in other statistics are between 54.7 and
90.3 per cent. The percentage of patients in whom the major
seizures occurred at intervals of greater than one month was
47.9 in the material investigated. This figure is greater than
that given by any other writer. Thus it appears that extra-
mural, nondeteriorated patients have major seizures less fre-
quently than do the deteriorated patients in institutions. A
search of the literature revealed only one statistical statement
regarding the frequency of petit mal attacks; Gowers stated
that in half the cases the attacks occurred daily. In the material
analyzed by the authors the frequency of petit mal attacks could

1672

CURRENT MEDICAL LITERATURE

be determined in 137 cases. They occurred at intervals not
exceeding one day in 21.2 per cent of cases. In the conclusion
the authors emphasize once more that in noninstitutionai, non-
deteriorated patients with epilepsy, seizures are significantly less
frequent than they are in deteriorated institutional patients.

Annals of Internal Medicine, Lancaster, Pa.

13 : 225-384 (Aug.) 1939

Nicotinic Acid in Nutrition. C. A. Elvehjem, Madison, Wis.— p. 225.
Observations on Experimental Use of SuHapyridine: I. Relation of
strain Resistance to Chemotherapeutic Effects of Sulfapyridine in
Experimental Pnetimococcic Infections in Mice. P. II. Long and
Eleanor A. Bliss, Baltimore. — p. 232.

Epidemic Syphilis, Its Recognition and Management by the Physician.

E. G. Clark, Nashville, Tenn.— p. 238.

Anaphylaxis and Allergy. C. A. Dragstedt, Chicago.— p. 248.

Value and Significance of Tuberculin Test. A. J. Logie, Jacksonville,
Fla. — p. 255.

'Relative Value of Basal Metabolic Rate, Velocity of Blood Flow and
Creatine Tolerance Test in Differential Diagnosis of Graves’ Disease
and Allied Conditions. F. H. King and A. R. Sohval, Netv York.—
p. 261.

Electrocardiographic Findings Following Carotid Sinus Stimulation.

\V. K. Purks, Vicksburg, Miss. — p. 270.

Subacute Bacterial Endocarditis Due to Streptococcus Viridans, with Spe-
cial Reference to Prognosis. J. A. Capps, Chicago. — p. 2S0.

'Role of Upper Small Intestine in Control of Gastric Secretion: Effect
of Neutral Fat, Fatty Acid and Soaps; Phase of Gastric Secretion
Influenced and Relative Importance of Psychic and Chemical Phases.
H. Shay, J, Gershon-Cohen and S. S. Fels, Philadelphia. — p. 294.
'Observations on Specific Treatment (Type A Antiserum) of Staphylo-
coccic Septicemia. L. A. Julianellc, St. Louis. — p. 308.

Benign and Malignant Gastric Ulcers: Their Relation and Clinical
Differentiation. W. L. Palmer, Chicago. — p. 317.

Postgraduate Portion of Mcdicat Education. C. S. Burwell, Boston. —
p. 339.

Differential Diagnosis of Exophthalmic Goiter. — King
and Sohval say that whereas typical cases of exophthalmic
goiter present no difficulty in the diagnosis, borderline cases, in
which the symptomatology is not so clearly delineated, are not
so easy to differentiate on clinical grounds. Efforts have been
made by previous workers to find some objective laboratory
tests which would simplify the differentiation of such conditions
as autonomic imbalance, the menopause, hypertension and non-
toxic goiter from true exophthalmic goiter. In this study King
and Sohval investigated the comparative value of the determina-
tion of the basal metabolic rate, the creatine tolerance and the
velocity of the blood flow. These tests were made in a group
of eighty-seven cases comprising seventeen of exophthalmic
goiter and seventy of borderline and allied disorders. Regard-
ing their experience with the determination of the basal meta-
bolic rate, the authors say that the basal metabolic rate is
uniformly elevated in exophthalmic goiter and is reduced by the
administration of iodine and by subtotal thyroidectomy. In the
borderline and allied cases, initial determinations are frequently
elevated and misleading. At times repeated determinations are
necessary before the true basal rate is obtained. Especially does
this hold in cases of autonomic imbalance. In some instances
the authors succeeded in obtaining an accurate (normal) figure
only after hospitalization. An elevated figure obtained in a
random determination of the basal metabolism of an ambuiatory
patient is wholly unreliable. The determination of the velocity
of blood flow as measured by the saccharin method in terms of
arm to tongue circulation time has not been used as an adjuvant
in the clinical diagnosis of exophthalmic goiter. Since, accord-
ing to investigations, the velocity of the blood flow is roughly
in direct proportion to the basal metabolic rate, the authors
decided to determine it in their cases. They measured the cir-
culation time by the interval elapsing between the injection of
saccharin into the antecubital vein and the perception of the
sweet taste in the tongue. One hundred and sixty-seven deter-
minations were made in eighty-eight cases. The authors found
that the determination of the circulation time fails to afford a
laboratory aid in the differential diagnosis between exophthalmic
goiter and the borderline cases, since the differences are not
clearcut enough and there is considerable overlapping of figures.
Their experience with the creatine tolerance test, discloses that
it is also limited in its usefulness and may give discordant
results Laboratory aids in general are inadequate as absolute
criteria in the differential diagnosis between exophthalmic goiter
and the borderline cases which simulate it. However, the deter-
mination of the basal metabolic rate excels the circulation time
test and the creatine tolerance test in usefulness. In the last

Jour. A. )l. a.
Oct. 23, l!;j

analysis, clinical judgment surpasses in value any of the=»
laboratory aids. The latter should assume a secondary role ard
be employed with distinct knowledge of their limitations aid
shortcomings.

Upper Small Intestine and Gastric Secretion-Slay and
his associates studied the effect on gastric' secretion of neutral
fat, fatty acid and soap in the upper intestine, the phase ci
secretion influenced from the intestine and the relative impor-
tance of the psychic and chemical phases of gastric secret’®
They selected eight patients with a normal or high gastric add
response to the Ewald meal and with no demonstrable organic
gastrointestinal disease. In order to satisfy any questions tint
might be raised regarding the chemical effect of zwieback arc!
water as the test meal, numerous studies were done with 200 cc.
of 2 per cent Liebig’s extract as the gastric meal. The change
in gastric secretion produced by duodena! stimulation was im-
pendent of the type of mouth meal used. After an overnight
fast two Rehfuss tubes were introduced into the stomach. One
was passed into the duodenum by the usual technic, whereas til
other remained in the stomach. When the duodenum was
intubated, the positions of the tubes were determined fluoro-
scopically. The fasting gastric contents were removed and the
test meal was administered by mouth. The Ewald meal con-
sisted of 30 Gm. of zwieback and 300 cc. of distilled water at
body temperature. Duodenal instillation of the test substances
in the separate studies was begun with the mouth meal, except
when the effect of a time lapse in their administration was Was
studied. The effect on gastric secretion of the additional tw
through the pylorus was investigated. As previously reported,
a tube so placed did not influence gastric, emptying; amt
similar conditions it failed to modify gastric secretion. L'
studies reported by the authors demonstrated consistent iw
depressions of gastric secretion in man when neutral fats, i f
acids and soaps in proper concentrations were instilled into ,
duodenum simultaneously with the mouth meal. All secr£ 27
fractions were involved : acid, chloride and enzymes,
depression of secretion continued for a considerable pem
the instillation of the stimulant was stopped. A secondary s
rise in gastric secretion was nearly always observed a
duodenal stimulating effect was overcome. The an (il ® rs
unable to confirm the opinion that this secondary rise in
tion is dependent on the formation of soaps in the uPP cr j
tine, the action of which is supposed to cause stmwai
gastric secretion. The duodenal instillation of a soap,
sodium oleate, in proper concentration (IS per cent) pro
just as oil, first depression and then rise in secretion. ^
authors frequently saw a sharp rise of gastric sccr £.| l( , fcsll {|
the depression stage from agents other than fats. 1
obtained with 40 per cent dextrose, used to illustrate ^
of agents other than fat or fat derivatives, represen 5 ,
striking secondary rise of secretion. Obviously, soap n -
is not involved here. By the use of duodenal ins ^
different concentrations (2 and 15 per cent sodium ,
authors obtained a difference between the thres w 1 ^

of the gastric motor and secretory mechanisms. t0IJ .

mechanism appears to have a lower threshold than • e!

The mechanism of enzyme secretion also appears o
differently from the acid mechanism. This is seen i ^
consistent earlier rise in enzyme concentration a
denal stimulant is stopped. The question was r ;ec -c
the secondary rise in the gastric secretion,. fo o» m j j, t r -‘.
tory depression from the duodenal instillation o i jeprtf
represent a discharge of secretion stored up influence

sion period. The authors believe that the
exerted chiefly, if not entirely, on the p syeme
secretion and, further, that this phase represen
one. This is based on the prevention of tnc » ■
gastric secretion during insulin hypoglycemia an

secret:"

of duodenal stimulation to prevent a rise in gastri
following histamine injection. _ ntice®'*-"'

Specific Treatment of Staphylococcic hep. ^
. lianelle says that the differentiation of staph) _ ,

A and B was established primarily

illular the

from the respective organisms and secondan y n athos tI!! ’ c ct '
distinction that type A strains are derived r . n . t j c _ IX'-

ditions while type B strains are apparently saproi .

Julianelle says that the differentiation oi stapny , c!; or.:S-
’ •’ by immunology

differences between the intracellular poljsacc ia^,. ^

Volume 113
Number 18

CURRENT MEDICAL LITERATURE

1673

the determination of types was simplified by the mannite fer-
mentation test, which separates type A from type B by the
ability of the former to metabolize acid from this sugar. Cuta-
neous’ tests indicated that, while the polysaccharide of type B
is cutaneously inert, the similar preparation from type A elicits
reactions in approximately 12 per cent of normal infants and
children and 70 per cent of normal adults. An additional obser-
vation of greater importance was that, irrespective of skin
reactivity, precipitins for the specific carbohydrate were demon-
strable in the serums of only those patients suffering from
severe, prolonged, generalized infection and, indeed, only in those
eventually recovering from the infection, so that the appearance
of precipitating antibodies in the serums of patients has been
accepted as a sign of favorable prognosis. Reflecting on the
significance of the presence of precipitins only in the serums of
patients recovering from critical infection, it was proposed to
treat patients who had staphylococcic septicemia with antiserum
containing a high titer of the precipitins capable of reacting
with the specific carbohydrates. All the antiserums used in this
study were prepared from rabbits but it is probable that the
antiserums from other animals may be equally effective. After
describing the preparation and administration of antiserums,
the author describes his clinical observations. Seventeen patients
suffering with staphylococcic septicemia secondary to a primary
lesion yielded on culture staphylococci belonging to type A and
capable of fermenting mannite. All the patients were treated
with type A antiserum prepared in rabbits and were given in
addition whatever supplementary measures were indicated ; such
as surgical drainage and blood transfusions. The untoward
reactions ascribable to the serum were mild, and in four cases
the treatment was followed by serum sickness. The cutaneous
reaction to the carbohydrate of type A is suggested as an index
of sufficient treatment. Of the seventeen patients treated with
type A antiserum, seven recovered and ten died. Of the ten
patients dying, four died before the end of the first day of
treatment, four had developed sterile blood cultures (and of
these, three died of other causes) and two died with typical
signs of staphylococcic infection. Exclusive of the four patients
who succumbed within the first day, type A antiserum apparently
sterilized the blood in eleven of thirteen cases.

Archives of Internal Medicine, Chicago

04: 409-660 (Sept.) 1939

Range of Normal Blood Pressure: Statistical and Clinical Study of
.1.1,383 Persons. S. C. Robinson and M. Brucer, Chicago. — p. 409.
Bilirubin and Urobilin Content of Bile Obtained by Duodenal Drainage:
Normal Values and Values for Patients with Cholecystitis. AI. Royer,
buenos Aires, Argentina. — p. 445.

Cardiac Cirrhosis" of Liver: Clinical and Pathologic Study. H. Af.
Katzin, J. V. Waller and H. L. Blumgart, Boston. — p. 457.

Hematology of Sternal Alarrow and Venous Blood of Pregnant and of
Nonpregnant Women. H. H. Pitts and Evelyn A. Packham, Van-
couver, B. C.— p. 471.

Phosphatase Activity in Chronic Arthritis. C. L. Steinberg and Louise
Catherine Suter, Rochester, N. Y. — p. 453.

Electrocardiographic Findings in Cases of Ventricular Aneurysm. AI.

Ehaser Jr. and J. Konigsberg, San Francisco. — p. 493.

Effects on Cardiovascular System of Alan of Fluids Administered Intra-
venously: III. Studies of Glomerular Filtration Rate as Measured by
Urea Clearance. D. R. Gilligan, AI. D. Altschule and A. J. Linenthal,
Boston.— p. 505.

• Renal Insufficiency Produced by Partial Nephrectomy:

Al. Diets Containing Dried Extracted Liver. A. Chanutin and S.
T Ludewig, University, Va. — p. 513.

Nil. Diets Containing Dried Extracted Aleat. A. Chanutin and
S. Ludewig, University, Va. — p. 526.

^Etracerebral Carcinomatous Aletastases. C. C. Hare and G. A. Schwarz,
Aew York.— p. 542.

Primary Carcinoma of Liver: Tumor Thrombosis of Inferior Vena
tiv Va ant ^ R'Sht Auricle. R. Gregory, Washington, D. C. — p. 566.
thiocyanate Dermatitis: Report of Case. AL E. Green and J. S. Snow,
Ann Arbor, Alicli. — p. 579.

Lipoid Pneumonia: Report of Two Cases. C. F. Garvin, Cleveland. —
Pe 586.

Vascular Diseases: Review of Some of Recent Literature, with Critical
Renew of Surgical Treatment. G. W. Scuphani, G. de Takats, T. R.
1 an Dellen and W. C. Beck, Chicago. — p. 590.

‘Cardiac Cirrhosis” of Liver. — In examining 2,000 con-
secutive necropsy' protocols, Katzin and his collaborators found
that 286 of the deaths were due to congestive cardiac failure.
Increased hepatic fibrous tissue was found in one third of these
cases and this was approximately three times the incidence found
m the remaining 1,714 cases in which congestive failure was
absent. The incidence of fibrosis in cases of chronic passive
congestion increased with the duration of congestive failure, and
tile more severe grades were found in cases in which the illness

was of longest duration. The causal significance of chronic
passive congestion in the production of hepatic fibrosis was
emphasized by the increasing incidence and severity of the
fibrosis with increasing duration of congestive cardiac failure.
The only type of increase of fibrous tissue peculiar to this group
of cases of cardiac decompensation was central fibrosis, for,
with a single exception, no instance of central fibrosis was found
among the 1,714 cases in which necropsy failed to disclose con-
gestive failure. Portal fibrosis also was found in a larger per-
centage of such cases than in cases in which chronic passive
congestion was absent. This suggests that chronic passive con-
gestion with resulting anoxemia, by increasing the susceptibility
of the hepatic tissue, is also a contributing factor to fibrosis in
the portal areas.

Phosphatase Activity in Chronic Arthritis. — Steinberg
and Suter determined the phosphatase content of the serum of
forty-four patients with atrophic arthritis, eight with hyper-
trophic arthritis, five with mixed atrophic and hypertrophic
arthritis, five with osteitis deformans and six healthy persons.
In the only case of arthritis in which the value for serum
phosphatase was above 4 & units it was later proved that malig-
nant tumor of the prostate gland was present, with secondary
involvement of osseous and pulmonary tissue. An increase of
serum phosphatase in this type of malignant disease has been
described by' Gutman and his co-workers. Determination of the
phosphatase content of the serum in cases of chronic atrophic
and hypertrophic arthritis is therefore important in the differen-
tial diagnosis. A normal value for serum phosphatase is char-
acteristic of chronic atrophic or hypertrophic arthritis; an
abnormal value suggests the possibility of a complicating con-
dition or an erroneous diagnosis of this condition. Determina-
tions of the phosphatase content of the serum should be made a
routine procedure in the study of diseases of the bones and joints.

Intracerebral Carcinomatous Metastases. — Hare and
Schwarz describe the clinical features of 100 cases of intra-
cerebral carcinomatous metastases and the pathologic features
in thirty'-four of these cases in which necropsy was performed.
The study is limited to cases in which the tumor has spread,
presumably by way of the blood stream, to involve the paren-
chyma of the brain. The authors’ conclusions are that :
1. Bronchogenic and mammary carcinoma commonly metastasize
to the brain. 2. The primary carcinoma in cases of cerebral
metastasis is most commonly in the lung or breast; sixty-five
of the 100 primary tumors were so located. 3. A bronchogenic
carcinoma often manifests its effects by cerebral metastasis
before there are any pulmonary signs. 4. Carcinoma with cere-
bral metastases is not uncommon in persons less than 40 years
of age. This occurred in twenty-seven of the 100 cases. 5. The
disease occurs predominantly in male patients in the ratio of
3.2 : 1, provided the cases of primary carcinoma of the breast
are excluded. 6. Symptoms of metastasis are usually of short
duration before the patient becomes seriously ill. 7. The onset
of intracranial symptoms occurred suddenly in thirty-six cases.
8. Patients with metastatic cerebral tumor do not tolerate sur-
gical procedures well. The average duration of life from the
time of the first neurologic symptom until death was 3.6 months
for the thirty-two persons who died while under the authors’
care. The survival period was much shorter for those who were
operated on. 9. Mental alterations of varying degree were
present in SO per cent of the patients studied. 10. Severe head-
ache may be a prominent symptom. It may or may not be
associated with papilledema. 11. Signs of chronic debilitating
disease may be absent. They were lacking in 40 per cent of
the cases. 12. Abnormality of the spinal fluid occurred in 70 per
cent of the cases in which it was examined. 13. X-ray evidence
of erosion of the sella turcica may be present. It was not
uncommon in spite of the short duration of the cerebral metas-
tases. 14. Encephalographic and clinical studies may localize
one of the metastatic masses, which is usually the largest, and
may fail to show the presence of other, smaller, nodules.

15. Even after metastasizing to the brain, bronchogenic car-
cinoma may not appear as such on roentgenograms of the chest.

16. Metastatic cerebral tumors may be single or multiple. Mul-
tiple tumors were observed in twenty brains removed.at necropsy.

17. In practically all cases of cerebral metastasis there are
metastases to other organs. 18. Cerebral disease in addition to
the metastases may be present. Such was the case in four' of the

1674

CURRENT MEDICAL LITERATURE

Joot. A. Jt. A
On. 28, 181 )

present series : cholesteatoma in one and syphilis of the central
nervous system in three. 19. Surgical removal of single metas-
tases in a few cases may prolong life for months or even for
several years; however, such cases form a small percentage, as
most patients die shortly after craniotomy. 20. Subtemporal
decompression often relieves the headache and affords great
comfort to the patient. 21. When craniotomy is to be performed,
x-ray studies of the chest should be made, regardless of the
age of the patient.

Archives of Otolaryngology, Chicago

30: 319-496 (Sept.) 1939

''Atrophic Rhinitis: Treatment with Estrogenic Substances, with Biopsy-
Before and After Treatment. W. W. Eagle, R. D. Baker and E. C.
^ Hamblen, Durham, N. C, — p. 319.

Nasograph Mirror of Glatzel as Measure of Nasal Patency. C. C. Lieb
and M. G. Mulinos, New York. — p. 334.

Motion Pictures of Human Larynx. W. A. Lei!, with technical assis-
tance of W. J. Sullivan, Philadelphia. — p. 344.

Congenital Tracheo-Esophageal Fistula Without Atresia of Esophagus:
Report of Case with Plastic Closure and Cure. C. J. Imneratori New
York. — p. 352.

Neurologic Complications of Infections of Temporal Bone and Paranasal
Sinuses: Summary of Twenty Years’ <1919 to 1938) Experience.
J. C. Yaskin, Philadelphia. — p. 360.

* Larynx in Infantile Beriberi. V. C. Alcantara and G. deOcampo,

Manila, Philippine Islands. — p. 389.

Oro-Antral Openings and Their Surgical Correction. A. Berger, New
York.-~p. 400.

* Constitutional Background of Infection of Upper Part of Respiratory

Tract. J. B. Price, Norristown, Pa. — p. 411.

Larynx of the Tuberculous Child. H. Rubin and S. Galburt, Brooklyn,
— p. 421.

Paranasal Sinuses. S. Salinger, Chicago. — p. 442.

Atrophic Rhinitis. — Eagle and his associates used estrogens
in the treatment of fourteen patients with atrophic rhinitis.
Sections of their nasal mucosa were studied before and during
or after treatment with regard to specific histologic alterations
attributable to the local action of the estrogens. Tiie first biopsy
specimen in each case was obtained previous to any treatment
and the second one was taken from twenty-seven to 216 days
after the first treatments with estrogenic substances were started.
No patient complained specifically of deafness and tinnitus.
Twenty-two patients started the estrogenic treatment and had
the original biopsy but, owing to economic reasons and the dis-
tance to the clinic, eight did not return for the second biopsy.
The patients irrigated their noses twice daily with physiologic
solution of sodium chloride or 1 : 10,000 solution of potassium
permanganate and ten minutes later repeated the irrigation to
remove the crusts that had been loosened by the earlier wash-
ing. Then 0.5 cc. of estrogenic substance was sprayed into the
nose twice daily, giving each patient the equivalent of 1 cc., or
1,000 international units, of estrogen daily. Twenty-one of the
twenty-two patients reported clinical benefit and each wished to
continue treatment. The patient with stormy menopausal symp-
toms stated that she was not improved to the slightest degree.
Inspection of the nose revealed certain marked diminution or
complete eradication of crusts in all fourteen cases in which
the study was completed, and in no instance was the odor char-
acteristic of the disease detectable. The only changes noticeable
in the mucosa were a slight increase in hyperemia and a
smoother surface. Patients complaining of a burning sensation
in the scalp and occipital headache were relieved of these symp-
toms. The authors are unable to state whether the patients'
noses were free of crusts because of the more frequent irriga-
tions or because of the estrogenic therapy. The impression was
that the surface epithelium and the subepithelial glandular sys-
tem contained more mucous cells after treatment than before.
It appeared that the amounts of squamous and ciliated epithelium
and the vascularity, as well as various other features, were not
altered. No perfectly consistent change in any one direction
existed. Fibrosis was recorded more frequently before than
after treatment. The protocol method of analysis suggested
increased function of the mucous glands, and the statistical
method decreased density of the tunica proper after treatment.

It is possible that study of a far larger series of patients might
give significance to some of these suggestions. The present
observations indicate the absence of obvious morphologic
changes.

Larynx in Infantile Beriberi.— Alcantara and deOcampo
examined the larynxes of thirty-seven infants from I to 9 months
of age with infantile beriberi. In eleven the disease was com-
plicated bv acute infection of the respirator)- tract. Hoarseness

and weakness of the voice, or aphonia, was the most frequent
symptom. The final diagnosis of infantile beriberi was given
in all these cases by the pediatrician. The laryngeal lesions
found were as follows : The five patients with acute cardialgic
beriberi, in whom the impairment of voice was slight, showed
only slight congestion of the vocal cords, their motility being
normal. In the rest, impairment of motion of the vocal cords
existed. The right vocal cord was paretic or could not mow
completely to the median line in four cases, stayed immobile in
the middle in nine and assumed a cadaveric position in three.
The left vocal cord was paretic in five cases, completely immo-
bile in the median line in nine and cadaveric in one. The vocal
cords were bilaterally affected in three cases. In some case;
the paretic vocal cord appeared at a lower level than the
normal. Twenty-two of a control group of thirty-one children
with diseases other than infantile beriberi but with hoarseness
as a complaint also, examined laryngoscopically, showed only
congestion of the vocal cords, which moved normally. The rest
had impairment of movement of the vocal cord, but in almost
all of them there was a coexistent pathologic condition which
might explain the paresis. In the rare cases in which the
impairment of motion seemed to be entirely attributable to
the inflammatory congestion of the larynx, the hoarseness and
the impaired mobility were of short duration in contrast to that
long duration in the cases of beriberi. The authors believe that
impaired mobility of the vocal cords should he added to the
already recognized diagnostic factors of infantile beriberi. In
cases in which beriberi and acute infection of the respiratory
tract coexist, the motility of the cords is of help in determining
whether both are present and what degree of deficiency of vth-
min Bi exists in the child. Irritation and then degeneration o
the abductor fibers of the vagus nerve followed by
changes in the other fibers, the tensors and adductors appear to
be the clinical facts in the production of the laryngeal lesions.
Cardiac enlargement does not seem to have any influence on t '
degeneration. Clinically and probably pathologically, at as
with regard to the laryngeal lesions, there is a close smn an y
between adult and infantile beriberi.

Constitutional Background of Respiratory InfectiM.
— Price studied the influence of constitutional factors w to
tions of the upper part of the respiratory tract by exa®®
two groups of subjects. One of these groups was sclecte
754 male and female students at Ursinus College and was co
posed of young men and women who came from g°° > 5 ’
substantial, middle class families, representing the avenge,
mal type. The other group was a cross section of .
and female inmates of Pennhurst State School, degcu
types. Members of both these groups live in the same vi ^
the institutions being within 10 miles of each other. .
of the degenerative type are more affected by the cons ^
factors in their basic background than are those o . , ^
type, who are slightly affected. The difference w ie iif0
of infection of the upper part of the respiratory trac 1 ( j (ut ; on a!
groups strikingly indicates the variation of the con
factor. In an analysis of this factor, the. vas ° m ° 0 rm0trr aphic
in the two groups were compared by studying the ® - n t j,e
response. The dermographic reaction was more de m0(of
degenerative group. It is pointed out that abnorma ‘ . Jin 0 j

reactions may be an important element in the m ^ jj-.e
infection of the upper part of the respiratory trac •
constitutional factors in the case can be changed « . . 5 ). 0 u’'i

ment will accomplish but little. Physiologic cqui i t£jn c :
be the goal. If the autonomic system, the endoenn
the acid-base metabolism is at fault, one nws
condition and attempt to regulate it physiologica )•

Canadian Public Health Journal, Toronto

30 : 419-468 (Sept.) 1939 ^ Jn C#**

resent Situation Regarding - the Adequacy of Medica ^

G. Fleming, Montreal.— p. 419. TiWth Educate

/hat Can the University Contribute to Publtc
Fraser, Sackville, N. B. — p. 424. 431 .

utrition in Canada. E. W. McHenry, Toronto.-P*^ R ^ rfr*
tudy of 456 Deaths in Ontario Attributed to '

Mary A. Ross and A. H. Sellers, Toronto. P« ' cj, V-*

be British Columbia Peace River Health Unit. J*

Coupe, B. C. — p. 445. Tnronto . — ?•

impaign Against Ragweed. H. B. Anderson,

Volume 113
Number IS

CURRENT MEDICAL LITERATURE

1675

Delaware State Medical Journal, Wilmington

11: 171-190 (Aug.) 1939

Ten Year Comparison of Sanatorium Patients. L. D. Phillips, Marsliall-
ton. — p. 171.

•Incidence of Syphilis in Delaware. J. R. Beck, Dover. — p. 172.
Classification of Cases Admitted to the State Board of Health Venereal
Disease Clinics. T. E. Hynson, Dover. — p. 174.

Epidemiologic Control of Syphilis in Delaware. L. L. Fitchett, Felton.
— p. 176.

Infant Mortality in Delaware. F. I. Hudson, Dover. — p. 179.

Approval of Laboratories Making Serologic Tests for Syphilis. R. D.
Herdman, Dover. — p. 181.

Another Step Forward in Public Health. R. C. Beckett, Dover.— p. 182.
Why Care for the Deciduous Teeth? Margaret H. Jeffreys, Dover.—
p. 184.

Place of Nutrition in a Health Program. Charlotte Spencer, Dover.—
p. 185.

Incidence of Syphilis in Delaware. — Beck states that 868,
or 94.5 per cent, of the students at the University of Delaware
were given Kahn and Wassermann tests and only one positive
blood reaction was obtained. Other groups (domestics, food
handlers, nursery school children and industrial school girls)
were also tested and the proportion of positive reactors ranged
from 0 to 4.5 per cent in the white persons and from 4.8 to
47.2 per cent in the Negroes. From the figures presented, it is
estimated that less than 2 per cent of the white and about 30 per
cent of the Negro population of Delaware have syphilis.

Indiana State Medical Assn. Journal, Indianapolis

32: 445-556 (Sept.) 1939

•Chronic Rheumatic Brain Disease as Factor in Causation of Mental Ill-
ness: Report of Two Cases. W. L. Bruetsch and M. A. Bahr,
Indianapolis. — p. 445.

Present Status of Shock Therapy in Treatment of Dementia Praecox.

P. B. Reed, Indianapolis. — p. 451.

Metrazol in Schizophrenia. E. R. Smith, Indianapolis. — p. 456.

Results of Insulin Shock Therapy in Ten Cases. H. A. Stellner and
H. L. Watson, Evansville. — p. 459.

Sinusitis Diagnosis and Nonoperative Treatment. W. F. Gessler, Fort
Wayne. — p. 463.

Surgical Treatment of Sinusitis. R. J. McQuiston, Indianapolis. —
p. 466.

Early Diagnosis and Prevention of Deformity in Crippling Diseases of
Childhood. A. R. Shands Jr., Wilmington, Del. — p. 471.

Theoretical Considerations of Clinical Electrochemical and Electrophysical
Phenomena. W. L. Green, Columbus. — p. 474.

Chronic Rheumatic Infection and Mental Illness. —
Chronic rheumatic infection might be the etiologic factor in
certain cases of long standing mental illness. In the necropsy
service of the Central State Hospital of Indianapolis, Bruetsch
and Bahr observed that, in some subjects with old rheumatic
changes on the heart valves, gross lesions in the form of small
or large infarctions were present in the brain and at times in
other organs. In most of these instances the clinical record did
not give reference to a previous rheumatic infection, and none
of the patients had gone through an acute attack of rheumatic
fever while an inmate of the institution. Particular attention
was given to the presence of rheumatic valvular heart disease
in the necropsies of 500 mental patients. Other forms of endo-
carditis, such as the subacute bacterial form, were ruled out by
gross and microscopic examination. The anatomic investigation
disclosed chronic rheumatic valvular disease to be present in
4 per cent. Microscopic examination of all the organs of these
patients showed that the long-continued rheumatic infection had
involved not only the heart but also the brain and other organs,
such as the kidneys, spleen and pancreas. The changes in the
brain consisted of an obliterating rheumatic endarteritis of
small and larger vessels having resulted in gross and micro-
scopic infarctions and in numerous minute' areas of incomplete
softening (acellular areas). Small connective tissue scars origi-
nating from proliferating vessels and extending over several
cortical cell layers were frequently observed. Glial nodules
^cre occasionally seen in the cortex and in the white matter.

"° patients with a psychosis of short duration had a rheumatic
encephalitis. Some of the cases were diagnosed as dementia
Praecox, others as manic depression or as involutional and
senile psychoses. In two cases the diagnosis was psychosis with
cerebral arteriosclerosis, because residual signs of a “stroke"
^ ere present. If the rheumatic infection produces brain lesions
m childhood, mental deficiency may result.

Journal of Urology, Baltimore

42: 269-480 (Sept.) 1939. Partial Index
Adenocarcinoma of Kidney with Metastasis to Lung: Cured by Nephrec-
tomy and Lobectomy. J. D. Barney and E. J. Churchill, Boston. —

p. 269.

Parenchymal Calculosis of Kidneys. M. Muschat and L. Koolpe, Phila-
delphia. — p. 293.

Migration of Renal Stones Associated with Pyonephrosis and Perinephric
Abscess into Lung. M. A. Granoff, Gloversville, N. Y. — p. 302.
Unilateral Renal Agenesis with Associated Genital Anomalies. D. H.

Drummond and H. D. Palmer, Rockford, III. — p. 317.

Carbuncle of Kidney: Report of Ten Cases. G. A. Ingrish, Chicago. —
p. 326.

Asymptomatic Hydronephrosis Resulting from Papilloma of Ureter.

Elizabeth M. Ramsey, Washington. — -p. 341.

•Hormone Control of Prostate and Its Relation to Clinical Prostatic
Hypertrophy: Survey of Literature. B. Vidgoff, Portland, Ore. —
p. 359.

Estrogenic Property of Testosterone Propionate: Allen-Doisy Test as
Questionable Indicator of “Female" Hormone in Urine of Men. J. F.
McCahey and A. E. Rakoff, Philadelphia. — p. 372.

Endocrine Control of Prostate. — Vidgoff points out that
an endocrine relationship is implied because man's sexual activity
is supposedly waning when prostatic hypertrophy becomes
troublesome. The accidental finding of epithelial metaplasia in
the prostate of animals after the injection of theelin has led
to the theory of estrogenic dominance in a bisexual organ as
the explanation of the clinical picture. The author is not con-
vinced that this is a specific observation because it is well known
that estrogenic substance is a general epithelial stimulant.
Furthermore, the anatomic evidence does not support this theory.
The many reports of remarkable relief from the clinical picture
with testosterone are not convincing. In animals, testosterone
causes a hypertrophy of the prostate. The clinical experimental
work has been insufficiently controlled. The beneficial effects
obtained by the use of the testosterone in prostatic hypertrophy
is probably due to the effect on the congestion surrounding the
adenoma. For the same reason, prostatic hypertrophy in the
human being is capable of undergoing spontaneous amelioration.
There is evidence to show that the testis elaborates a substance
which has an inhibitory effect on the prostate. This inhibitory
substance has not been isolated as yet, but work going on at
present shows promising results. Much experimental work on
the problem, rigidly controlled, is necessary.

Laryngoscope, St. Louis

49: 603-738 (Aug.) 1939

Rhlnology in ChUdrcn: Resume of and Comments on Literature for
1938. D. E. S. Wishart, Toronto. — p. 603.

Modern Views Regarding Anatomy and Physiology of Vestibular Tracts.
O. Marburg, New York. — p. 631.

Tmmunologic Aspects of Blood Invasions, with Special Reference to Sinus
Thrombosis. G. Shwartzman, New York. — p. 653.

Use of Monochord in Routine Tests of Hearing. F. T. Hill, Waterville
Maine. — p. 666 .

Skull Fractures Involving the Ear: Clinical Study of 211 Cases. W. E
Grove, Milwaukee. — p. 678.

Nebraska State Medical Journal, Lincoln

24 : 281-320 (Aug.) 1939

Inoperable Sarcoma of Bone: Cures After More Than Five Years
J. P. Lord, Omaha. — p. 281.

Reduction of Colies Fracture. H. R. Miner, Falls City.— p. 286
Orthopedic Care of the Arthritic Patient. H. F. Johnson and G.
. whiston, Omaha. — p. 289.

Skin Diseases Commonly Encountered During the Summer. O. J.
Cameron, Omaha. — p. 294.

Use of Bee Venom in Treatment of Arthritis and Neuritis. G. W.
A ini ay, Fairbury. — p. 298.

Surgical Aspects of Acute Abdomen in Infancy and Childhood. C. W.

McLaughlin Jr. and H. H. Davis, Omaha. — p. 304.

Review of Hypertension: Case Report. E. J. Kirk, Omaha. — p. 308.

New England Journal of Medicine, Boston

221: 329-366 (Aug. 31) 1939

•Studies on Heredity in Jewish Diabetic Patients. A. Rudy and C. E.
Keeler, Boston. — p. 329.

Surgery of Extrahcpatic Biliary Tract. C. K. P. Henry, Montreal.

p. 333.

•Complete Heart Block Resulting from Overdosage with Thyroid Extract
M. Aisner and J. F. Dorsey, Boston. — p. 336.

Bacteriology. C. A. Janeway, Boston. — p. 339 .

Heredity in Jewish Diabetic Patients.— Rudy and Keeler
collected data on the importance of heredity as an etiologic factor
in diabetes mellitus in the families of 1,037 Jewish patients.
Among 1,000 successive nondiabetic patients admitted to the

1 676

CURRENT MEDICAL LITERATURE

Jous. A. M. A
Oct. 23, 19!)

Beth Israel Hospital, sixty-three reported one or more members
of their families as having had diabetes. The disease was at
least four times as frequent in the families of the 1,037 diabetic
subjects. According to Camtnidge it is even more than eleven
times as frequent. From the data of their hospital records the
authors found 29.1 per cent with one or more diabetic indi-
viduals in their families. Interviews with 246 Jewish diabetic
patients revealed a higher proportion of positive family histories,
eighty-seven (35.3 per cent). Of 302 patients with a positive
family history of diabetes, 164 (15.8 per cent) gave a hereditary
history and 138 (13.3 per cent) only a familial history. Adult
Jewish diabetic patients (aged 20 or more) show 28.6 per cent
diabetic heredity : 15.3 per cent hereditary and 13.3 per cent
familial. Jewish patients show a higher frequency of the familial
type of diabetic heredity regardless of age. The ratio of women
to men is nearly 2:1. Of twenty married couples with diabetes,
from the ages of 48 to 77, two couples had no children, and six
of the remaining eighteen had one diabetic child each. In the
majority of the Jewish men and women diabetes developed
between the ages of 50 and 54, the same age Joslin found for
all his men and women patients. A study of the A and B blood
groups and the M and N blood types has been carried out in
some diabetic patients in order to determine whether there is
any relation between the diabetic constitution and the known
blood characters. The data are not considered conclusive but
it may be said that the distribution of the blood types M and N
and the blood groups A and B in diabetic patients shows no
striking difference from that in nondiabetic patients already
reported in the literature.

Heart Block from Thyroid Extract. — Aisner and Dorsey
cite a case of complete heart block following an overdose of
thyroid extract taken for obesity. A review of the literature
since 1882 shows ten cases of complete heart block developing
during the course of true hyperthyroidism but no cases in which
the block was induced by the administration of thyroid extract.
The transient nature of the heart block in the case reported
suggests that the disturbance may be a function of reversible
chemical changes in the myocardium rather than of morphologic
alterations. The case illustrates what may be expected from
the uncontrolled use of thyroid extract in the treatment of
obesity.

New York State Journal of Medicine, New York

39: 1637-1706 (Sept. 1) 193 9

Multiple Traumatic Ulcers Superimposed on Postosteomyelitic Scar of
Tibia: Successful Plastic Repair. D. Warshaw, New York. — p. 1643.
Atypical Surgical Abdomen. M. Frieberg and R. L. Siegel, Brooklyn.
— p. 1646.

•Use of Flask as Simple Aid to Tactile Fremitus. N. E. Reich, Brooklyn.
— p. 1654.

Problem of Aftercoming Head in Obstetrics. R, J. Lowrie, New York.
— p. 1655.

Agranulocytosis Due to Sulfanilamide. J. Taub and L. Lefkowitz, New
York.— p. 1659.

Chronic Meningococcemia: Report of Case. J. J. Friedman and J. A.
Buchanan, Brooklyn. — p. 1662.

Gaucher’s Disease: Brief Review of Disease with Report of Case in a
Male. R. C. Schleussner and C. F. Schnee, New York.— p. 1665.
•Hematogenous Tuberculosis. E. W. Billard, New York. p. 1670.

Use of X-Ray in Diagnosis of Placenta Praevia. A. C. Beck and F. -P.
Light, Brooklyn. — p. 1678.

Cancer of Cardia, Roent gen ographi call y Considered. W. H. Stewart and
H. E. Illick, New York. — p. 1685.

Flask as Aid to Tactile Fremitus.— Just as the stetho-
scope lias been an improvement over direct auscultation, Reich
found that a 100 cc. Erlenmeyer flask was capable of tncreas-
ing and localizing tactile fremitus.- The flask conveyed the
vocal vibrations from the wall of the chest to the hand m a
most satisfactory manner. This was found to be especially
suitable because of the thinness of the glass, the smooth, small
localizing mouth flaring out at the base to cover a large area
of palmar tactile endings. Less satisfactory was a 75 watt
electric light bulb. The flask or bulb is applied lightly to
the various regions of the wall of the chest with gentle pres-
sure on the base with the open palm (ulnar side of the hand)
or fingertips, with the patient repeating a short. phrase of
words or numbers. The usual variations exist ; increase or
decrease of tactile fremitns in pathologic conditions has the

same interpretation as that done with the hands only. Tr:
flask can prove useful in helping to localize small or early
lesions of the lungs.

Hematogenic Tuberculosis.— Billard discusses the clinical
aspects, pathologic changes and pathogenesis of hematogenic
tuberculosis and in summary points out that pulmonary tuber-
culosis resulting from infection by way of the blood stream
produces a clinical entity separate and distinct from the disease
acquired by the usual bronchogenic route. The condition nay
he acute generalized miliary tuberculosis, producing a fulminat-
ing- fatal condition involving the lungs and other organs is
the body, or it may be chronic miliary tuberculosis in which
the demonstrable lesion is limited to the lungs, although extra-
pulmonary foci, especially in the bones, joints and- genito-
urinary tract, may occur without clinical evidence. These
pulmonary lesions may be of varying extent, are usually
bilateral and have a tendency to symmetry and localization in
the apexes and the upper lobes. Symptoms of pulmonary dis-
ease may be mild or absent. Chronic hematogenic lesions are
produced by single or repeated disseminations of bacilli into
the circulation from various sources, as caseating tracheobron-
chial nodes, the primary pulmonary focus or extrapulmonary
foci. They' may heal by complete absorption, diffuse, line
fibrosis or dense, discrete calcified deposits. On the other
hand, the lesions may run a low grade chronic or subacute
course or they may progress and break down, producing bron-
chogenic dissemination. Foci are created simultaneously lfl

extrapulmonary organs. They may be of the abortive type » r
they may give rise to chronic low grade infection. In chronic
hematogenic tuberculosis, acute fatal dissemination may occur
at any time; however, in the majority of cases the course ':
mildly protractive and patients suffer less than those w
bronchogenic infection.

Surgery, St. Louis

6: 327-490 (Sept.) 1939

Curability of Carcinoma of Stomach. L. Parsons and

Boston. — p. 327. , r J e foUts,

•Pulmonary Embolism: Experimental and Clinical S u )• ■ r un ; ce f,

W. C, Beck and G. K. Fenn, with technical assistance
Roth and C. Schweitzer, Chicago. — p. 339. j uin o:«.

•Ovarian Tumors and Uterine Bleeding: I* Granu
G. E. Seegar and H. W. Jones, Baltimore.— p ; 368.

Cystadenoma of Ovary Incorporated Between Lea\e

E. A. Gaston, Framingham, Mass.— p. 389. . an( j Seccffl*

Simple Efficient Method to Diminish Incidence ot t nn* / H j afksC -
dary Infection in Surgical Wounds. R. H. Jackso
Jr., Madison, Wis. — p. 398. n f Lumbar V* f

Lesions of Intervertebral Disk and Ligamentum Fla\nm T 1{cr .

tebrae: Anatomic Study of Seventy-Five Hutna
witz, Philadelphia.— p. 410. _ Washington, D-

Cellophane as Wound Dressing. E. L. Howes,

p. 426. T u Pt dock. > T C"’

New Colostomy Spur-Crushing Clamp. J- •

Clamp^and Spur Crusher for Obstructive Colonic Resection. A. ^
Touroff, New York. — p. 431. . ,,u. Suture Matt""

Acute Intestinal Obstruction Caused by Aonabso
T. J. Snodgrass, Janesville, Wis.— p. 437. .

Pulmonary Embolism. — De Takats and hisass
duced experimentally two types of fatal pu m ara cterit^
one which plugs the terminal vascular e an e . en t s an

by cyanosis and dyspnea, and the other " 1 ,.y (5 3 <yf.-

obstruction to the main pulmonary artery a 11 nrc ssiire.
copal attack with pallor and a fall in the 0 ,, „j nej papav-
possible mechanisms of death are analyze . - o j crrl iy

erine and oxygen are helpful in the per'P ,er an( j a Rer
lism. Electrocardiograms taken of dogs a pic™*

production of a massive pulmonary embolism p ^
resembling serious interference with coronary . j n hibition r:

sible causes of this interference are reflex tag

He causes or tms micuauiu. - • „ f ro m

le heart, peripheral vascular collapse arising ' cUt e «'
ypertension through the depressor nerve an __ 0 f

icular failure. In the authors series o an( ] (kirk'-'

onary embolism there were eighty'-sei cn than 1-

irvivals. Of the fatal cases, death occurred ^ {; .

:r cent within the first ten minutes, t : u er j me nts
nergency measures. On the basics o j * avC rinc t0 c ^‘
commend a combination of atropine an P P or ;girn!C c
ract the radiation of autonomic reflexes, «wc

Volume 113
Number 18

CURRENT MEDICAL LITERATURE

1677

the affected lung. Oxygen is obviously useful in the periph-
eral type of • embolism, in which vasomotor collapse is absent
but cyanosis predominates. The commonly employed drugs
epinephrine, neosynephrine, digitalis and strophanthin are dis-
cussed but not recommended. As manifest thrombosis of the
veins of the pelvis and lower extremities is comparatively
rarely seen in patients with massive pulmonary embolism and
heparinization of a large number of postoperative cases is yet
impossible, early and active interference with the autonomic
reflexes may be the only available life-saving measure.

' Uterine Bleeding and Granulosa Cell Tumors. — Seegar
and Jones state that abnormal uterine bleeding in association
with ovarian tumors has been analyzed as to cause and fre-
quency in a group of 376 cases. The mechanism responsible
for the abnormalities in menstruation varies with the patho-
logic type of ovarian tumor. The highest occurrence of abnor-
mal uterine bleeding was found in association with the tumors
of granulosa derivation. In thirty-five papillary granulosa cell
tumors, 45 per cent were associated with abnormal uterine
bleeding. Of the fifty-nine solid granulosa cell tumors, 62 per
cent were found to be associated with menstrual abnormalities.
In both groups in which endometrium was available, endo-
metrial hyperplasia was the direct cause of the uterine bleed-
ing. The hyperplasia is presumably produced by the estrogenic
secretion of the tumor itself. A more careful study of the
uterine endometrium, together with endocrine studies on the
blood and urine of patients with ovarian neoplasms, will render
valuable assistance in the correct classification of ovarian
tumors.

Surgery, Gynecology and Obstetrics, Chicago

GO: 257-416 (Sept.) 1939

Carcinoma of Cervix Treated by Roentgen Ray and Radium. J. V.

Meigs and H. L. Jaffe, Boston. — p. 257.

Pathologic Features of Soft Tissue Fibrosarcoma, with Special Reference
to Grading of Its Malignancy. A. C. Broders, Rochester, Minn.;
R. Hargrave, Wichita Falls, Texas, and H. W. Meyerding, Rochester,
Minn. — p. 267.

Surgical Gastritis: Study on Genesis of Gastritis Found in Resected
Stomachs, with Particular Reference to So-Called “Antral Gastritis”
Associated with Ulcer. R. Schindler, H. Necheles and R. L. Gold,
Chicago. — p. 281,

Problem of Intractable Peptic Ulcer. F. G. Connell, Oshkosh, Wis. —
P. 287.

Surgical Treatment of Acute Profuse Gastric Hemorrhages. H. Fin-
sl fe r . Vienna, Austria. — p. 291.

^w'. E:nant Tumors of Small Intestine: Study of Their Incidence and
Diagnostic Characteristics. F. G. Medinger, Wrentham, Mass.— p. 299.
Oxygen Therapy in Reactions Following Barbiturate Anesthesia and
Cisternal Intervention. J. G. Schnedorf, Detroit. — p. 305.

Management of Hematogenous Pelvic Osteomyelitis. J. Kulowski, St.
Joseph, Mo. — p. 312.

The Mikulicz Operation — Development and Technic. R. W. McNealy
and M. E. Lichtenstein, Chicago, — p. 327.

Surgical Treatment of Exophthalmic Goiter. E. Bernabeo, Bologna,
Italy. — p. 333 .

Clinical Aspects of Sacrococcygeal Teratomas. L. Chaffin, Los Angeles.
— p. 337.

Conservative Treatment of Diabetic Gangrene. S. S. Samuels, New
York. — p. 342.

Repair of Large Defects After Removal of Cancer of Lips. E. M.
Dal and, Boston. — p. 347.

Nontraumatic Paralysis of Dorsal Interosseous Nerve. L. M. Wein-
berger, Philadelphia.— p. 358.

Pulsion Diverticula of Hypopharynx: Review of Forty-One Cases in
Which Operation Was Performed and Report of Two Cases. S. W.
Harrington, Rochester, Minn. — p. 364.

Treatment of Carcinoma of Uterine Cervix. A. Grossman, Chicago. —
p. 373.

Malignant Tumors of Small Intestine.— Medinger gives
the incidence o£ malignant tumors of the small intestine found
in the pathologic material of the New England Deaconess and
Palmer Memorial Hospitals during a period of twelve years.
In a total of 1,456 postmortem examinations, malignant con-
ditions were found in 63 per cent. There were approximately
41,000 surgical specimens and in 20 per cent of these the pri-
mary diagnosis was malignant growth. A review of the same
series shows only ten cases that came to necropsy with malig-
nant tumors of the small intestine, or an incidence for all
necropsies of 0.69 per cent. The surgical material shows
twelve, cases, an incidence for malignant neoplasms of the
small intestine of 0.03 per cent of the total specimens and 0.15
Per cent of the total malignant growths removed surgically.
Three of these twenty-two tumors were of duodenal origin,
twelve jejunal and seven ileac. Sixteen were carcinomas and
six sarcomas. The author’s analysis of 134 cases of malignant
growths of the small intestine, including bis own series, shows

malignant tumors of the duodenum and ileum to occur slightly
more frequently than malignant tumors of the jejunum. Car-
cinoma occurs most frequently in the duodenum and jejunum
and sarcoma in the ileum. The clinical picture of carcinoma
of the small intestine is variable. Biliary obstruction is most
often seen with growths about the papilla of Vater, and intes-
tinal obstruction with neoplasms of the lower duodenum, jeju-
num and ileum. Gross bleeding or occult blood in the stools
is a frequent observation in malignant tumors of the small
intestine. Any patient presenting signs of intestinal obstruc-
tion, change of intestinal habit or melena, in whom studies
have eliminated any pathologic change in the esophagus, stom-
ach, colon or rectum, should be carefully studied to eliminate
the presence of a malignant growth of the small .intestine.
X-ray study with a special barium sulfate series of the small
intestine is generally recognized as the best positive means of
diagnosis but, by itself, is not infallible. Of the twenty-two
patients, eighteen are known to be dead. Of the survivals,
three patients are living and well with no recurrence for periods
of eleven years, three years and less than one year. A fourth
patient was living with no recurrence for one year and has
since been lost to follow-up. The surgeon and the roent-
genologist should look for malignant growths of the small
intestine so that the proportion of cases diagnosed early and
cured may be increased.

West Virginia Medical Journal, Charleston

35 : 399-446 (Sept.) 1 939

Diagnosis and Treatment of Irritable Colon. P. \V. Brown, Rochester,
Minn. — p. 399.

Obstetric Forceps. C. S. Bickel, Wheeling. — p. 404.

Coronary Disease and Coronary Thrombosis. C. G. Morgan, Moundsville.
— p. 408.

•Preliminary Survey on Relation of Physical Defects to Scholastic Stand-
ing. A. C. Woofter, Parkersburg. — p. 413.

Pyloric Stenosis in Infancy. T. G. Folsom, Huntington. — p. 416.
Training for Emotional Health. E. F. Reaser, Huntington. — p. 418.
Pneumococcic Meningitis: Sulfapyridine Therapy, Recovery: Case
Report. P. A. Haley 2d, Charleston. — p. 428. ^

Pneumococcic Meningitis Treated with Sulfapyridine and Specific Serum:
Case Report. I. D. Cole and E. F. Hurteau, Clarksburg. — p. 429.

Physical Defects and Scholastic Standing. — Woofter
studied the relation of diseases and defects to scholastic stand-
ing of 360 unselected students near the same age from various
primary schools. The grades were obtained for the previous
semester and classed accordingly as excellent, good, fair and
poor. A separate list was compiled demonstrating the defects
of each child. In plotting grades of the same number of
students it was found that excellent students were absent an
average of two and one half days while poor students lost
twelve and one tenth days. This observation is again borne
out by contrasting the number of children with infected tonsils
having excellent grades, which is 10.5 per cent, with those of
poor standing, 31.5 per cent. Among 159 students having
norma! tonsils, 18.2 per cent could be classed as excellent and
16.3 per cent as poor. Therefore infected tonsils can be con-
sidered detrimental, if for no other reason than loss of time
from school. One group of 230 students contained 152 with
unclassified defects, minor or major, with an increase of 25.5
per cent among the poor students over those of excellent stand-
ing. Serious eye defects are apparently the greatest scholastic
handicap a student can have, since only 4 per cent having a
visual acuity of 20/40 or worse were excellent students, while
44 per cent had a poor scholastic standing. With normal
vision 16.8 per cent were doing excellent work and 17.6 per
cent poor. Of 231 unselected students, 24.5 per cent of the
excellent students had eye defects as contrasted with 40 per
cent of those doing unsatisfactory school work. Testing with
the Betts eye view apparatus revealed a variation of from 50
to 75 per cent of failures to have defective vision. Malnutri-
tion, that is, a weight of 6 pounds (2.7 Kg.) or more below
the accepted normal for the height and age of that particular
child, cannot be regarded as serious, except that underlying
physical or environmental conditions should be corrected. The
curve for these children is somewhat less satisfactory than the
class average. The relation of deafness to class standing could
not be definitely studied as only sixteen cases were discovered,
hut only a few of these are known to be doing unsatisfactory
work. There was such a small group of children with speech
defects that no conclusions could be reached.

1678

CURRENT MEDICAL LITERATURE

Joint. A. M. A.
Oct. 28, 19J8

FOREIGN

An asterisk (*) before a title indicates that the article is abstracted
oelow. cringle case reports and trials of new drugs are usually omitted.

British Journal of Dermatology and Syphilis, London

51: 343-404 (Aug.-Sept.) 1939

Classification and Definition of Clinical Varieties of Erytliematodes
(.Lupus Erythematosus), with Particular Reference to Its Acute and
Subacute Course. E. Urbach and Carmen C. Thomas. — p. 343.

Use of Sulfanilamide in Streptococcic Dermatoses. J. At, Flood and
J. H. Stokes. — p. 359.

Periadenitis Mucosa Necrotica Recurrens (Sutton); Ulcus Neuroticum
Mucosae Oris (Loblowitz) : Discussion of Condition with Description
of Case. A. G. Fergusson. — p. 366.

Infection of Peacock with Erysipelothrix Rhusiopathiae, Followed by
Case of. Human Erysipeloid. Averil W. Greener. — p. 372.

Gowers’ Case of Local Panatrophy. S. Barnes. — -p. 377.

Chlor-Acne in Railway Workers. H. Haldin-Davis. — p. 380.

Ergotamine tartrate (0.0005 Gm.) given intramuscularly at the
onset of one of her attacks altered the syndrome, as no hemi-
anopia or paralysis of the extremities developed. The headache,
nausea, vomiting and confusion which always accompanied the
attacks were not relieved. The patient is being treated with
estrogenic substance in an attempt to regulate her menses and
also to evaluate, if possible, the effect on the migraine syndrome.

3: 551-592 (Sept. 9) 1939

Genito-Urinary Infection in Childhood. W. Sheldon.— p. 551.
Anesthesia in Dental Surgery. Freda B. Pratt.— p. 555.
Cerebrospinal Fluid in Anterior Poliomyelitis. Joan C. Drury and
A. F. Sladden. — p. 557.

Acute Yellow Atrophy of Liver: Two Cases, with One Recovery'. E
Townsend. — p. 558.

Puerperal Agranulocytosis Following Sulfanilamide Treatment: Record
of Fatal Case. I. K. Gayus, V. B. Green-Armytage and J. K. Baler.
— p. 560.

Sulfanilamide for Streptococcic Dermatoses. — Flood and
Stokes present six cases of severe dermatitis in which cultures
showed hemolytic streptococci in significant numbers. These
cases were treated with sulfanilamide and showed definite
improvement. Hospitalization is indicated for proper treatment
and control of complications. Other etiologlc factors must be
considered and, after the condition is brought under control
with sulfanilamide, they must be dealt with.

British Journal of Ophthalmology, London

33: 505-584 (Aug.) 1939

Intracapsular Extraction of Cataract with Forceps: Is Its Use Justi-
fiable? R. Buxton. — p. 505.

Analysis of Judgment of Relative Position (Preliminary Communication).
P. C. Livingston. — p. 540.

Disablement and Social Conditions of Patients with Past Syphilitic
Interstitial Keratitis. Esther Dalsgaard-Nielsen. — p. 544.

Treatment with “Glaucosan" of Cases of Glaucoma Operated on Without
Success, and of Complicated Cataracts. C. Hamburger. — p. 55 7.

Double Vision After Squint Operation. Alice Sternberg-Raab. — p. 568.

British Journal of Radiology, London

13: 505-568 (Sept.) 1939. Partial Index
Radiographic Demonstration of Circulation Through the Heart in the
Adult and in the Fetus, and Identification of Ductus Arteriosus. A. E.
Barclay, J. BarcroD, D. H. Barron and K. J. Franklin. — p. 505.
Suggestions for Radiodiagnosis of Fractures of Labyrinth: Medicolegal
Importance. C. Chausse. — p. 536.

Intensity of Radiation and Selective Action. _ J. van Roojen. — p. 547.
Rapid and Convenient Method of Checking Kilovoltage in X-Ray
Therapy. D. E. A. Jones. — p. 554.

Radium-Needle Threading Apparatus. R. K. Scott. — p. 559.

Radium Plaque Accessory. R. K. Scott. — p. 562.

British Medical Journal, London

3: 383-432 (Aug. 19) 1939

Varicosities of Veins: Choice of Treatment and End Results. L.
Rogers. — p. 383.

Nervous Disorder After Injury: Review of 400 Cases. J. Ramsay. —
p. 385.

Structure and Functions of Synovial Membrane and Articular Cartilage.

A. G. T. Fisher. — p. 390.

Relation of Anterior Pituitary Gland to Carbohydrate Metabolism. F. G.
Young. — p. 393.

Ocular Reaction to Foreign Protein: Account of Slightly Unusual Case.

T. G. W. Parry.— p. 396.

2: 433-476 (Aug. 26) 1939
Toxic Goiter. C. A. Joll. — p. 433.

Postpartum Hemorrhage, with Special Reference to Partial Detachment
of the Placenta. R. M. Corbet. — p. 438.

Preoperative and Postoperative Treatment of Hepatobiliary Diseases.

B. O. C. Pribram. — p. 441.

Nephrectomy with Partial Resection of Other Kidney. R. C. Begg. —
p 445.

♦Alternating Hemiparetic Migraine Syndrome. J. B. Dynes. — p. 446.

Alternating Hemiparetic Migraine Syndrome— Dynes
records the cases of a mother and daughter who suffered from
migraine and paralysis on the side opposite to that of the head-
ache. They usually were warned of an approaching attack by
prodromes : general malaise and chilliness. The attack itself
was ushered in by numbness, tingling, marked weakness and loss
of power in the arm and leg opposite to that of the headache.
The migraine was not always on the same side, but the paral-
ysis was always on the side, opposite to it. Three years ago,
at the age of 46, the mother was treated with radium for a uterine
carcinoma. Her menses stopped. She has had no migraine
headaches since and is in fairly good health at the present time.
The daughter has noticed that a severe migrainous headache
seems to be precipitated whenever her menstrual period is irreg-
ular and runs over the usual interval of twenty-eight days.

Postoperative Treatment of Appendicular Peritonitis with Sulfanilamide
and Its Derivatives. D. C. Corry, A. C. Brewer and C. Nieol.—
p. 561.

Acute Yellow Atrophy of Liver. — The two cases of acute
liver atrophy that Townsend cites present certain features in
common. Both occurred in puerperal women, in both a small
amount of chloroform had been given and in each case the onset
of symptoms had been preceded by vomiting with restricted
food and fluid intake. In the first case the period of restricted
intake was three days, but it was at a time when a great deal
of energy was being expended and the extent of the diminished
intake and its significance were not appreciated at first. In
the second case diet had been restricted for three weeks because
of preeclamptic toxemia, and fluid intake had been minimal for
twenty-four hours following induction of labor, because of post-
anesthetic vomiting. Each patient was partially exhausted and
believed to have been partially dehydrated, though not to a
degree recognizable clinically, and was given chloroform, a sub-
stance highly toxic to liver cells. The dangerous potentialities
of chloroform in this respect have been shown by the work of
Whipple and Sperry, Opie and others. It is suggested that
these facts have an important bearing on the etiology of acute
yellow atrophy : that exhaustion and dehydration are predispos
ing factors to hepatic damage, that a patient who is vomiting
and dehydrated from whatever cause should be regarded as a
potential candidate for hepatic atrophy, and that the adminis
tration of any protoplasmic poison or drug known to affect
cells of the liver be done with extreme caution, prefera y
preceded by saline dextrose intravenously. These cases a so
emphasize the importance of maintaining the strength an
intake of women during prolonged labor. Recovery o
second patient is attributed to the use of dextrose and a un
fluids and it is believed that the early and energetic use
dextrose and fluids is of prime importance in the treatmen
acute yellow atrophy.

Sulfanilamide for Appendical Peritonitis and Absces .
—Corry and his colleagues report the results obtamea ,
sulfanilamide in the treatment of twenty-six cases 9 ® ...

peritonitis (with a mortality of 11.5 per cent) and s

of appendical abscess with no deaths. These for y o
came from a series of 232 cases of appendicitis an^ ^ ^

peri-
had

deaths gave a mortality rate of only 1.1 per cent.
patients who died, only one at necropsy still had a
tonitis of the lower part of the abdomen and this pa .j_
been given what is regarded as an adequate dose
amide. When toxicity due to sulfanilamide occurs, '
must be stopped. In several cases anaerobic an a
organisms were present in the peritoneal cavity. . re in

amide has been of value against these organisms e ^

the body, it is reasonable to suppose that it was o
in appendical peritonitis.

Edinburgh Medical Journal

46.- 509-580 (Aug.) 1939 ^ Brt3S ,

Some Reflections on Pathogenesis ant! Treatment of Cancer

T. Fraser. — p. 509. _ vf.tastaser- 1* * ’

Radiologic Treatment of Breast Cancer and Its

Maisin. P. Estas and D. Line.— p. 529. _ Vitro s-" 3

Effect of p-Aminobenzene Sulfonamide on Various B

in Vivo. R. Knight.— p. 542. . . , rj,f, r ence to -A 3 - 1

Pulmonary Tuberculosis in Children, with Special

Types of Disease. J. A. Wilson, p. 536. Results of Tie 3 -

Tuberculosis of Lungs in Childhood: Problems and Resu.
ment. C. Cameron. — p. 565.

Volume 113
Number 18

CURRENT MEDICAL LITERATURE

1679

Glasgow Medical Journal

14:1-44 (July) 1939

Chemotherapy of Pneumonia by Sulfapyridine in Practice. J. Macrae.
— p. 1.

Nomograms for Hematologists. G. H. Bell. — p. 16.

14: 45-96 (Aug.) 1939

Personal Experiences in Vascular Surgery. J. IP. Pringle. — p. 45.
'Hemochromatosis: Two Cases. A. W. Harrington and Anne C. Aitken-
head. — p. 61.

Hemochromatosis. — Harrington and Aitkenhead report two
cases of hemochromatosis; one came under observation because
of diabetes and the other because of hematemesis. Lawrence
has recorded a pedigree whicli suggests that hemochromatosis
may be a sex-linked hereditary disease, transmitted by women,
and affecting men mostly. However, the authors state that in
their cases there was no suggestion of familial incidence. The
blood copper was normal. The only certain etiologic {actor
was alcohol, in which both had indulged freely. The woman
patient had a large cirrhotic liver with moderate ascites, and
a severe diabetes with little tendency to acidosis. The man, who
also had a large firm liver and marked diabetes, had two fairly
severe attacks of hematemesis but no ascites. Pigmentation was
marked in both and appeared to vary in intensity from time to
time. The prognosis is said to be uniformly bad but the intro-
duction of insulin may prolong life. Of the present patients,
the man is working as a commercial traveler. The woman,
who was in poor social circumstances, kept very well, with no
recurrence of ascites until she contracted septic complications
which caused her death.

Journal of Laryngology and Otology, London

54: 443-530 (Aug.) 1939
Otogenic Meningitis. T. Cawthorne. — p. 444.

Journal of Physiology, London

96: 233-366 (Aug.) 1939

Respiratory Accelerator Action of Carotid Sinus-Cardiac Depressor
Mechanism. Ruth C. Partridge.— p. 233.

Further Observations on Release of Histamine by Skeletal Muscles.

G. V. Anrep, G. S. Barsoum, M. Talaat and E. Wieninger.— p. 240.
Use of Dietary Anestrous Adult Rat for Assay of Estrus-Inducing
Gonadotropic Substance. R. D. H. Heard and S. S. Winton. — p. 248.
Acetylcholine Synthesis in a Sympathetic Ganglion. G. Kahlson and

F. C. Macintosh. — p. 277.

Apparent Augmentation of Pituitary Antidiuretic Action by Various
Retarding Substances. R. L. Noble, II. Rinderknecht and P. C.
Williams. — p. 293.

Central Action of Anticholinesterases. A. Schweitzer, E. Stedman and
S. Wright. — p. 302.

Effect of Hydrogen Ion Concentration on Stability of Antidiuretic and
Vasopressor Activities of Posterior Pituitary Extracts. H. Heller, —
p. 337.

Peripheral Action of Tetanus Toxin. A. M. Harvey. — p. 348.

Lancet, London

»: 549-580 (Sept. 2) 1939

'Trauma and Progressive Muscular Atrophy. J. W. A. Turner. — p. ^549.
Treatment of Fractures by Local Anesthesia. H- Cullumbine.— p. 552.
Urethral Obstruction Following Prostatectomy. S. Power. — p. 553.
Accidental Transmission of Malaria to a Child by Injection of Blood. D.

Nabarro and D. G. F, Edward. — p. 556.

Surgical Treatment of Facial Paralysis: Review of Forty-Six Cases.
# W. M. Morris. — p. 558.

"Picrotoxin in Treatment of Barbiturate Poisoning. J. L. Lovibond and

G. C. Steel. — p. 561.

Trauma and Progressive Muscular Atrophy. — Turner
says that the part played by trauma in the initiation of progres-
sive generalized nervous diseases becomes occasionally subject
to dispute in relation to workmen’s compensation. In view of
the lack of data derived from any notable series of cases, it
seemed to him worth while to analyze a series of cases of
progressive muscular atrophy to find out in what proportion
a history of trauma exists. The term progressive muscular
atrophy is taken to include amyotrophic lateral sclerosis and
Progressive bulbar palsy with muscular atrophy. The author
studied a series of 100 consecutive cases. In thirty-seven cases
there existed signs of progressive degeneration of the bulbar
nuclei associated with generalized muscular atrophy and fibril-
lation cither with or without evidence of involvement of the
Pyramidal tracts. Forty patients presented progressive muscular
wasting associated with evidence of involvement of the pyramidal
^act. Widespread muscular wasting and fibrillation of the
classic type of progressive muscular atrophy without involve-
mc "*- of the pyramidal tract was observed in nineteen cases.

Postmortem confirmation of the diagnosis was obtained in four
cases. For purposes of control a second series of 100 cases of
other organic nervous' diseases were analyzed. These 100 cases
included patients of the same age groups and sex groups suffer-
ing from various organic diseases of the nervous system in
which trauma is not thought to be an etiologic factor. A table
records frequency of trauma in the two groups of 100 cases.
There was no history of trauma in seventy-nine cases of the
group with progressive muscular atrophy and in seventy-eight
cases of the control group. Thus the total number of cases
with a history of trauma was practically identical. It was only
when an arbitrary period of a year was taken that a small
difference in favor of the group with progressive muscular
atrophy was apparent. In five of the cases of progressive mus-
cular atrophy there was a history of injury within a year of
the first symptom, and in three of these the injury was within
a month of it. The author reports the details of these five
cases. He reaches the conclusion that trauma has no primary
part in the causation of the disease but in a small minority of
cases seems to precipitate the appearance of symptoms.

Picrotoxin in Treatment of Barbiturate Poisoning. —
Favorable reports on the use of picrotoxin as a physiologic
antidote for barbiturate poisoning induced Lovibond and Steel
to try this method in a case of poisoning of this type. The
results which they obtained with the treatment were so striking
that they feel justified in reporting the case. A woman aged 35
had been found unconscious in bed in the morning, having prob-
ably been in coma since the preceding night. The diagnosis of
barbiturate poisoning was made from the clinical appearance
of the patient and was afterward confirmed by the identification
of this substance in the cerebrospinal fluid (cobalt nitrate and
Millon’s tests positive). On admission she was in a deep coma,
collapsed and failing to respond to any form of stimulus. Until
it was possible to obtain the picrotoxin some three hours later,
the routine treatment for hypnotic poisoning was initiated. This
consisted of gastric lavage, lumbar puncture, intravenous saline
solution and intranasal oxygen. However, no significant change
was observed in the patient's condition and she was still in deep
flaccid coma when the treatment by picrotoxin was started. This
was given by intravenous injection in divided doses of 2 cc. of
a 0.3 per cent solution. The picrotoxin was at first given
intermittently for two hours until the patient had been fully
stimulated into effectual restlessness. For the next ten hours
it was discontinued until a gradual relapse required a further
18 mg. In the intervening hours and subsequently, until 10 p. m.
two days later, 4 cc. of coramine (a 25 per cent solution of
pyridine betacarbonic acid diethylamine) was injected intra-
venously at two hour intervals. A total of 54 mg. of picrotoxin
and 112 cc. of coramine was given. The effect of the picrotoxin
after every injection was dramatic and obvious, whereas no
remarkable result was evidenced at any time from the coramine.
The problem of dosage remains controversial but it seems that
far larger therapeutic doses are both possible and safe. The
authors gained the impression from this case that if it had been
more severe they could with impunity have given larger doses
of the drug. Intravenous picrotoxin should be given continu-
ously until spontaneous movements, restlessness and a substan-
tial decrease in the coma are apparent. After this, intramuscular
injections may be sufficient to sustain the stimulatory effect.
As a precautionary measure, barbiturates such as evipal or
pentothal should be kept ready as a rapid antidote to an over-
dose of picrotoxin.

»: 581-628 (Sept. 9) 1939

Acute Rheumatic Carditis. W. T. Ritchie. — p. 581.

•Familial Adenomatosis of Colon and Rectum: Its Relationship to Cancer.

J, P. Lockhart-Mummery and C. E. Dukes. — p. 586.

•Bacteremia Following Tonsillectomy. S. D. Elliott. — p. 589.

Production and Prevention of Cardiac Mural Thrombosis in Dogs. D. Y.

Solandt, R. Nassim and C. H. Best. — p. 592.

Monocytic Angina (Glandular Fever) Treated with Sulfapyridine:

Report of Case and Experimental Transmission. H. S. Stannus and

G. M. Findlay. — p. 595.

Familial Adenomatosis of Colon and Rectum.— During
the last fourteen years, Lockhart-Mummery and Dukes observed
the course of adenomatosis of the colon and rectum in ten
families whose histories convincingly demonstrate the general
familial character of the disease and its close relationship to
cancer. The starting point in each case was a person with
adenomatosis. As complete a family history as possible was

1680

CURRENT MEDICAL LITERATURE

obtained from the patient, information being asked particularly
about the present health or cause of death of parents, grand-
parents, uncles and aunts. Almost invariably the patient was
aware of the high incidence of death from intestinal cancer
among his relations. As many of the surviving relations were
seen as was possible and sigmoidoscopic examinations were
carried out. It was impossible to find out whether or not
deceased relations dying of cancer had also been affected by
adenomatosis. Probably in most cases the fatal cancer was
secondary to adenomatosis. Although this disease is familial,
it does not manifest itself as a rule before childhood or puberty.
The age at which adenomas begin to develop varies in different
families. In twenty cases the average age at which adenomas
were discovered was 22. The tumors were probably present
for at least a year or two before they were discovered; so the
average age at which adenomas developed may be taken as
about 20. In two families recently investigated by McKenney
(1936) the average age was 19(4 years. Malignant disease
secondary to adenomatosis is characterized by its early onset
and the fact that more than one primary focus of carcinoma
may be present. Among the general population it is rare for
cancer of the rectum or the colon to develop before 40 to SO,
but in families affected by adenomatosis it often begins to
develop between 30 and 40 or even earlier. The age of death
from cancer in adenomatosis families is also younger (42 years)
by about twenty years than in the general population. As a
rule in families affected by adenomatosis the tumors begin to
develop at about 20 years of age, malignant changes may be
expected about fifteen years later and untreated patients die
from cancer in the early forties. From an observation of the
genealogical tables it is seen that the disease may be trans-
mitted by either sex. In most cases only one parent was
affected. In two instances there is evidence that both husband
and wife died of cancer and in most of the descendants adenomas
developed at an early age. In one family having twins, symp-
toms of adenomatosis developed in both twins at about 30 years
of age. One was treated by colectomy at the age of 41 but
died from the operation. His twin sister died of intestinal
cancer also at 41. The familial character of adenomatosis is
not congenital in the ordinary sense of the word, since it does
not manifest itself for several years; but it is certainly due to
an inherited defect, and the most likely explanation seems to be
that it is caused by a gene mutation. Evidence is steadily
accumulating that tumors are the result of a genetic change in
a normal growing somatic cell. This explanation is applicable
also to adenomatosis, in which disease the genetic defect appears
to be a tendency to a more rapid growth of the intestinal
mucosa, leading first to hyperplasia and later to adenomas.
Because of the more rapid growth of the intestinal epithelium
there must be a greater frequency of mitotic division, and this
again increases the probability of a further gene mutation which
manifests itself as cancer. In a rapidly growing adenoma the
chance of this happening is much greater than in normal mucosa,
in which mitosis takes place only at comparatively rare inter-
vals. The explanation suggests that familial adenomatosis is
the result of an inherited instability of the epithelial cells of
the large intestine, which renders their nuclei peculiarly liable
to undergo mutation for excessive rate of growth. The treat-
ment of adenomatosis presents a difficult problem. Constant
medical supervision is necessary so that a radical excision may
be undertaken as soon as a malignant change is detected.

' Bacteremia Following Tonsillectomy.— Elliott noticed a
transient bacteremia in thirty-eight of 100 patients within a few
minutes of tonsillectomy. Bacteria were found m the blood
regardless of whether the tonsils were removed by blunt guil-
lotine or by dissection. The organisms, isolated included
•Streptococcus pyogenes, Streptococcus viridans, Streptococcus
pneumoniae, Haemophilus influenzae, staphylococcus and coryne-
bacterium Serologic matches for Streptococcus pyogenes
recovered from the blood were isolated from the correspond-
ing tonsils after their removal. Hemolytic streptococci were
recovered from the tonsils of eighty-seven of 137 patients under-

lain. A. J[. A.
Oct. 28, 191)

animals and the possible bearing of these observations on the
etiology of subacute infective endocarditis are indicated by the
foregoing observations. Occasionally the causal organism in
subacute infective endocarditis is of the hemophilus or para-
hemophilus group and that these organisms may be found in the
blood after tonsillectomy is indicative. Of equal interest is the
observation that pathogenic organisms such as Streptococcus
pyogenes may circulate in the blood for short periods and in
small numbers without producing any observable ill effect. The
results of the tonsillar cultures here recorded suggest that some
60 per cent of patients admitted to the hospital for tonsillectomy
carry Streptococcus pyogenes in the throat. Most of these
patients had diseased tonsils, although it was not customary to
admit cases for tonsillectomy within six weeks of an attack of
tonsillitis. A carrier rate of about 60 per cent among patients
admitted to the hospital for tonsillectomy emphasized the risk
in otorhinologic wards of streptococcic cross infection, which
a previous inquiry has indicated as happening not infrequently
in the absence of special preventive measures (Okell and Elliott,
1936).

Medical Journal of Australia, Sydney

2: 267-302 (Aug. 19) 1939

-Inquiry into Effects of Occupation on Pulmonary Condition of Stone
Masons. K. R. Moore and C. A. Kuhlmann, — p. 267.

Acute Cholecystitis: Study of Series of Cases in Which Consemtive
Methods of Treatment Were Used. V. M. Coppleson. — p. 274*
Portable All-Purpose Anesthetic Machine. A. D. Morgan. — p. 284.

Pulmonary Condition of Stone Masons.— Moore and
Kuhlmann determined the clinical and roentgen pulmonary con-
dition of 355 employees in the stone mason allied industries in
New South Wales, Victoria and South Australia. This
been accompanied by inspection of working conditions and t c
taking of dust counts. The existence of industrial pulmonary
fibrosis of two distinct types was revealed, as well as evidence
of other more acute respiratory disorders which may be the
result of occupational conditions. Of 268 masons examined,
were found to be suffering from pulmonary fibrosis of modern e
or advanced degree or from tuberculosis. This quota compos
seventy-nine cases of moderate fibrosis of the diffuse )P
(pneumoconiosis), thirteen of advanced fibrosis of similar yP >
eight of advanced fibrosis of silicotic type, two of pulinona
fibrosis complicated by active tuberculosis and one case o ac
tuberculosis only. The remaining cases were of doubtful “
culous lesions, either alone or complicating a fibrosis. *
of moderate fibrosis were not associated with incapacitation
work. Of the eight cases of silicosis detected, all **jep ^
were found among workers in sandstone, which has a mg
tent of free silica (from 86 to 95 per cent). Workers ian “
this stone were found to develop fibrosis earlier and in a ^
severe form than those using granite or other ston ^, ' •
low free silica content. The incidence of pulmonary 1 r ^ ffS
marble and limestone workers was very low. , Groups o « ^

examined, other than masons, including polishers an s
were relatively small; but there is evidence to show ^
disease develops among these workers. An apparei
incidence of emphysema and old or recent pleurisy was
by the roentgenograms.

New Zealand Medical Journal, Wellington

28 : 231-300 (Aug.) 1939 yf sc ler^

•Symptoms and Diagnosis of Cancer of Body of Uterus. - * ^

Morbid Anatomy and Treatment of Cancer of Body

Chapman. — p. 238. . r PoH‘ 3 '~

Pact ©rs Which Govern Proper Nutritional Manage

Normal Lead 4F in Electrocardiography. J. < T° U vi.,V":Zedand L
Incidence and Prevention of Hydatid Disease n _

Barnett.— p. 256. Report of C**-

going tonsillectomy (64 per cent). Of forty-four cultures of
streptococci so isolated and examined serologically, thirty-nine
(86 per cent) belonged to group A, one to group B, one to

' r (T mrefield') and three could not be typed. The source „ - - ,

for the common occurrence of transient bacteremias in man and is no enlargement, but there may be

xsarncii. — p. . T

Diabetes Mellitus Associated with Diabetes insipidus-
G. E. Moloney. — p. 263.

Physiology of Water Balance. N. L. Edson.— V- JJespi K

Symptoms and Diagnosis of Uterine ^.”“ r ^[ aC kenE'-
the rarity of cancer of the uterus without ()C fyr.t

declares that it is imperative that curettement spCCU !in
in all cases of leukorrhea in which it is seen > cCrv ;sj
that watery or purulent discharge is coming 1 r n0 vis'

canal. The size and consistency of the utm r a ^ t htf«

bearing on the diagnosis of uterine cancer. usual!)' oi 3

td-rwnmont h„t there mav be enlargement,

Volume 113
Number 18

CURRENT MEDICAL LITERATURE

1681

uniform character, up to several times the normal size of the
uterus. The mistake that the author has seen made has been
in cases of enlargement of moderate degree in which a diagnosis
of fibromyoma has been made, not corrected at operation, and
supravaginal hysterectomy carried out at a level too near to
the tumor for safety. He does not discuss the symptoms of
advanced cases of uterine cancer. He believes that while the
course which a disease runs should be sketched out for the
student, the symptomatology of early disease only should be
stressed and emphasized. Oversight in the diagnosis of cancer
may be self excused on the ground that there were no pain, no
ill smelling discharge and no deterioration of general health.
The points of cardinal importance are that (1) irregular bleed-
ing is the dominant symptom of carcinoma of the uterus, (2)
such bleeding, at any age, must not be treated symptomatically
and (3) the curet and the microscope must be used in diagnosis.

Practitioner, London

143: 237-356 (Sept.) 1939

Rheumatic Problem: Plea for National Campaign Against Rheumatic
Diseases. L. S- P. Davidson. — ]>. 237.

Diagnosis and Treatment of Chronic Articular Rheumatism. F. D.
Howitt. — p. 246.

Diagnosis and Treatment of Fibrositis and Neuritis. A. R. Neligan. —
p. 263.

Diagnosis and Treatment of Trunk Sciatica. J. B. Burt. — p. 275.
Orthopedic and Surgical Aspects of Chronic Rheumatism. A. G. T.
Fisher. — p. 286.

Laboratory Investigations in Chronic Rheumatism. J. W. Shackle.—
p. 297.

The Abortion Report. J. Young. — p. 309.

•So-Called Obstetric Shock. C. D. Lochrane. — p. 317.

Advances in Medical Treatment of Congenital Pyloric Stenosis. R.
Lightwood. — p. 326.

Modern Therapeutics: III. Calcium in Therapeutics. N. Morris. —
p. 333.

So-Called Obstetric Shock. — An increased susceptibility to
shock, Lochrane points out, is characteristic in labors associated
with most of the toxemias of pregnancy. These conditions are
held to be due to the circulation of incompletely disintegrated
protein substances of fetal or maternal origin in the maternal
blood. There is a toxemic influence in the development of the
shock-collapse picture in the majority of instances. The cause
of the shock not infrequently reported to follow a supernormal
degree of hemorrhage in obstetrics as in other more general
conditions may not, at first sight, seem to be explained on the
foregoing suggestions, as, in obstetric instances at least, hemor-
rhage is by no means invariably associated with gross trauma
or pregnancy toxemia. The obstetric conditions with which the
shock-collapse syndrome is most often associated (e. g. toxic
accidental hemorrhage, placenta praevia, acute inversion of
uterus, manual removal of placenta) emphasize the fact that
trauma and toxemia in some, and trauma or toxemia in others,
is incidental in greater or lesser degree to labor associated with
such abnormalities. A distinction between the preliminary or
primary shock phase and the secondary collapse phase of the
shock-collapse syndrome appears to be justified in obstetrics.
The percentage incidence of fatal degrees of shock in obstet-
rics is not large in comparison with the total incidence of the
condition. In the absence of gross trauma, lesser degrees of
primary shock of a more or less temporary nature may arise
from some minor operative intervention such as the giving of
a rather hot intra-uterine douche or the lifting of the fetal head
over an intact perineum. The opinion may be hazarded that
in these temporarily shocked cases there is a nerve center dis-
turbance with little or no subsequent traumatic toxemia. In
many of the more profound cases of obstetric shock the patient’s
condition may improve temporarily in an hour or so without
oi^jor resuscitative measures, only to relapse into a worse state,
the early nervous phase having been succeeded by the later
toxic collapse. The observation that shock may be experienced
after minor interventions without demonstrable gross trauma,
undue hemorrhage or pregnancy toxemia in obstetric conditions
provides the conclusion that, quite apart from any of these
predisposing complications, there is an intrinsic variation in
the degree of susceptibility of different individuals to shock.
This seems to apply to both phases of the condition. At times
there arc obstetric patients in whom the degree of shock experi-
enced is ' out of all proportion to apparent stress of labor.
Here, if anywhere, there is a justification for the use of the
term “obstetric shock” in a particular and restrictive sense.

In obstetrics there are other complicating conditions usually
present which may well accentuate or even replace hemor-
rhagic and traumatic factors in producing a predisposition or
an undue susceptibility to shock-collapse effects. Some of these
are acidosis, a lowered carbon dioxide content of the blood,
the extreme expenditure of muscular energy', waste products
from muscular contractions and the blood-carbon dioxide reduc-
ing effect of most forms of inhalation anesthetics. It was
shown by Yandell Henderson and later by Cannon that the
fall in blood pressure which is a feature of shock is coincident
with the lowering of the carbon dioxide content of the blood.

Bull, of Health Org., League of Nations, Geneva

8: 1-386 (Nos. 1 and 2) 1939

Report on Work of Health Organisation Between June 1938 and April

1 939 and on Its 1939 Program. — p. 1.

Skeleton Standard Report on State of Health of Population and Factors

Influencing It. — p. 63.

Rural Housing and Planning. — p. 87.

‘Leptospiroses. B. Walch-Sorgdrager. — p. 143.

Leptospiroses. — In an extensive review on the subject of
leptospiroses, Walch-Sorgdrager declares that the study of the
disease was placed on a sound basis only when the specific
cause was discovered by' Inada and Ido, who transmitted the
disease experimentally to guinea pigs in 1913 and discovered
the spirochete which they called Spirochaeta icterohaemor-
rhagiae in 1914 and demonstrated that it is the actual cause
of the disease. However, Weil’s disease is not the only form
of human leptospirosis. In Europe, but more especially in
other continents — first in Japan and later in the Netherland
East Indies, Federated Malay States, Russia, Andaman Islands,
Netherlands and Australia — diseases have been desaribed which
are more or less related to it, though occasioned by other
leptospirae. The several forms in man, and those occurring
in dogs, rats and other rodents, are discussed in some detail.
The author also discusses the epidemiology of icterohemor-
rhagic leptospirosis in man and its clinical features, including
incubation, clinical symptoms, complications, diagnosis, prog-
nosis and treatment. Measures for the prevention of lepto-
spirosis have been chiefly applied in countries in which the
disease is prevalent, such as Japan, and also in countries in
which it is not frequent but causes local epidemics, for example
in slaughterhouses, baths and among sewermen and sugar-cane
cutters. Some of these procedures are the prevention of con-
tamination of the ground and surface water with rat urine,
the destruction of leptospirae in nature and the protection of
workers in infected districts by preventing the organisms from
penetrating through the skin or mouth. In places in which
drainage and other measures are impossible or when the
infected district is too large for disinfection to be effective,
vaccination should be resorted to, for example in factories,
mines, slaughterhouses, in instances in which the ratproofing
of buildings is too costly or deratization is ineffective, on sugar
plantations (on some Australian plantations the annual inci-
dence of the disease among cane cutters sometimes reaches 18
per cent) and among sewer workers. When the risk of infec-
tion is limited to an occupational group, vaccination becomes
practical. By immunization laboratory infections, where con-
tact with rats is frequent and infections sometimes prove fatal,
may be avoided. Wani mentions that he inoculated 10,268
miners in a coal mine in Fukuoka, 2,259 of whom received
only' one injection. The vaccination generally caused only'
slight discomfort: 50 per cent were able to continue working,
33 per cent lay off for one or two days and a slight rise of
temperature or at least a complaint of a local feeling of
warmth was experienced by from 30 to 40 per cent of the
miners. Inoculation with other kinds of leptospirae than that
causing Weil’s disease, which are not in themselves dangerous
to life (such as the leptospirae of “mud fever" or nanukayami)
is of no valucj as their immunizing properties, if any, are
insignificant against Weil’s infection. These kinds of lepto-
spirae produce pathologic conditions, which arc undesirable
accompaniments of preventive inoculation. It is preferable,
even essential, to vaccinate only with killed cultures. Health
education and propaganda (films, lectures and the like) and
compulsory notification arc obvious necessities for an earlier
recognition of cases as well as the stamping out of epidemic
outbreaks.

1682

CURRENT MEDICAL LITERATURE

Presse Medicale, Paris

47: 1277-1284 (Aug. 23) 1939

‘Anorexia Nervosa and Its Immediate Therapy. P. Chatagnon and P.

Seherrer. — p. 1277.

Anorexia Nervosa. — Chatagnon and Seherrer discuss the
symptomatology and therapy of anorexia nervosa. Persons
affected are generally women between the ages of IS and 25
years. The clinical picture presents the following features:
gradual self restriction of food leading to extreme emaciation,
with a possible decline from a weight of 132 pounds (60 Kg.)
to SS pounds (25 Kg.) ; excessive physical and mental activity
in striking contrast with the physical deterioration ; the growtli
of bizzare, onesided gastronomic tastes, e. g. for prunes, biscuits,
olives, unseasoned salads and so on ; complete apathy in the face
of bodily degeneration. Food forcibly administered is rejected
by self-induced exertions. Amenorrhea is present. Usually
there is found a neuropathic heredity and an unfavorable family
environment provoking, on occasion, an inferiority complex
toward a successful member of the family of the same sex. In
certain cases the psychosis may be prodromal to dementia prae-
cox; the majority of the patients develop conditions bordering
on obsession. The occurrence of death is exceptional; however,
some investigators set the mortality rate at 13 per hundred.
Relapse after recovery is always possible. The authors discuss
and reject the various views of others of the nosologic classi-
fication of anorexia nervosa within the framework of an estab-
lished neurosis; neither do they favor an endocrine etiology of
the disease, in spite of parallel indications simulating anorexia
nervosa. They differentiate particularly between anorexia
nervosa and Simmonds’ syndrome. In Simmonds* syndrome
emaciation .develops gradually without an appreciable food
diminution or, in its incipience, with none at all ; there is present
only a simple loss of appetite or distaste for certain foods, which
the patient may seek to overcome and for which the metabolic
dysfunction of his organism penalizes him by diarrhea; mental
disorders are late, characterized by melancholia and unaccom-
panied with physical self neglect. On the other hand, in anorexia
nervosa emaciation is the direct result of a food refusal that
excludes all cooperation of the patient to improve his condition,
the patient not only forcibly resisting alimentation but deliber-
ately regurgitating what he has consumed; mental disturbances
are immediate and compatible with a high degree of alert
activity. Even amenorrhea is of a secondary nature in anorexia
nervosa. According to the authors, therapy consists in isolating
the patient in a sanatorium or hospital, in artificial alimentation
and in psychotherapy, to the exclusion of medicaments of all
kinds. Therapy will vary according to whether the patient is
in an advanced or an incipient stage of the disease. Artificial
alimentation in both classes of patients consists, with due regard
to the age of the patient, of two daily doses, preferably of raw
sweet milk with the addition of the yolks of one or two fresh
raw eggs, together with fresh fruit juices (lemon, orange and
so on). To restore tissue balance, from 250 to 500 cc. of dex-
trose solution is daily administered subcutaneously for a variable
period and occasionally physiologic solution of sodium chloride.
Reeducation of the patient in the use of his muscles needs also
to be done. In cases presented at once for clinical study, psycho-
therapy should be employed immediately and should enlist also
the cooperation of the family physician. Readjustment of the
patient to social and family environment after her release from
the institution constitutes a problem.

Jobs. A. 1!. A.
Oct. 28, 1919

arteriosclerotic changes in the vessels of youthful individuals
with adenomas of the medulla or tumors of the cortex of the
adrenal capsules and in Cushing's disease usually accompanied
with . hyperplasia of the cortex ; degenerative changes in the
arterial muscular layers of animals corresponding to media-
sclerosis, produced by protracted injections of epinephrine;
increased infiltration of cholesterol in the intima of the aorta
of rabbits following administration of epinephrine; a tissue
cholesterol fixing faculty of the cortex hormone; changes pro-
duced in the vessels by repeated implantations of the entire
substance of the adrenal capsules, which however do not quite
correspond to typical arteriosclerosis. Recent research drew the
attention to the close morphologic, functional and even physical
and chemical connections between the products of secretion of
the medulla and the cortex of the adrenal gland. Investiga-
tions on the constrictive effect of lipoid epinephrine compounds
directed Raab’s attention to the problem of a lipoid-epinephrine
complex presumably formed in the adrenal capsules and the
characteristic way in which it affected the structure of the ivail
of the artery. He carried out experiments on groups of animals
with lipoid epinephrine complexes obtained from the adrenal
capsules of animals and from the serum of persons with arterio-
sclerosis and hypertonia, assuming that the lipoid epinephrine
complex should likewise be present in the serum. The extracts
did not contain free epinephrine or cholesterol and produced the
following effects in experimental animals: increase of blood
pressure; increase of blood sugar; general nervous irritation
such as trembling, nervousness, eventually edema of the lungs
and death ; injury of the media of the aorta, such as necrosis and
calcification; injury of the intima, such as loosening and thicken-
ing, and an increased deposit in the intima of cholesterol ingest™
with food. As to the modifying effect of lipoids on the epi-
nephrine in the lipoid-epinephrine complex, a satisfactory chemi-
cal explanation is not available at present. On the basis o
these results as well as numerous clinical, pathologic and ana
tomic data the following factors appear to be of importance in
the etiology of arteriosclerosis: prolonged action of an adrena
capsule lipid epinephrine complex on the vessel wall ; profrac e
ingestion of food with large amounts of lipoids and choles cr
in particular, whose deposit is increased by the adrenal capsu
lipoid epinephrine complex; disposition of the vessels o
attacks of these injurious agents. According to the mother,
frequent simultaneous occurrence of arteriosclerosis, hig ^
pressure and diabetes can perhaps be explained by the ac 10
the adrenal capsule lipoid epinephrine complex.

Bibliotek for Laeger, Copenhagen

131:323-333 (July) 1939 - sttia .

•Measurement of Venous Pressure in Thoracoplasty Patients.

— p. 323. ^ h 1 t£S

Venous Pressure After Thoracoplasty. Stein ( a 1 “
the results of his bilateral determinations of the vc nc ’j’f ses sioti
of forty-six patients, thirty-six before and after the
of thoracoplasty, twenty-two of these also before an . j( j c
second session, seven patients before and after repea
operation several years after the first operation,

patient

with

Zeitschiift f. d. ges. experimentelle Medizin, Berlin

105:657-783 (June 21) 1939. Partial Index
•Adrenal Capsule Lipoid Epinephrine Complex and Formation of Arteri-

osclerosis. W. Raab. — p. 657. , , Tr T7 .

Bactericidal Effect in Urine of Certain Constituents of the uva Ursu

G. Madaus and F. E. Koch. — p. 679.

Hydrostatic Pressure Action of the Bath on Circulation of the Blood.

H. -J. Heite and E. Lerehe.-— p. 693. • - n .

Kinetics of Extrahepatic Bile Duct System. R. Bayer.-— p. 702.

Quantitative Examinations of Ascorbic Acid Content of Endocrine Organs

as Measuring Stick of Their Function. H. Winkler.— p. 723.

Effect of Various Kinds of Paprika on Kidney and Urinary Passages.

Margarete Raunert. — p. 736.

Arteriosclerosis and Adrenal Capsule Lipoid Epineph-
rine Complex.— A dose connection between the formation of
arteriosclerosis and the functioning of the adrenal capsules has
been frequently assumed, based on the following observations :

with thoracoplasty according to Monaldi, one l '“~"
plombierung and one operated on for pulmonary a ’ {

drainage; the conditions which might be assume o p ^ ^
in the venous pressure are also noted. In the maj 5UJC(
cases operation was followed by a rise in the veil becoming
usually brief, the venous pressure in thirty-one cas £ w as
normal on from the seventh to the seventeenth ay. vcnoU ;
no definitely established relation between the heigh increased
pressure and the operative course. Preoperativ ) ; n( jj ca tion
venous pressure, the author says, is not always
that operation will not be well borne. Theoretics y ^
the postoperative increased venous pressure to c a re gion,
thoracal pressure and stasis in the vena cava so mc pises
but he thinks there may also be other causes , c )ectro-

heart disease may be at least partly responsi > j - 3C( fJ-jt

cardiographic changes were often observed, a jj, c blood

in most of the cases there was a considerable ; n the

pressure during the operation might pom
peripheral circulation as a factor.

THE STUDENT SECTION

of tlie

Journal of the American Medical Association

Devoted to the Educational Interests and Welfare of Medical Students, Interns and Residents in Hospitals

SATURDAY, OCTOBER 28, 1939

Organization of the Small Hospital Library

WILLIAM D. INLOW, M.D.

SHELBYVILLE, IND.

From time to time the American Medical
Association 1 through the Council on Medical
Education and Hospitals issues suggested lists
of medical books and journals suitable for hos-
pital libraries. Such libraries are now required
in all institutions approved for the training of
interns and for graduate study in the specialties.
The library requirements of the private clinic
and of various medical associations are similar
to those of the hospital and can be considered
with them. The Council in its recommendations
discusses the organization of such a library only
in the briefest way, leaving aside entirely the
problem of - the classification of the collection
which would accrue if their suggestions should
be followed.

The needs, aims and uses of the library in the
hospital and clinic are special and differ both
from those of the public library with a medical
department and from those of the large medical
library associated with a medical school or
research institution. Its function is practical
and clinical. In the hospital it exists for the
use of the intern and the attending physician;
in the clinic it is consulted by the staff for aid
in the solving of the many problems that daily
arise. Stress therefore comes on the fields of
diagnosis and of therapeutics, and the require-
ments in the departments of fundamental medi-
cal science and medical research are not great.

The type of library here described has its
chief role to perform in the small city more or
less isolated from the large medical center. It
is frequently impossible for the individual prac-
titioner to purchase a sufficient number of books
or to subscribe to enough journals to give him
anything more than the most meager reference
store. Too often he has but few books, and
bis journals are unbound, stored awaj r and
unavailable. Libraries in small hospitals gen-

Prom the Inlow Clinic.

n |V nier ? us suggestions and criticisms were made by Miss Berilia
uoNvlby, librarian, Carnegie Public Library.

m-n " 0S P>tal Medical Library Suggestions, J.A.M.A. lOSslOo-.-
10o9 (March 27) 1937; 102:1785-1791 (May 26) 1934; 92:1122-
(March 30) 1929: S4: 980-983 (March 28) 1925. Jenkins,
29) 193^ er * OC ^ Cfl * S ^ or Libraries, ibid. 97:C08-C10 (Aug.

erally are made up of gifts or brought together
by the pooling of individual collections and are
supplemented by unsystematic and intermittent
new purchases and subscriptions. There is no
paid librarian, the use of the material is not
great, no organization exists and interest lags.
It is doubtful whether many such collections
justify their existence.

All worth-while journals should he bound.
Periodical files are the most valuable part of
any medical library. Here only is the living
advancing front of medicine visible. Here only
in many instances can be found that detail of
information concerning specific subjects neces-
sary for the most successful prosecution of
medical practice. Periodicals, however, offer
little difficulty in classification, for they may
be placed simply on the shelves in alpha-
betical order, and all material which they
contain is readily available through the Quar-
terly Cumulative Index Medicus and other
indexes.

The chief task therefore in library organi-
zation has to do with classification of the store
of books. These may be recent or old. The
shelves tend to accumulate many volumes that
appear out of date. Some of these, generally
gifts of collections assembled a generation or
two ago, are so old that their material is of
historical interest only. Others, more recent
but still not new, contain a surprising amount
of valuable content applicable to modern prac-
tice. There is a tendencj r among medical men
to consider solely works of very recent publi-
cation worth their attention. In a certain few
fields, where changes are rapidly taking place,
they are doubtless right, but with regard to the
bulk of the fundamental information on which
medicine rests they are not. Especially when
such books are supplemented by the record of
contemporary progress depicted in the peri-
odical literature, they are still worthy of a place
on the active working shelves. However, in a
library used chiefly by interns, who may rely
largely on textbooks, it should be seen to that
these are recent.

1684

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Jora. A. M. A.
Oct 28, 1931

Among the older books, a few will be found
worthy of the title of medical classic, works
deserving perusal on the basis of their own
intrinsic value and persistent significance in the
history of medicine. These should be culled
out and placed in a separate division. Other
older books will have value only as being repre-

ried out by the use of the alphabet, the second
place in the notation being occupied bv capitals
and the third by small letters. This gives the
possibility of twenty-six primary and twenty-
six secondary' subdivisions.

Phalen and Garrison present two main head-
ings, “Basic Disciplines” and “Medicine and

sentative of the medical knowledge of the par- ™ .^mcme ana

ticular time in the «neeifie Subdivisions, under each of which in separate

ticular time in the specific field represented,
and of course there is little point to collecting
these unrestrictedly. A few illustrative works
for each field in each period will be found
sufficient. Most of these older books will come
within the nineteenth century, for they will have
been derived largely from American sources.
Books older than this again deserve separate
space and, if rare and valuable, may he put
under glass.

lists are given one group of disciplines as “Sub-
ject” and another group as “Congeners or
Related Subjects.” There is no further attempt
at integration and no notation other than single
arabic numerals given to the main topics under
“Subject.” Barnard, using the alphabetical
method of notation, divides the whole field of
medicine into twenty-six classes, with numer-
ous divisions, subdivisions and sections. His

Information concerning the details of library odiously has been developed ta

. i • t ... , „ . - _ J flip usp nf inp vprv Inrcm institution, one rltli

cataloguing, and tire getting ready of books for
lending is easily available; it is given in suffi-
cient fulness for the small library' in the pam
phlet issued by the Library Bureau. 2 It is chiefly
with the classification of the books themselves
that I am here concerned.

CLASSIFICATION OF BOOKS

Many methods of classification for medical
libraries are in use and have been suggested;
any one chosen will be found to he more or
less arbitrary. 3 In 1920 the Medical Library
Association adopted the Boston Medical Library
Classification 4 as a standard for American
medical librarians. It has much to recommend
it, and it may seem superfluous as well as pre-
sumptuous to offer anything different. It has
withstood the test of time and is in active use
in many libraries. As is true of any good
classification for general medical needs, it
attempts to “refrain from any bias of an
anatomical, physiological, clinical or surgical
nature.” The type of library which I am dis-
cussing possesses a bias, namely the clinical one.
No more apology is needed in following it than
in excusing the medical bias exhibited in all
medical libraries with regard to knowldege in
general. Libraries are of different sorts and
exist for specific purposes. In formulating a
classification primarily subservient to clinical
requirements, however, it is still possible to have
a system elastic enough to be adaptable to
other ends.

The Boston schema has forty-two mam classes
denoted hy numerals. Further division is car-

tlie use of the very large institution, one
in the field of tropical medicine and parasitol-
ogy, and its basis is largely etiologic. None of
these schemata seem to meet the needs of the
small clinical library'.

What are these needs?

Any' system adopted must be simple and at
the same time susceptible of indefinite expan-
sion. It must be one that can be administers
on occasion by' the record clerk or clinic secre-
tary, untutored in the intricacies of
management; it must be one by _ which t ^
average physician rapidly and readily can
the material he wants without assistance,
must be compact yet comprehensive in f >a
must include all fields in which the phy sicl ‘
is likely to seek help. . ,

The classification of the Boston jy ef . ic ^
Library was formulated with the idea of rin n
ing “together under one heading all materia .
a special nature,” so that everything re a o
to a system of organs or individual org ’
whether of an anatomical, physiologica , P
logical, clinical or surgical aspect, is P u 111 .
place.” This is quite admirable so far as ^
systematic theoretical study' of medical °P
concerned and doubtless fits well the req ^
ments of many institutions. However,
library made use of as an adjunct o . ^
medical practice, such concentration >

Ilvo niinicinn’s WOT K,

2 Miller, Zana K. : How to Organize a Library, ed. 8, Buffalo,
Lib r r 4“ U Fielding " LttSrie “dical, in Reference

"fK ^ai, P |d|ai J ;K-,

Mil Surran 60:271-300 (March) 1927. Barnard. Cyril C.. A
Sassmcltionror Medical

Index of Parasites and General Index,

fbr^MeclIcal 'Literaturef'edf'^^^Uxdlie^Tenn.f Cullom and Ghert-

* ~ -» ftorr

""LBo^Medi^l, ClasslOeallon, ed. 2, Bos-

ton, Boston Medical Library,

rather than expedites the clinician s .

Furthermore, forty-two or even
classes are too many for rapid one
Letters are less easy to follow and 0 a “ j.j nCC
with certain topics than are numera s - j n
1879 the Dewey r 5 decimal system has ^ j ia s
use in great numbers of public libraries. . c .
been elaborated on and added to m ca . £( |
quent edition until it leaves little . J ons
for the needs o f those general lay' i

5. Dewey, Melvil : Decimal CIass j n ‘?j,°" n jocks? N- v -
for Libraries anti Personal Lse, ed. lit A
Press, Lake Placid Club.

Volume 113
Number 18

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

1685

for which it was designed. In it the whole field
of knowledge is divided into ten classes (general
works, philosophy, religion, sociology, philology,
natural science, useful arts, fine arts, literature,
history), which are subdivided and resub-
divided decimally ad libitum. Medicine is given

section in this classification, however, shows the
organization of the medical field itself far
from satisfactory from the clinical standpoint.
The domains of anatomy, pl^siology and pub-
lic hygiene are adequately and exhaustively
treated, but man}' other fields are sadly neg-

Syslem of Classification for the Small Library in Hospital and Clinic

Class

0

00

01

02

03

04

05
0G

07

08
09

Class

1

10

11

12

13

14

15

16

17

18

19

Class

2

20
21
22

23

24

25
2G

27

28

29

Class

3

30

31

32

33

34

35

36

37

38

39

Class

4

40

41

42

43

44

45
4G

47

48

49

Gcncralia, Reference Works
Bibliography

Nomenclature, terminology and classification
Dictionaries

Languages, grammar, composition of scientific
papers

Encyclopedias — general
Encyclopedias — medical

Collections of tables, formulas, useful data

Directories

Atlases

Commercial publications, price lists, trade cata-
logues

Class

5

Class

G

General Science

General works, scientific method

Mathematics

Physics

Chemistry

Geology, geography, meteorology
Biology

Anthropology, anthropometry, constitution, eth-
nology
Psychology
Sociology
Philosophy

Class

Medical Science
General anatomy
Topographic anatomy
Embryology
Histology
Physiology

Physiologic chemistry, biochemistry
Pathology

Bacteriology, parasitology
Serology, immunology, allergy
Experimental medicine, research

Medicine and the Medical Specialties

Manuals, textbooks, systems in general medicine

Infectious diseases, fevers

Cardiovascular and renal diseases

Diseases of the respiratory system, tuberculosis

Gastro-enterology

Diseases of the blood and lymphatic systems,
hematology

Dermatology, syphilology

Endocrinology, diathetic and deficiency diseases,

metabolism

Pediatrics

Neurology, psychiatry

Class

8

Class

9

Surgery and the Surgical Specialties

Manuals, textbooks, systems of general surgery

Anesthesia, operative surgery

Minor and traumatic surgery, first aid, bandaging

Fractures and dislocations, orthopedic surgery

Ophthalmology, otolaryngology

Oral and plastic surgery, surgery of head and neck

Neurosurgery, thoracic surgery

Abdominal surgery

Urology,- proctology

Gynecology, obstetrics

50

51

52

53

54

55
5G

57

58

59

GO

61

G2

63

G4

G5

GG

67

G8

G9

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85
80

87

88
89

90

91

92
03

94

95
9G

97

98

99

Diagnosis, Technical Methods

General works, medical and surgical diagnosis

Symptomatology, semeiology

Clinical methods, history taking

Physical and instrumental diagnosis

Laboratory diagnosis, chemical, bacteriologic and

microscopic

Electrodiagnosis, electrocardiography
Roentgenologic diagnosis
Postmortem examination, microtechnic
Differential diagnosis
Prognosis

Therapeutics

General works

Personal hygiene

Dietetics, nutrition, vitamins

Pharmacology, materia medica, toxicology

Vaccine and serotherapy

Hydrotherapy, climatotherapy

Mechanotherapy, massage, exercises, gymnastics

Physical therapy, electrotherapy, actinotherapy

Radium and roentgen therapy

Psychotherapy, psychoanalysis

Social Medicine

Social medicine, marriage, sexology

Public health, preventive medicine, racial hygiene,

eugenics

Epidemiology, geographic medicine
Biometry and statistics
Industrial medicine
Medical jurisprudence

Medical education, medical schools, museums
Medical societies

Medical economics, state medicine, health insur-
ance

Medical profession, medical ethics

Medical History, Cultural Medicine
General works in medical history
General history, archeology
The periods of medical history
History of special subjects
Biography
Medical essays '

Philosophy of medicine, medical theory
Classic works in medicine
Illustrative works from the nineteenth century
Special collections

Associated Medical Fields, Miscellany
Mysticism, faith healing, cults
Tropical medicine and hygiene
Military and naval medicine, aviation
Comparative and veterinary medicine
Dentistry

Pharmacy, pharmaceutical manufacturing
Nursing

Hospitals, clinics, research institutions
General literary works

Medical miscellany, collected papers, transac-
tions, reprints, government reports, etc.

the number 610 and listed under useful arts
along with engineering, agriculture and domestic
economy.

The decimal system used in this classification
recommends itself immediately for adoption in
spite of certain criticisms of its use. For
instance, a misplaced point or a forgotten
numeral works havoc. Errors of notation are
possible in all systems, and this seems small
justification for rejection. Study of the medical

lected, in fact just those most important in a
working clinical library.

Any system of classification may have many
valid criticisms leveled against it, and no gen-
eral formula can be found which fils all needs.
In presenting therefore a classification of my
own, based on the Dewey system, with certain
borrowings from many other sources, I appreci-
ate fully that it represents solely the schema
which has been found hv experience to fit the

1686

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Jom. A. M. i,
Oct 28, 11']

needs of one organization, the library of the
Inlow Clinic. It is in the belief, however, that
libraries very similar in their requirements to
this one exist that the suggestions herein made
are offered. This classification in outline form
should be posted in a prominent place in the
library. Furthermore, the ten main headings
and many of the chief subheadings should be
clearly indicated on the shelves by large labels.
The shelves should be arranged so that the num-
bers follow in regular succession and little diffi-
culty is experienced by any one coming into the
library for the first time in locating the field he
is seeking. Much material is thus readily avail-
able without consultation of the card index.

CATALOGUING OF HOOKS

Cataloguing in many instances may be diffi-
cult. Many works fall under more than one
heading. It is best to place the book under that
caption in which it appears to have most use
in the individual institution. The whole spirit
which should activate the clinical library is that
of utility. Other headings under which a book
may come are adequately taken care of by list-
ings and cross references in the card catalogue.

It will be noted that this classification
attempts an organic integration of medical
knowledge and associated fields. It is func-
tional and instrumental. In the formation of
the classes and divisions I have followed in
a broad way the order in which subjects are
met in the course of medical education. From
the standpoint of the intern this is desirable,
for it is the sequence to which he is accustomed.
First come the tools with which the physician
works: indexes and volumes for ready refer-
ence, volumes on the languages, dictionaries
and encyclopedias. The languages are the
means by which medical writings in other
tongues are made available. Preliminary bibli-
ographic investigation is the sine qua non for
the adequate tapping of periodical literature,
and cyclopedias furnish rapid orientation in
any subject. Then there is the broad field of
scientific and medical knowledge in general.
This is the material collected through the cen-
turies, and it naturally falls into three groups:

(1) the whole gamut of the natural and the
social sciences with the exception of astronomy;

(2) the medical sciences, those sciences which,
though forming a part of other disciplines,
nevertheless may be taken as integral parts of
medicine itself, and (3) those subjects detailing
the natural history and course of disease which
constitute the true content of clinical knowledge.

Mathematics is the handmaiden of all the sci-
ences; physics, chemistry and biology are at the
basis of physiology and of pathology; geogra-
nhv geology and meteorology have their role in
geographic medicine and dimatology; anthro-
pology and psychology furnish material for he
understanding of man himself; sociology is the

basis for many problems in prevenfive medi-
cine, public health, medical jurisprudence and
medical economics, and true critical philosophy
is the discipline which weaves all these things
together into an organic whole for the develop-
ment of an adequate scientific world view.

The listing of the medical sciences here
employed is quite familiar, since it includes
those subjects encountered in the first two years
of the usual medical course. The field of experi-
mental medicine and research naturally fits in
with this group of distinctly scientific studies.

In the practice of curative medicine, so called,
the end which hospital and clinic subserve, there
are two elements : the store of knowledge with
which the practitioner works and the technical
means at his disposal for the recognition and
the control of disease. These two fields greatly
overlap, and many works, especially those on
medicine, surgery and the various medical and
surgical specialties, contain material concerning
both. Though in theory' the knowledge on which
curative medicine is based forms one integrated
whole, yet from the practical standpoint it is
divided into medical and surgical portions,
Surgery in the strictly philosophic sense is
merely a branch of therapeutics, the operative
treatment of disease. In practice, however, n
has assumed such importance and taken unto
itself so much of the content of medical know-
edge and theory that it approaches or equals
the domain of internal medicine itself, espe-
cially so far as hospitals and private clinics are
concerned, and should therefore be given scpa*
rate consideration in any' clinical library class'
ficatory' scheme.

The field of medical knowledge and pr_ ac : 1
has been divided into specialties. Acco : rd ing I
whether the medical or surgical element in 1
(for each specialty contains something of J ^
predominates, they may' be classified ei ia
medical or as surgical specialties. Tins P° ,
of the clinical library, which I h& ve f ■„],
under classes 3 and 4, doubtless will ou «
any other, for it will contain many of ie ,. fC
forming the real working nucleus of 1C
collection. . . n ipc

The real function of the practitione ^
hospital or clinic staff is the recognition ‘ rV
treatment of disease processes. tlis
working tools lie largely in the Gelds ^
nosis and of therapeutics. Prognosis re-
taken as a part of diagnosis; there * g QinC
works devoted to this subject alone,
specialties will be found to owe J C1 ' j for
to diagnostic and therapeutic needs - . n0 [ 0 g.r
instance, are clinical pathology, ro S ^. g „,
and physical therapy. The domai s ^
nosis and of therapeutics are fa J C { a c«c5
raied, bat in making of
roentgenology', which consists of dug _
of therapeutic elements, is separa

clossc*
: and
on f * |C

Volume 113
Number 18

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

1687

shelves rather than located in a single place,
which would be more desirable to a specialist
who united the two fields in his practice. No
matter what system of classification is adopted,
it will be found that such separations will some-
where have to be made.

The clinician as a rule in consulting the
library has some specific problem in mind. He
may already have made a tentative diagnosis,
for example of trichinosis. His knowledge of
this subject, however, may be hazy, for it has
been a decade since he has observed a similar
case. He consults the library for systematic
information on the subject. He will turn to
the section on general medicine therefore, where
he will find in sufficient detail the material to
satisfy his immediate needs. The laboratorian
to whom he sends a specimen of stool or blood
for verification of his diagnosis will consult the
division of laboratory diagnosis. Only if they
are curious to know more of the life history of
Trichina spiralis will the clinician and labora-
torian consult the division of parasitology in
the class medical science. There are degrees
of need and interest exhibited by those who
consult tire library and gradations of the extent
to which any subject may require investigation.

THE CLINICAL LIBRARY

The problem, on the other hand, may be a
purely diagnostic one. The clinician may wish
not to overlook any of the possibilities relative
to a presenting symptom; be may desire to
verify what he can expect from some particular
test; he may already be reasonably certain that
the case is a medical or a surgical one but still
be not satisfied as to just what is going on. He
will consult the diagnostic divisions. Or again
lie may have arrived at a diagnosis and be
undecided as to what is the best procedure
to follow in treatment. Just what may be
expected in this instance from physical thera-
peutic procedures? He may know the drug or
endocrine preparation he wishes to give; but in
what form and in what dose shall he prescribe
it? This patient desires to go to a certain resort
for rest and recuperation and asks for infor-
mation concerning it. This one needs a certain
diet. To answer these questions and to meet
these desires he will consult the therapeutic
section.

This brief discussion shows how in a clinical
library attempted concentration of all mate-
rial concerning one topic in one place may
hinder instead of expedite diagnostic and thera-
peutic work. A library of this kind is of more
service when it is departmental, that is, when
the classificatory division is made on the basis of
the separation of the field of medical practice
among various types of practitioner (internist,
surgeon, ophthalmologist, urologist, roentgen-
ologist, laboratorian, physical therapist, dentist,
uurse) rather than on the basis of anatomic

part or etiology. It leads to less confusion to
have each specialist find the whole field in
which he is primarily interested segregated in
one part of the library without finding also
before him on the shelves works concerning the
topic in question treated from points of view
which have little bearing on bis particular
approach.

In the classification here proposed, material
on various topics is scattered purposely. If the
practice of medicine in hospital and clinic were
not itself departmentalized (specialized) this
would be a serious drawback, but with condi-
tions as they are this is not the case. It is
seldom indeed that any one working in a clinical
institution will consult the library to find out
all that it contains about any one particular
topic viewed from every possible approach.
The place for concentration of all material con-
cerning one subject is in the card catalogue and
not on the shelves. For in fact the ideal of
concentration aimed at in some classifications
cannot be attained; some dispersion is inevitable
from the very fact that most books discuss many
topics but permit themselves physically to be
put only in one place.

Medicine has broad social as well as indi-
vidual personal functions to perform. There
are those fields which have to do with the con-
trol of disease en masse, the topics of public
health and preventive medicine; those which
have to do with the application of medical
knowledge to the solving of strictly social prob-
lems, such as the subjects of medical juris-
prudence, criminology, juvenile delinquency.
There is the domain of the relation of physician
to patient, physician to physician and physician
to society, medical ethics; that of the applica-
tion of knowledge in a department of sociology,
economics, to the problems of medical organi-
zation and practice. There is the charge of
transmission of medical knowledge from one
generation to another, medical education. All
these I have segregated under the class social
medicine.

Medical history is a part of cultural medicine.
This subject has assumed such large importance
in the field of medical bibliography that it
deserves to be placed as a separate class. As a
division under this are grouped all obsolete
works of the nineteenth century. Besides being
assigned their own distinctive notation, these
volumes are classified according to the general
schema, i. e. they likewise are assigned the num-
ber of the subject of which they treat. By this
means two things are accomplished: 1. The
seeker after recent information in any field
does not find the shelf of liis subject cluttered
up by nonusable books. 2. He who is histori-
cally minded can find what he desires already
separated for him. By this procedure gifts of
old books can be put to their proper use.

1.688

AMERICAN MEDICAL ASSOCIATION. STUDENT SECTION

Jain. A. 3), A
Oct 2S, IS;)

The divisions of the last class, that of miscel-
lany, are in a way parts of social medicine.
Cults, hospitals, sanatoriums and pharmacies,
as well as veterinary medicine, dentistry and
nursing are social institutions. Yet on practical
grounds they belong in a group by themselves.

Naturally in the artificial placing of the whole
field of medicine in classes and divisions of ten
there will be apparent crowding of subjects in
one place and lack of sufficient diverse head-
ings in another. From the standpoint of mak-
ing material available this drawback is more
apparent than real. Throughout, those subjects
have been grouped together which are allied
either organically on the basis of content or in
accordance with medical custom. Thus ophthal-
mology and otolaryngology are placed together,
neurology and psychiatry and so on. These
fields are similarly united in the person of a
single practitioner in many of the smaller medi-
cal centers. However, though two or more
specialties in many instances are placed under
the same division, they can he separated easily
as the 1 ibrary grows by the addition of a dis-
tinctive further notation.

SUBDIVISION OF SUBJECTS

In order to present the classification in as
simple a manner as possible I have offered here
only 100 headings over the whole medical
domain. Even small libraries, however, will
find it desirable in certain fields to go beyond
this. Besides classes and divisions, subdivisions
and sections can be established by adding a
decimal point and more numerals. The use of
more than four digits will seldom be found
necessary even in the largest libraries. It must
be emphasized that subdivision carried too far
becomes a hindrance instead of a help.

The method of further classification can be
explained briefly. In the instance of two or
more main subjects grouped together under
the same two digit symbol, these topics can be
separated by the addition of letters from the
alphabet to designate them, as employed in the
classification of the Boston Medical Library.
Thus, for example division 44, class 4, becomes
broken up into 44A ophthalmology, 44B otology,
44G rliinology, 44D laryngology, and so on.

Small hospitals today are largely surgical
institutions. Surgery rests on the disciplines of
anatomy and pathology. The human body is
readily divisible into various structures and
organs; pathologic processes are easily recog-
.nizecl as being of different kinds. Further
classification in the surgical specialties there-
fore naturally makes use of these time honored
divisions; the anatomic classification will vary
with the specialty and the organs and body
system involved; the pathologic classification
is largely the same for all structures. The
subdivsion is created on an anatomic basis
and the section on a pathologic one. Thus,

division 47, abdominal surgery, falls into
subdivisions 47.0 general works, ,1 abdomi-
nal. wall, hernia, .2 peritoneum, .3 slomadi,
.4 intestine, .5 liver, .6 gallbladder and bile
passages, .7 pancreas, .8 spleen, .9 mesentery,
miscellaneous. The same method of subdivision
is applied to thoracic surgery, urology, gyne-
cology and other branches. The pathologic
classification is .00 surgical and pathologic
anatomy, .01 anomalies and malformations, .02
regressive and degenerative changes, .03 dis-
turbances of circulation, .04 general inflamma-
tions, .05 specific inflammations, tuberculosis,
syphilis, etc., .06 changes in lumen, position,
size, .07 injuries, .08 foreign bodies, concre-
tions and parasites and .09 tumors. Tims, for
instance, a surgical work on carcinoma of the
stomach would he labeled 47.39.

In other classes the basis of division cannot
of course be anatomic and pathologic but must
he suited to the material in hand. For instance,
the division periods in medical history can be
subdivided into .0 prehistoric medicine, paleo-
pathology, .1 ancient medicine, .2 Gracco-Ronian
medicine, .3 Byzantine period, .4 Mohammedan
and Jewish period, .5 medieval periods; •
renaissance and reformation period, .7 seven-
teenth century, .8 eighteenth century and •
modern period.

By subdivision and further elaboration,
unlimited expansion can be taken care o>
and, though designed for the use of the sn
library, the classification can be employe
the largest clinical collections.

It must be emphasized, however, tha >
particular system of classification adoptee is
as important as the fact that any library a ,
than a certain minimum size has to he o *
ized if any one other than the person v ,
seen to amassing it is to make maxim ‘
effortless use of it. Systematization a
are requisites to all intellectual house v
18 West Washington Street.

Red Blooded Young People jf ,
A prime fascination of medicine is L ‘ ,j, 8 | joti
never ending study. Merely not to 8 ^yjMlioW
have learned cannot keep you ready f . that }' oU
of medicine. Without forgetting any * sur gcoi«-
learn in medical school, soon as pay® V- /fellin'!
specialists, etc., you will become hi j or g C |iis!
the times, unless you continue to study jn mf( i-
will not keep you from rapidly j0SI ? ! ’ , e c oropl c ’ cI ',
cine; what you may know soon is ap , jca ] school
outmoded by new discovery, m cm /fng s (m -

days, I dare say, this idea of a ne ( j u u <i pr£
did not seem such a jot'. Ho\vc\e , sUHfo' '■

fession medicine would be if in a . . )/,,,/ «s
the medical school you had learned • ini!cr d
needed to practice the profession -vvouri ? r '‘

your lifetime. That sort of a
attract into it red blooded young pP y youth:
Henrv A.: The Lure of Medicine, Virginia
65:515 (Sepi.) 1938.

Volume 113
Number 18

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

1689

Comments and Reviews

THE PRACTICE OF MEDICINE

Abridgment of an address by Dr. Rufus Cote,
delivered at the commencement exercises of Cornell
University Medical College, June 15, 193S, and pub-
lished in Science, Oct. 7, 193S.

The subject of medicine is sufficiently impor-
tant and the knowledge concerning it suffi-
ciently well organized to justify its designa-
tion as a science, and its devotees are worthy
to he called scientists. Under these circum-
stances it seems that medicine would be a
proper subject to be taken into the university
as a discipline worthy to be studied, even if all
applications were entirely lacking.

The question remains whether there are rea-
sons why future practitioners should pursue the
subject from this point of view. It is possible
that a student might, through repeated obser-
vation and didactic instruction, become familiar
with the characteristic features of disease, that
he might learn empirically the procedures
employed in treatment and that he might
through experience alone acquire skill in prog-
nosis. Formerly this was about all that was
attempted in the training of physicians. But the
university and society at large now demand that
physicians shall be familiar with what is known
about the nature of the processes constituting
disease and of the lesions associated with them.
The phenomena of disease are natural processes
occurring in conformity with the laws of nature,
and these phenomena can be understood only by
using methods universally employed in reveal-
ing the mechanisms of other natural events.
These are the methods of science. Now are you
trained physicians ready for practice?

You may have knowledge of the structure and
functions of the human organism in health.
You may be able to picture at a moment’s notice
the characteristic lesions of all diseases, to pass
a perfect examination on the functional dis-
turbances produced by all types of injurious
agents, and yet you may not be a good phy-
sician. There is such a thing as the technic of
practice and this technic j'ou cannot learn in
the true university medical school. No one
except the self-deluded men who examine you
for license to practice expects you on graduation
to be proficient practitioners. This does not
mean, however, that you are not well prepared
to master the technics necessary to make you
good physicians.

It is not easy to differentiate between the
study of the science of disease and the practice
pf medicine. The practitioner is primarily
interested in the diseased individual and he
must concentrate attention on those features the
miportance of which has been demonstrated.
The university student may spend days in the

investigation of a single case. The practitioner
must investigate, judge and act quickly. The
university lays stress on complete understand-
ing; practice lays stress on skill. It is not a
question of treatment. The patient no longer
employs a physician merely to have him admin-
ister remedies. But what he rightty demands,
first of all, on the part of the physician is
understanding of his entire constitution as an
individual. The university student and the prac-
titioner both are interested in treatment, but
the practitioner is especially concerned with the
technics employed in the individual case. What-
ever the differences, the university student and
the practitioner must both employ the methods
of science. They must both have the scientific
habit of mind, and this is especially what the
university should give. Both must have curi-
osity, the desire to learn; both must have
honesty, and both must be critical. Unverified
opinion can have no place as guides to action.

If you have not yet acquired the technic and
skill for practice, how are you to get it? It can
be acquired only by practice itself and by hard
unremitting labor. In earlier years the. rudi-
ments of the technic of practice were obtained
by following a preceptor and, so far as it went,
this was not a bad way.

THE WEAKEST LINK

Today the preceptor system has been replaced
by the hospital internship and there are defects
in the intern system. It is the weakest link in
present day medical education. In most cases
all the hospital does is to offer opportunities to
the intern. The preceptor cared whether the
student did or did not learn, the hospital usually
does not care. But hospital physicians can be
interested in the training of interns, to their own
as well as to the student’s great advantage. Hos-
pital authorities can undertake more seriously
their educational responsibilities.

In the first place the hospital can realize that
its interns are highly educated, cultivated, seri-
ous men whose ambition is to serve the patients
under their care and whose greatest desire is,
through practice, to become technically skilful,
more gentle, more humane, more wise. The
hospital can provide facilities so that interns
may live like cultivated men and students; this
does not mean provision for higher standards of
living but for higher standards of work and
study. When visiting hospitals I have made a
point of seeing the interns’ rooms. Even in some
of the most modern hospitals I usually find
small, dark rooms, containing a bed, a chair or
two, a small desk and a few books, and these
mostly textbooks, remnants of the student life.
I was surprised to find no evidence of any
interests at all, even in science. To find that a

1690

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Jour. A, 51. A.
Ocr 28, 1932

young man could have acquired a university
degree and have no interests outside his daily
job was a surprise. The hospital cannot create
these interests but it can assume that the intern
has them. The hospital should not treat interns
as employees and provide to the minutest detail
the Rind and amount of work they shall per-
form. Interns must have freedom. This in
large hospitals is difficult but not impossible.

I recall experiences under Osier. He was
personally interested in every intern, consider-
ate of their sensibilities and their time; he
seized on the least evidence of curiosity in an
intern, stimulated his interest and aided him
with advice and help. His contacts with his
interns were not confined within the wards.
He never missed a meeting of the hospital medi-
cal societies. Above all he influenced the interns
by his example. He taught them to become
good doctors by being one himself. All prac-
titioners connected with large hospitals come
daily into contact with the interns. By spending
a limited amount of time with them, by guiding
them, by working with them, these practitioners
may be of great educational service. Prac-
titioners in a small place have the same oppor
tunity to become great teachers as had Daniel
Drake in the little Transylvania University
beyond the mountains.

After all, whether interns become good doc-
tors or not depends on the interns themselves.
Our hospitals have arrangements for making all
kinds of technical investigations. The intern
becomes a part of this organization and he is
able to use any one of a dozen different labora-
tories to aid him. This is useful but it carries
with it dangers. The student begins to deal
with formulas, with words, instead of with the
things themselves. One of the chief disadvan-
tages of the present arrangement is that when
the intern becomes an independent practitioner
this convenient arrangement will no longer be
available to him. Aid he must have but it must
be carefully chosen. At present a large part
of the work of contributing services in the hos-
pital is probably unnecessary. This results from
the fear of omitting something. It is this fear
of omission that impels taking the most minute
and extensive histories and the recording of
routine elaborate physical examinations, all of
which occupy much of the intern’s time and
leave little opportunity for thinking and inde-
pendent action. How many interns keep their
own records of cases, classify them, think over
them, formulate their own concepts and try
to rationalize the methods of treatment they
employ? Records of cases carefully abstracted,
compared and digested are of greater edu-
cational value than random experiences, how-
ever exciting. To pass through your intern
years in a fever of agitation, interested only in
obtaining a rapid series of impressions, will add

little to your real experience or improve your
training for practice.

When I contrast the long lists of interns and
residents in hospitals today with the handful of
workers forty years ago, I cannot believe that
the intern’s life need be more strenuous today.
The master word in the hospital, as in the uni-
versity, is still Work.

Hospital days should be laborious days, but
they may be also days of the greatest joy. For
the first time you will come into a position of
real responsibility for the lives of your patients.
It is a cold individual who is not moved by this
close contact with those in distress.

During the internship, the hospital should be
your home, your workshop and your play-
ground. Shun outside affairs that will compli-
cate your life and disturb concentration on your
work, rejoice if you are too poor to own an
automobile to carry you from the straight road,
avoid the movies, above all avoid entangling
affairs of the heart.

A SCIENTIFIC ATTITUDE

The difficulties of maintaining a scientific
attitude will be enormously increased once you
have left the protecting walls of the hospital.
Amid the distractions of domestic life, tne
competition in professional work, whether you
will be able to continue to exercise the scholar y
and scientific point of view will depend large)
on the use you made of your hospital years.
The best guard against retrogression is a con-
stant desire to learn more about the real na u
of disease and particularly about some one j
ease. Some of the most important medica
coveries have been made by men m ac 1
practice. Tlxe late Dr. Meltzer’s example s
impress you. For many years he drove ®
New York every day with a horse and ' »
seeing patients and then spent all the im
could in a laboratory, during winch pwoo
made important contributions to meaicin
physiology. After the Rockefeller Institute ^
established he went there to work. H .

of the most productive students of disease

our country lias had. . . » er

The practice of medicine today is far w ^
„.an it was forty years ago. Some \
blame for the defects on the present me
universitv education.

P ut , t
Ibo d of

In interviewing students I frguentlj s fa^
amazed by the fluency and skill yffh , p
discuss the most complicated su ije oVcr |cs
ology and pathology and the lates ] J(nV ever,
in medicine. I sometimes woncl » .

whether the facts have been digested w a JjC

muted into wisdom. A doctor shoul
ignorant of any fact relating to m f j oC5 j|
is this cramming scientific educa
produce scientists? u} jnen

Let the university heed that jt f tu 5 * „j, {) n ot
who have the scientific habit of

Volume 113 .
Number 18

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

1691

merely men stuffed with facts; however, if the
prevailing standards of practice do not fulfd
expectations, let us not place the blame for it
all on the university. The hospital, the visiting
physicians and even the interns and practi-
tioners themselves play parts in the training of
good physicians.

We are still far from perfect. The future
rests with you. May you continue to he scien-
tifically and critically minded. May you con-
tinue to he students as long as you live.

THE ORIGIN OF THE MICROSCOPE

Abridgment of a paper by Dr. Russell L. Haden,
published in the Annals of Medical History, January
1939.

The name microscope was suggested h} r a
physician; three of the five great microscopists
of the classical period were physicians; one of
the first applications of the microscope was the
study of medical problems by a physician. The
microscope is an application of the science of
optics. Books on optics were written by Euclid
300 years before Christ. The first person to
mention the actual use of lenses for a definite
purpose was the English monk Roger Bacon
(1214-1294), who was the initiator of experi-
mental physics.

The first important application of magnifying
lenses was in spectacles, which were invented
independently in Italy at about 1285 by Salvino
degli Armati. An inscription in the church of
St. Maria Maggiore in Florence says “Here lies
Salvino degli Armati of Florence, inventor
of Spectacles. May God pardon his sins.
MCCCXVII.” Perhaps the allusion to his sins
refers to the fact that he kept secret the method
of making spectacles.

The possibility of combining lenses for distant
vision and for high magnification was dis-
covered later and thus the telescope and
compound microscope were invented. The
discovery of both the telescope and the micro-
scope belongs to Holland, although the first
significant observations with both instruments
were made in Italy.

The inventor of the compound microscope
seems to have been Zacharias Janssen, who with
his father was a spectacle maker in Middelburg
in the Dutch province of Zeeland. Janssen
discovered in 1590 how to combine convex
lenses in a tube to make an instrument for
magnifying minute objects and so invented the
microscope.

Probably the oldest compound microscope in
existence is now in the museum of the Zeeland
Scientific Society of Middelburg. Harting, after
a careful studjg concluded that it is probable
that (bi s instrument was made by Janssen. Its
greatest magnification is 9 diameters.

One of the most noted of the early microscope
makers was Eustacliio Divini. A Divini micro-
scope made in 1672 is now in the Museo di
Fisica, Padua. Another famous maker of com-
pound microscopes in Italy was Joseph Campani
of Bologna, a contemporary of Divini. Little
was done in England in the way of making
instruments until Robert Hooke in 1665 des-
cribed his compound microscope. Hooke’s
microscope initiated a new era in microscopy.
He ground his own lenses, constructed his
microscope, made observations with it and
drew his own remarkable illustrations. A
microscope of this pattern used by Hooke is
now in the South Kensington Museum in
London. The compound microscope remained
optically about as Hooke left it for more than a
hundred j'ears.

Leeuwenhoek excelled all other early workers
in making simple microscopes because of his
skill in grinding lenses. He never described his
method of grinding. When he died in 1723 he
bequeathed to the Royal Society of London
a cabinet containing twenty-six microscopes
equipped with double convex lenses magnifying
from 40 to 160 diameters. Leeuwenhoek at his
death had 247 complete microscopes and a total
of 419 lenses. His observations were first com-
municated to the Royal Society of London by
letter in 1673.

The most successful of all early simple micro-
scopes is associated with the name of Wilson,
although not original with him. This type was
first made by Tortona. Wilson’s microscope
was first made in 1702.

The further development of the compound
microscope is due largely to English instrument
makers. The next important microscope after
Hooke’s was made by Marshall in London in
1693 with a magnification up to 100 diameters.
Culpepper in 1730 suggested the three pillar
type of stand. He also used a concave mirror
in the optical axis of the instrument. Focusing
was done entirely with the draw tube. The
Cuff microscope first made in 1744 includes
most of the features of the modern microscope.
With this microscope the origin of the com-
pound microscope may be said to end. The
later history is one of development.

The most active early investigators with the
microscope were members of the Academy of
the Lynxes (Accademia di Lincei) in Rome, a
scientific society formed in 1603. Among the
members were Galileo, Fabio Colonna, a
botanist, Francisco Stelluti, a scholar and
naturalist, James Faber of Bamberg, resident in
Rome as physician of Pope Urban VII, Fran-
cisco Fontana of Naples, an astronomer, and
Gianbattista della Porta, who probably first
suggested combining lenses to make the tele-
scope and microscope (1589). It was Dr. Faber
who first suggested the name microscope in a

1692

AMERICAN MEDICAL ASSOCIATION. STUDENT SECTION

Joub. A. 51. A
On 28, 1531

letter April 13, 1625, to Federigo Cesi, president
and a founder of the academy. The word
perspicillum had previously been used to desig-
nate both the telescope and the microscope.
Galileo had called his microscope an occhiale
or occliialino. The first plate made with the
aid of the compound microscope comprised
observations on the bee made by Stelluti about
1630.

The first medical work based on the use of
the microscope is the “Ilistoriarum et observa-
tionum medieo-physicarum” by Pierre Borel,
published in 1563. His “Centuria observationum
microscopicarum” records 100 microscopic
observations, mainly on minute insects. This
is the first book devoted to microscopy. Borel
describes how he found ingrowing eyelashes
which are invisible to the naked eye and the
removal of which relieved conjunctivitis. This
was probably the first practical use of the micro-
scope in medicine. Singer suggests that Cesi
and Borel should be looked on as the fathers
of microscopy.

The first medical illustration with the use of
the microscope seems to be in an article in the
Acta Eruditorum published in 1686 entitled
“Description of a New Microscope Made by
Joseph Campani and Its Use, communicated by
Dr. Schelftrateus, prefect in the Vatican
Library, in a letter dated Rome, June 15, 1686.”
The illustration shows how the microscope was
used in examining a wound.

THE STUDENT HEALTH SERVICE IN A
MUNICIPAL UNIVERSITY

Abridgment of an article by Dr. Irvin IV. Sander
published in the Journal-Lancet, January 1939.

Strictly^ tax-supported municipal colleges and
universities had their beginning in 1837 with
the founding of the University of Louisville in
Kentucky. At present about 20 per cent of
college students in the United States attend
municipal tax-supported institutions.

Since the beginning of the first student health
service at Amherst in 1860 for the purpose
of selecting students physically capable of
engaging in athletics and sports, the scope of
the service rendered by student health services
to the student and to the school has grad-
ually increased. The amount of responsibility
assumed varies with the size of the college, its
location and the underlying philosophy of its
health obligation to the student. The older,
larger and privately endowed schools have for
the most part developed student health services
which provide essentially a complete medical
and surgical service for the payment of an
annual fee. This broad interpretation of a
college’s obligation to the student is a form
of health insurance.

The objectives of a student health service in
a college may be outlined as follows:

1. Sufficient education and training of the student
to enable him to care for his health intelligently,
through hygienic and proper habits of living. The
college health problem is not so much concerned with
disease as with the fostering and increasing Hie
strength of people not yet mature, so that a foundation
may be laid for long, healthy lives.

2. Protection of the student body from contagious
and communicable diseases.

3. Supervision of the sanitary facilities of the school
buildings, dormitories and rooming houses.

4. Care of acute illness which requires emergency
attention.

5. Physical examinations of all entering students
to determine their fitness to participate in required
courses of physical education and in the more
strenuous elective intercollegiate athletics. Adequate
records must be kept of all students and competent
interpretation made of the results of the examination,

C. Assisting students in planning their course ot
study so that it will correlate with their physical and
mental abilities. The prevention of overwork on the
part of some students is often a necessity. As students
seldom pay by their tuition the actual cost of education
to the school, this phase of the student health service
work may be interpreted as a safeguard of the capital
investment of the institution. There is no economy
in graduating students who will be shortly compelled
to withdraw from the practice of their profession
because of illness due to poor supervision of their
health habits while attending college.

Fundamentally, the problems of the student
health service in a municipal university arc
the same as in any school of higher education.
The students are of the same age group an J
are no better nor any less prepared for college
life than students of other schools. There : is.
however, less need for the broad administra n
development of the health service in '
municipal school that is found in the larg
endowed school. Many of the city colleges in'
no dormitories; the few students attending
school from out of town find their own acco
modations. As the school district is in a c -j
these roomi ng houses will be supervised h)
local department of health and sliou
constitute a health problem to the unive /. j
The fact that most students in a muihc uj
university live at home makes the hanc j tl
their health a different problem than m
ordinary school. There will in most i case * j cn f
family physician who has cared for Hie s ^
during previous illnesses and who has a
knowledge of the personal and family -j
than the student health service physician c ^
hope to learn with his brief contacts. jan
no logical reason why the family I - , en(
should not continue to care for such a ^
in the same manner he would / ,a ' e jj iC
student had not enrolled in the univcrsn .
same thing may he said of hospitalization

a student. , , ; n (lie

The few cases of out of town s . tlKl . e " - can
city university who require liospitalizauo
be cared for in an emergency by sending

Volume 113
Number 18

AMERICAN '"MEDICAL ASSOCIATION ' STUDENT SECTION

1693

to the city hospital. The school is in this way
saved the expense of erecting and maintaining
an infirmary for ill students. This will perhaps
make the health service less adequate in caring
for the students than it might be; but, in general,
local facilities will be sufficient to care for the
few cases in which the school must assume some
degree of emergency responsibility.

Wayne University, operated by the board of
education of the city of Detroit, was formed by
the union in 1934 of five colleges operated by
the hoard. The Student Health Service was
first organized in 1928 as part of the College
of Arts and Sciences. Thorough physical
examinations are made of all entering students,
who are graded in accordance with the results
of their physical examinations, and permission
is given or withheld for participation in athletic
activities. College sports are supervised by the
health service and a physician is in attendance
at all football games. Since its inception, the
Student Health Service has become of increas-
ing value to the students of the university. All
physical defects found during the examinations
and needing correction are referred to the
parents and the famity doctor for appropriate
care.

The students of Wayne University are not
given medical care within the usual meaning
of that term. Emergency care is given, but
subsequent treatment, if necessary, is referred
to the family physician. Athletes competing
or trying out for teams representing the
university are given medical care to the extent
of the facilities of the health service in the
event of injury. When such facilities are

inadequate, the student is referred to the family
physician or to an appropriate specialist. In
circumstances in which it is deemed advisable,
the physician’s fee is paid by the university.
No hospitalization is offered to the students by
the health service. A few beds are kept in
readiness in the health service building for
emergency illness, but tbe student is kept tliere
onty until arrangements are made for his
removal to the home or to a hospital if neces-
sary. These beds are available also to students
assigned to regular rest periods during the day
because of chronic ill health.

Education of the students in matters of health
and hygiene is considered the main objective
of the Student Health Service of "Wayne
University. An attempt is made during each
personal interview to give authentic advice
regarding personal health problems to the end
that the student may better understand what
can be done and where such aid may be
obtained. During tbe past 3 ^ear 2,080 students
were referred to their own doctors or dentists
for appropriate care and, when the student had
no family physician, aid was given in selecting
one appropriate to the need from a list
approved by the Wayne County Medical
Society. It is felt that the student completes
his four years in college with a better under-
standing of what medical science has to offer
and a knowledge of how to utilize that informa-
tion for his own benefit. He should by that
time be on good terms with his family doctor,
and every such contact made should be to the
benefit of medical science, the physician and
the patient.

Correspondence

UNEMPLOYMENT AND THE PUBLIC HEALTH

To the Editor . — I am a senior medical student expect-
ing to graduate in June of next year. From my conver-
sations with classmates I believe that a large percentage
of medical students are aware of some rather distinct
discrepancies between the things we have been taught
in medical school and the things which we observe in
•he actual practice and interests of the profession.

First, we are taught — and for that matter have come
to medical school believing — that the chief obligation
and interest of the physician lies in the preservation
of the health of the people of his country. One might
almost say that the sole social justification for the
existence of the medical profession in this country lies
in the extent of its execution of its alleged purpose
in striving to keep the health of the American people
as high as is possible and consistent with our present
medical knowledge.

Second, we learn that among the most important
causes for a number of important diseases today —
tuberculosis, rheumatic fever and others — arc the
social-economic factors of inadequate living standards.

The entire nation is now in the midst of a critical
situation brought about by the merciless cuts in relief

and public works budgets in the face of an economic
situation which cannot reabsorb even a small fraction
of the unemployed. We are daily faced with a rising
incidence of conditions either directly or indirectly
resulting from malnutrition and lowered living stand-
ards among a sizable percentage of the American
people. As this situation continues, I am reasonably
certain that we medical students are not alone in
questioning the value of, or the justification for, the
practice of medicine when the medical means which
the physician has at his disposal cannot begin to touch
the underlying cause of many of the cases of illness
current today.

The medical profession constitutes a rather powerful
political pressure group. It seems to me that, if the
profession is to be consistent with its teachings and
traditions, it is obligated to take up the fight for
increased relief budgets and for socially responsible
public works programs until a more fundamentally
sound “prosperity” can be achieved. Medical care can
be of little real value to several million people forced
to eat on fifteen cents a day.

James S. May, Rush 1940.

1694

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Joun. A. M. A.
Oct 28, 1939

Medical College News

Medical schools, hospitals and individuals ivill confer a favor by sending to these headquarters original
contributions, reviews and news items to be considered for publication in the Student Section.

The Victor C. Vaughan Dormitory at Ann Arbor
The Victor C. Vaughan House, the new dormitory
for medical students at the University of Michigan,
Ann Arbor, was opened for use at the beginning of
the new academic year. One of a group of dormitories
built recently at Ann Arbor, it offers accommodations
for 139 medical students. The staff of the Victor C.
Vaughan House includes a resident adviser who acts
as an overseer of student life, three assistant resident
advisers and a director-dietitian. The resident adviser
is Dr. Henry S. Emerson, instructor in anatomy. The
dormitory was named in honor of Dr. Victor C.
Vaughan, who was for many years dean of the Uni-
versity of Michigan Medical School.

Beginning a New Year at Jefferson
The 115th annual session at Jefferson Medical Col-
lege of Philadelphia was inaugurated September 20.
Robert P. Hooper, president of the board of trustees,
presided and the introductory lecture was delivered
by Dr. David M. Davis, professor of genito-urinary
surgery, on “Self-Reliance and the Medical Curricu-
lum.” The total enrolment is 498, of which number
145 are new students (135 admissions to the first year
class and ten admissions to the third year class). The
members of the first year class were prepared for
medical study in sixty different institutions. Thirty-
two states, Puerto Rico, Hawaii, Persia and Korea are
represented. Announcement was made of the election
of Dr. James R. Martin as James Edwards professor of
orthopedic surgery, succeeding Dr. J. Torrance Rugh,
who was made emeritus professor.

Medical Students’ Musical Fraternity
The musical group at the University of Illinois Col-
lege of Medicine in Chicago was first organized in
1931. After a few years this group was founded as a
musical fraternity, Phi Mu Phi. The Illini Scope claims
that this organization is the only musical organization
in a medical school in the United States. A medical
school in another state has requested permission to
inaugurate the Beta chapter of Phi Mu Phi.

Family Doctors and Scholarships at Tufts

The award of four Commonwealth Fund scholar-
ships to incoming students of Tufts College Medical
School, Boston, was announced September 20 by Dr.
A. Warren Stearns, dean. These provide 81,000 a
year to one resident of each of the four northern
New England states, on condition that the recipient
agrees to practice in a rural community in his state
for at least three years following two years’ intern-
ship after graduation. The scholarships were awarded
to George L. Cushman, Medford, Mass.; Eugene H.
Wozmak, East Jaffrey, N. H.; Charles R. Blackburn,
Brattleboro, Vt., and Stanley W. Staples, Gardiner,
Maine.

The Charles P. Thayer Scholarship and the Eliza-
beth A. Riley Scholarship for second-year women
students were awarded respectively to Miss Victoria L.
Maxwell, Mamaroneck, N. Y., and Miss Winifred San-
born, Boscowen, N. H.

Tufts College Medical School, which is one of three
medical schools in the country chosen as recipients of
the Commonwealth Fund scholarships, draws its stu-

dent body largely from the colleges of New England.
The announcement says that of 6,000 physicians trained
in New England and settled in New England com-
munities since 1900, one in three is a Tufts graduate.

Louisiana’s Graduating Class
Of the sixty-two fourth year students of the School
of Medicine of Louisiana State University who received
the Bachelor of Medicine degree at the university
commencement in Baton Rouge May 29, forty-six
were from Louisiana. Twenty-seven already had the
Bachelor of Science degree, eight the Bachelor of Arts
degree, one the degree of Doctor of Dental Surgery
and another the Doctor of Philosophy degree. The
five students in the class who made the highest grades
are, in the order of their standing, Joseph D. Lea,
New Orleans; Samuel Zurik, Brooklyn; Eustace V.
Chauvin Jr., Lafayette, La.; Robert B. Morrison, Austin,
Texas, and Melville Rosenbusch, Richmond Hill, N. Y.

Loans to Students at Harvard
Funds have been established at Harvard Medical
School, Boston, to which students in need of money
may make applications for loans. Amounts up to $400
may be loaned to a student during any one year and
up to a total of $1,000 during the course. Application •
should be made by May 15, but in an emergency it may
be made at other times. Notes are payable two years
after graduation and 5 per cent interest is charged.
Loans are made to students in the second, third and
fourth year classes whose records are sufficiently
creditable to make it probable that they will remain
in the school and will be able to repay the loan at the
time arranged for. Recent matriculants may apply for
their loans only in their second half year. Loans are
rarely made to married students. Among the various
loan funds are the David L. Edsall Revolving Loan
Fund, the Charles William Eliot Loan Fund, the John
Foster Fund, the Loan Fund of the Medical Class of
1879. Application should be made at the office of the
dean of the medical school.

Harvard also has a great many scholarships to offer
in the way of rewarding and aiding medical students.
Most of these scholarships are open only to students
who are members of the school at the time of applica-
tion; however, in order to make it possible for young
men of great ability and promise to come to Harvard
Medical School, one or two Harvard Medical School
National Scholarships are offered to incoming members
of the first year class. The stipend carried by these
two scholarships is sufficiently large, if necessary , to
meet all the student’s essential expenses. Successful
applicants who maintain a high honor record at the
school will continue to hold these scholarships
throughout the course at the medical school. These
scholarships are made possible by gifts from Edward
S. Harkness and Dr. Daniel F. Jones. Direct applica-
tion for these scholarships cannot be made, since all
accepted first year students are considered candidates
and the awards are made without reference to financial

circumstances. . ,

Harvard has available also fellowships for the pur-
pose of aiding students, graduates or teachers m
research or postgraduate study. Applications concern-
ing all the foregoing should be made to the office o
the dean, Harvard Medical School.

Volume 113
Number 18

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

1695

Medical Murals Presented to University of California
Murals depicting the history of California medicine
were presented to the University of California at a
special ceremony recently in the university hospital.
The murals occupy all the free portion of the circular
wall in Toland Hall above the demonstration pit.
One wall shows the development of medicine in north-
ern California and the other in southern California.
The earliest Indians are seen emerging from their
sweat houses, or being worked over by the medicine
man. Gold rush medicine is the subject of a mural in
the central background. Dr. Don Pablo Soler, Spanish
surgeon of the late eighteenth century, is seen attend-
ing an Indian. The transition from these early crude
forms of medical attention to the scientific procedures
of today is skilfully made by the artist. Another cen-
tral panel show's the first hospital of California, a
crude shelter put up at San Diego in 1789 to succor
members of the Portola expedition. The incident of
James Ohio Pattie, old California trapper, vaccinating
a number of early Californians against smallpox is
also shown.

Darthmouth Personal

Donald deForest Bauer, Brooklyn, a sophomore at
Dartmouth Medical School, Hanover, N. H., has been
awarded a Mellville Cramer Foundation Fellowship
and will study genetics at McGill University, Montreal,
where he will be a candidate for a doctorate in both
medicine and philosophy. Mr. Bauer is the son of
Dr. John L. Bauer.

Loan Funds at Emory University

Emory University, Atlanta, Ga., has a number of loan
funds which are used to assist wrnrthy students, about
which information may be obtained from the dean of
men. It is difficult, however, to secure loan funds for
students of medicine in the university except during
the junior and senior years, on account of the length
of time necessary for medical students to remain in
school. The demand for assistance is greater than can
be met by these funds, and a student who is able to
do so should make previous arrangements for financial
aid. University bills for tuition, fees and dormitory
are payable by the quarter in advance. There is a
matriculation fee of $5, payable only once. A student
activities fee of §4.50 is collected quarterly, and the
charge for tuition and fees is §112.50 a quarter. Each
student must keep on deposit a damage deposit fee of
§5 to guarantee against loss or damage of university
property entrusted to him. Each student must provide
himself with a microscope.

The charge for a single room in Dobbs Hall by the
quarter is §30. Meals may be obtained in a cafeteria
on the campus at from §17 to $25 a month.

entire university. It provides a lounge, billiard room,
banquet hall, refreshment counter, cafeteria and
reception room. The union aims to foster genuine
democracy among the students, to develop their sense
of responsibility, to promote their powers of self
government and to cultivate the social factors of har-
mony and refinement.

Estimate of Expenses at Marquette
Following is an estimate of about the low'est figures
on the expenses for the school year at Marquette Uni-
versity School of Medicine, Milwaukee:

Tuition and fees $450

Board and room. 270

Laundry 50

Books and stationery 75

Microscope, per year (if purchased on instalment

basis) 35

Incidentals 30

Total §910

Portrait o£ Irvin Abell

At the graduation banquet of the University of
Louisville School of Medicine, Louisville, Ky., the class
of 1939 presented to the school an oil painting of Dr.
Irvin Abell. Dr. Oscar O. Miller presented the painting,
which was received by the dean, Dr. John W. Moore.

Student Health Service at Indiana
With the opening of the 1939-1940 school year, a
student health and medical service was established
at Indiana University, Indianapolis. Dr. Willis D.
Gatch, dean of the Indiana University School of Medi-
cine, has been named director of the program. The
service will provide clinical facilities for all students
in the university with attendant physicians and nurses,
twenty-four hour provision for emergency calls, an
x-ray laboratory, beds for observation cases and
hospitalization.

Scholarship Available for Freshmen at Alabama

The local chapter of Phi Beta Pi medical fraternity
has established at the University of Alabama School
of Medicine, University, Ala., an annual scholarship of
$90 to be awarded to some wrnrthy freshman who has
matriculated by May 1 for the next regular session of
the school of medicine. A committee of Professors
Carmichael, Foley, Goss, Graves, Hunt, Jeller and
McBurney W'as nominated to make the award. For
guidance of the committee the donors made the follow-
ing statement:

In making tlie award, it is the sentiment of the donors that
the previous scholastic record and other qualifications of any
student shall have been such that the award would he granted
to a student who gave promise of a successful career in medicine;
and finally, other things being equal, the award should preferably
be given to a student, man or woman, who needed financial aid.

Loan Funds at Marquette

The Father Noonan Student Aid Society administers
a loan fund which is available only to seniors. The
Mary Connor Student Loan Fund was established by
the Wisconsin Council of Catholic Women for the
assistance of women students and is ordinarily
available only to juniors and seniors. Information may
be obtained regarding these funds from tlie dean of
men and the dean of women respectively. The uni-
versity has a residence hall for women students from
out of town known as the Alumni House and also a
social center for women students known as Drexel
Lodge, the latter providing study, rest and recreation
rooms and facilities for serving luncheons. The Mar-
quette Union is available for male students of the

Research Assistantships at Louisville
Research assistantships of $135 each are allotted
annually to seven students at the University of Louis-
ville School of Medicine, Louisville, Ky., who dis-
tinguish themselves in research. Preference is given
to candidates for graduate degrees.

Expenses at Vanderbilt

The average annual expenses of a student at Vander-
bilt University School of Medicine, Nashville, Tenn.,
exclusive of clothes and incidentals, are estimated at
from $800 to $1,000. Among the iter-’- ■ ■ ’ * ■■■

sum is the tuition fee for the year of : ■ , ■ ■ ....

1696

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Joun. A. M. A,
Oct 28, 1939

fee of 610, a diploma fee of $5, a fee for the support
of the Student Union of $5 and, for the fourth year
students, a rental charge of $2 for academic hoods at
commencement. Each student is required to possess a
standard microscope, but to aid first year students in
purchasing one the school will advance three fourths
of the purchase price, to be repaid in three equal
instalments at one, two and three years after the date
of purchase. The necessary books cost about 650 a
year. All students are required to provide themselves
with hemocytometers and hemoglobinometers before
the beginning of the second trimester of the second
year.

Tests for Premedical Students at Minnesota

The Minnesota Medical Aptitude, the Strong Voca-
tional Interest, and the Sophomore Culture Tests must
be taken at the end of the second premedical year or
in the first quarter of the third year. Students at the
University of Minnesota may take these tests on the
campus at a.time to be announced in the official bulletin.
Students in other colleges and universities should com-
municate with the University Testing Bureau to make
arrangements for taking these tests. Fees are payable
by the applicant.

The National Medical Aptitude Test is given in
December of each year at the various universities and
colleges of the country. It is best taken during the
second or sophomore year in college.

Scholarships and Medals at Vanderbilt University
A Founder’s Medal is awarded to the student in the
graduating class of Vanderbilt University School of
Medicine, Nashville, Tenn., who has attained the high-
est average standing in scholarship throughout the four
consecutive years of study.

The Commonwealth Fund provides an annual grant,
as a scholarship fund for deserving medical students.
The terms require that a student who receives such
consideration shall agree to practice as much as three
years in a rural area in Tennessee after graduation
and after having served an internship of not less than
two years. These scholarships may be renewed for
each of the four years of medical study, but only
bona fide residents and natives of Tennessee are
eligible. Application blanks, which may be obtained
from the registrar at the school of medicine, should
be filed prior to March 1,

The Beauchamp Scholarship is awarded to the stu-
dent showing the greatest progress in the department
of neurology and psychiatry and who is otherwise
worthy, and deserving.

The Dr. Ben Witt Key Annual Award, amounting to
$500, is made to the fourth year student who is among
the five highest in scholarship and judged by the
faculty to be outstanding in scientific ability, in char-
acter and in personality.

The Opening of School at Ann Arbor
The ninetieth annual opening of the University of
Michigan Medical School, Ann Arbor, was held in the
School of Graduate Studies, September 25, on which
occasion the president of the University of Michigan,
Dr. Alexander G. Ruthven, introduced Dr. Francis E.
Senear, of Chicago, who spoke on “Some Phases of
Medical Education and Practice.” A graduate of the
University of Michigan Medical School, Dr. Senear has
been head of the department of dermatology at the
University of Illinois College of Medicine, Chicago,
since 1925, and during the past year was president
of the American Dermatological Society. Following
the convocation address, Dr. Senear was granted the
honorary degree of Master of Arts. At this time, also,
the Sternberg Medal was awarded to Dr. Malcolm
Block, of the class of 1939, for outstanding work in
medical research and high scholarship.

Interns’ Organization

The annual meeting of past and present interns of
the San Diego County General Hospital was attended
June 22 at the Emerald Hills Country Club by thirty-
five physicians. Dr. Alfred J. Cooper acted as chair-
man, and a permanent organization was formed with
Dr. Alexander M. Lesem, president. An appropriate
greeting was voted for the incoming interns.

Internships in Baylor Hospital
Each year thirteen members of the graduating class
of Baylor University College of Medicine, Dallas, are
awarded internships in Baylor Hospital on their
scholarship standing and personal fitness. This is a
one year internship beginning July 1 and, according to
the official bulletin of the university, offers excep-
tional opportunities for a broad clinical training in
the treatment of a great variety of diseases. The 400
bed Parkland Hospital, which is jointly controlled by
the city and county of Dallas, offers a combination
graduated service of internship and residency extend-
ing over a period of two years.

Transfer of Students from North Carolina
Only the first two years of the medical course are
given at the University of North Carolina School of
Medicine, Chapel Hill. It is necessary for the students
to go elsewhere for the remainder of their studies.
Following are the transfers which the students have
made for the year beginning in September 1939:

Jesse Appel, Brooklyn, (o New York University College of
Medicine, New York.

Ralph M. Bell, Mooresville, N. C., to Jefferson Medical College
of Philadelphia.

Daniel H. Buchanan, Chapel Hill, X. C., to Harvard Medical
School, Boston.

Jesse B. Caldwell, Cramerton, N. C., to McGill University Faculty
of Medicine, Montreal.

Henry T. Clark, Scotland Neck, N. C., to the University of
Rochester School of Medicine, Rochester, N. Y.

Charles E. Cionjnger, Claremont, N. C., to the University of
Maryland School of Medicine and College of Physicians and Sur-
geons, Baltimore.

Joseph B. Crawford, Goidsboro, N. C., to Jefferson Medical Col-
lege of Philadelphia.

Alfred M. Elwcll, Camden, N. J., to the University of Penn-
sylvania School of Medicine, Philadelphia.

Benjamin F. Fortune, Greensboro, N. C., to Jefferson Medical
College of Philadelphia.

Eugene F. Hamer, McColl, N. C., to the Medical College of the
State of South Carolina, Charleston.

Pearl Huffman, Morganton, N. C., to the University of Maryland
School of Medicine and College of Physicians and Surgeons,
Baltimore. ,

Gilmer Mebane, Chapel Hill, X. C., to Harvard Medical Schoof,
Boston.

Balph S. Morgan, Penland, X. C., to Rush Medical College,
Chicago. . ...

Max M. Novicb, Newark, N. J., to the University or Louisville
School of Medicine, Louisville, Ky.

Irene Phrydas, Greensboro, N. C., to the University of Marjinn
School of Medicine and College of Physicians and Surgeons,
Baltimore. _ . ,,

Edwin A. Basherry, Snow Hill, N. C., to the University or
Pennsylvania School of Medicine, Philadelphia. .

Mack Simmons, Chapel Hill, X. C„ to the Medical College of
the State of South Carolina, Charleston.

Emmet R. Spicer, Goldsboro, N. C., to Cornell University Mem
cal College, New York.

Robert L. Strieker, Asheville, N. C., to the University of Jenn-
sylvania School of Medicine, Philadelphia. .

Edmund R. Tnvlor, Chapel Hill, N. C., to Johns Hopkins urn

C.„ to Harvard Medics.

S< Jamcs r Ward la v Jr., Calypso, X. C„ to New York- UnlwrsfU
College of Medicine, New York. t rnffetfe

Samuel B. Willard, Doylestown, Pn., h> Long Island C

of Medicine, Brooklyn. r „n„, ri.lengo.

Milton H. Yudcll, New York, to Bush Medical College, Chic g

The Journal of the
American Medical Association

Published Under the Auspices of the Board of Trustees

Vol. 113, No. 19

Copyright, 1939, by American Medical Association

Chicago. Illinois

November 4, 1939

RIBOFLAVIN DEFICIENCY IN
HUMAN SUBJECTS

V. P. SYDENSTRICKER, M.D.

L. E. GEESLIN, M.D.

C. M. TEMPLETON, M.D.

AND

J. W. WEAVER, M.D.

AUGUSTA, GA.

The possible relation of riboflavin deficiency to cer-
tain manifestations of human pellagra has been of
interest to investigators of various deficiency diseases
for a number of years. During 1935 and 1936 at
least four groups of observers 1 treated small groups
of pellagrins with relatively minute doses of riboflavin
with no evidence of curative effect. Our own experi-
ence with four patients treated with 3 mg. of lactoflavin
a day for five days was entirely negative. Sebrell,
Hunt and Onstott 2 observed no improvement in dogs
with experimental blacktongue given relatively large
doses of riboflavin by mouth. Nevertheless the close
similarity of the mode of death of dogs with experi-
mental riboflavin deficiency with that in fatal human
pellagra and the constant finding of extreme fatty degen-
eration of the liver in the two conditions seemed to
point to some significant relation.

No clinical sign of human riboflavin deficiency had
been recognized until Sebrell and Butler 3 in 1938
called attention to the incidence of “cheilitis” in a
number of patients maintained under experimental con-
ditions on a diet poor in riboflavin; this condition was
cured by riboflavin. The “cheilitis” described by
Sebrell and Butler occurs frequently in endemic pel-
lagra and has commonly been considered an accessory
sign of the pellagrous syndrome. Stannus 4 many years
ago described it as “marginal stomatitis.” The lesions
consist of redness, desquamation and finally ulceration
of the lips at the mucocutaneous junction with fissures
or “rhagades” at the corners of the mouth; either or
both may be present. A number of Sebrell’s experi-
mental subjects presented these phenomena before any
frank signs of pellagra were evident. The relation of

From the Department of Internal Medicine, University of Georgia
School of Medicine and the University Hospital.

1. Dann, W. J.: Vitamin G Complex: Nonidentity of Rat Dermatitis
Due to Vitamin Bn Deficiency and Dermatitis of Human Pellagra, J.
Nutrition 11:451*462 (May) 1936. Spies, T. D.: Personal com-
munication to the authors. Fouts, P. J. ; Lepkovsky, S.; Helmer, O. M.,
and Jukes, T. II.: Successful Treatment of Human Pellagra with
“Filtrate Factor,” Proc. Soc. Exper. Biol. & Med. 35 : 245-247 (Nov.)
1936. Authors’ unpublished observations.

2. Sebrell, W. H.; Hunt, D. J., and Onstott, R. H. : Lactoflavin in
Treatment of Canine Blacktongue, Pub. Health Rep. 53:235 (Feb. 26)

3. Sebrell, W. H., and Butler, R. E. : Riboflavin Deficiency in Man,
Pub. Health Rep. 53:2282 (Dec. 30) 1938.

4. Stannus, H. S.: Pellagra in Nyasaland, Tr. Soc. Trop. Med. &
Hvg. 5; 112-119, 1912.

these epithelial lesions to the dermatitis of pellagra is
of considerable interest, particularly since it has been
the common experience that “cheilitis” and dermatitis
heal slowly under nicotinic acid therapy of pellagra
while treatment with yeast or liver extract causes rapid
involution. It has also been observed that cheilitis may
develop while oral and neurologic manifestations of
pellagra are being cured with nicotinic acid. 3 In some
instances cure of rhagades has been observed in patients
treated with nicotinic acid alone, 3 but here the question
of increased appetite with consumption of large amounts
of “pellagra-producing” food containing some ribo-
flavin must be considered. Spies and the Vilters,"
thought that pellagrous dermatitis in patients treated
with nicotinic acid healed more promptly after the
administration of large doses of riboflavin.

During the past three months six patients have been
observed who showed evidence of possible riboflavin
deficiency; five of these had definite signs of pellagra
as well. Patient 2 was so ill that it was not considered
justifiable to hold her under experimental conditions ;
patient 5 had diabetes and was in urgent need of con-
trol, so her diet was that required for regulation of
her diabetes. The other four patients were kept on
our standard pellagra-producing diet during the period
of experimental therapy. Riboflavin used in treatment
was the synthetic crystalline product furnished by-
Merck & Co., Inc., and “Lactoflavin” for injection was
furnished by the Winthrop Chemical Company. An
extract of liver prepared fen- intravenous use but lack-
ing in hemopoietic activity was furnished by Parke,
Davis & Co.

REPORT OF CASES

Case I. — J. A. M., a white man aged 34, was admitted
Dec. 30, 1938, in severe alcoholic excitement. He was known
to have been on a prolonged debauch and to have eaten little
for about three weeks. There was a fine scaly dermatitis
of the nasomalar grooves and alae of the nose as well as of
the chin. There were deep radiating fissures at the corners of
the mouth, and the lips were red and excoriated along the line
of apposition. The tongue was typical of pellagra. There was
slight brownish dermatitis of the hands and elbows. General
physical examination as well as routine laboratory determina-
tions showed nothing of significance. The gastric contents
after histamine showed 20 degrees free hydrochloric acid and
30 degrees total acidity. He was maintained largely on dextrose
solutions given intravenously and liquids by mouth for ten days,
during which there was slight increase in the labial lesions
and glossitis. There was no diarrhea. A pellagra-producing
diet was begun Jan. 10, 1939, and on January 11, 12 and 13
the “nonhemopoictic” liver extract was given, 40 cc. intra-
venously each day. No effect on the glossitis or cheilitis was
evident after, six days. Lactoflavin was then administered

, Liiimii,

uumuia.

present report.

... R. filter, S. A, and Spies, T. D.: Relation Between

Nicotinic Acid and a Codehydrogenase (Cozymase) in Blood of Pellagrins
and Normal Persons. J. A. M. A. 113 : 420-4">? (Feb 4) 1939 E

1698

Jour. A. M. A.
Nov, 4, 1939

RIBOFLAVIN DEFICIENCY— SYDENSTRICKER ET AL.

intramuscularly, 3 mg. a day from the 19th through the 24th.
January 23 there was definite evidence of healing of the lips.
This continued slowly and was complete on the 30th. During
the same time the scaly dermatitis of the nose and chin resolved.
Later treatment with nicotinic acid caused rapid cure of the
glossitis.

Case 2. — U. B., a white woman aged 38, was admitted
Jan. 3, 1939, with a diagnosis of severe endemic pellagra. She

was emaciated, dis-
oriented and slightly
febrile and had severe
diarrhea. There was
marked fine scaly der-
matitis of the nose and
malar eminences with-
out erythema. The
lips showed extreme
redness and excoria-
tion along the line of
closure, and there were
deep radiating fissures
at the corners. The
gums, oral mucosa and
tongue were fiery red
with much superficial
ulceration and gray
exudate, the pharynx
and visible portions of
the larynx showed
similar lesions and the
patient was aphonic from involvement of the vocal cords. Gen-
eral physical examination revealed nothing noteworthy. The
vagina was intensely red with much seropurulent discharge.
Dermatitis of the neck, hands and feet was absent. The blood
showed 10 Gm. of hemoglobin per hundred cubic centimeters,
4,100,000 erythrocytes and 7,600 leukocytes per cubic millimeter.
The Wassermann reaction was strongly positive. Other labora-
tory examinations were not significant. It was not possible to
examine the gastric contents on account of the extreme sensi-
tiveness of the inflamed pharynx. The patient was given a soft
pellagra-curative diet without yeast, and nicotinic acid was
administered intravenously, 300 mg. a day from January 4 to 7;
thereafter it was given by mouth, 75 mg. a day. There was
the usual dramatic response of the glossitis, stomatitis and diar-
rhea; all were cured on the third day of treatment, and on this
day the mental state seemed quite normal. The patient ate of

Fig. 2. — (case 3). — Dermatitis of bands on admission.

the curative diet greedily after the first day of treatment. The
lips healed somewhat more slowly than the buccal mucosa, but
on the fifth day of treatment cheilitis and rhagades were cured.

Case 3. — F. P., a white man aged 54, was admitted Feb. 9,
1939, with a diagnosis of relapse of chronic pellagra; he had
been seen on four previous admissions with severe pellagrous
lesions. At this time there was slight branny desquamation
of the nose and malar eminences, the lips and buccal mucosa
were of norma! color, there were no fissures at the comers of

the mouth and the tongue was of normal color and texture
(figi. 1). The hands showed a bright red “dry 1 * dermatitis with
marked desquamation (fig. 2) quite different from the usual
vesicular and bullous lesions present on previous admissions
and the genitalia and feet were free from dermatitis. General
physical examination was negative. The blood contained 11
Gm. of hemoglobin per hundred cubic centimeters and 3,000,000
red cells and 11,000 white cells per cubic millimeter. There
was total achlorhydria after histamine. Other laboratory
examinations were not significant. This man was of particular
interest because he had been the subject of numerous therapeutic
experiments and was a very labile pellagrin in whom relapse
could be produced quite regularly by maintenance on dextrose
and water or on a “maize diet” for five or six days. His

Fig. 3 (case 3). — Hands after treatment with riboflavin.

Fig. 4 (case 4).- — Lesions of lips and nares before treatment.

present dermatitis was quite different from that seen on previous
admissions ; the usual severe stomatitis and glossitis were absent
and he did not have diarrhea. He was given the basal pellagra-
producing diet and riboflavin was administered subcutaneously,
50 mg. February 12, 13 and 14. No other treatment was used
and from February 15 the left hand was exposed to an infra-
red lamp for twenty minutes twice each day. On February 16
there was definite blanching of the hands; this was progressive
and by February 24 the skin was of normal color, though
there was still some desquamation. In the opinion of various
observers the hand exposed to heat healed somewhat more
rapidly than did the other, February 27 an attempt to produce
relapse was made by putting the patient on a dextrose and
water diet; this was continued for five days with no effect
(fig. 3). A “maize diet" consisting of 500 Gm. of cornmeal
mush and syrup as desired was then substituted for dextrose
and water and continued for four days without producing any
sign or symptom of pellagra. The experiment was then
terminated.

Fig. 1 (case 3). — Tongue on admission.

Volume 313
Number 19

RIBOFLAVIN DEFICIENCY— SYDENSTRICKER ET AL.

1699

Case 4. — L. J., a Negro girl aged 17, was seen Feb. 18, 1939,
on account of a “sore mouth” which had developed during
hospitalization subsequent to an arthroplasty of the left hip
joint. For about three weeks after the operation she had
refused regular ward diet and had eaten hardly anything except
white bread and syrup, corn bread and syrup and hominy with
gravy. She was excellently nourished and developed, afebrile
and free from gastrointestinal disturbances. The palpebral
and scleral conjunctivas were very red, there was a small
amount of serous exudate from the conjunctival sacs, and photo-
phobia was extreme. There was no evidence of iritis. The
lips were intensely red, almost denuded, with deep fissures in
the vermilion and slight fissures at the corners ; the upper lip
showed an oozing moist dermatitis; there was a deep fissure

Fig. 5 (case 4). — Lips and nares after treatment with riboflavin.

Fig. 6 (case 5). — Lesions of lips and corners of mouth on admission.

at the junction of the nasal septum and lip, and the septum
and lower portions of the alae showed dermatitis similar to
that on the upper lip. The skin elsewhere was of excellent
texture. The tongue and buccal mucosa showed nothing
abnormal. General physical examination and routine labora-
tory procedures were not significant. Cultures from the lips
and nose showed no unusual bacteria and no fungi (fig. 4).
The patient was put on a pellagra-producing diet, which she
ate well, and on February 19 riboflavin was given by mouth,
30 mg. in doses of 10 mg. three times a day; this was con-
tinued until February 23. During these five days there was
some improvement in the lips but none in the nasal lesion;
the amount of riboflavin was increased to 60 mg. a day on
February 24, and this dose was continued until February 26,
at which time the lips were cured and the deep fissure at the
base of the nasal septum was almost healed. Two days after
treatment was discontinued there was a rapid recurrence of
cheilitis and the nasal fissure reopened. On March 1 and 2

riboflavin was given hypodermically in doses of 10 mg. once a
day, and by March 4 the lesions were again healed; on this
occasion there was marked improvement in conjunctivitis and
photophobia. On March 9 a second relapse occurred, the lips
nose and conjunctivas being quite as much affected as at first.
On this day 20 mg. of riboflavin was given intravenously.
From this time on there was rapid healing of the lips and
nose with disappearance of conjunctivitis and photophobia. On

t:

Fig. 7 (case 5).— Lips after treatment with riboflavin.

March 15 no abnormality of the lips could be seen, the naso-
labial fissure was healed and the eyes were normal (fig. 5).
The patient was then given a regular diet and has remained
well.

Case 5. — M. W., a white woman aged 58, was admitted
March 1, 1939, with the diagnosis of diabetes mellitus. She
was slightly obese, somewhat pale and had slight edema of the
feet. There were deep fissures at the corners of the mouth,
and the lips were red and slightly excoriated along the line
of apposition (fig. 6). The tongue was bright red, atrophic
and fissured. General physical examination showed cardiac
hypertrophy, severe hypertension and moderate enlargement of
the liver. There was vaginitis with some seropurulent discharge.
The fasting blood sugar was 330 mg. per hundred cubic centi-

F‘S- 8 (case 6). — Lesions of corners of nioulli which developed during
treatment with nicotinic acid.

meters, and 1 1 Gm. of dextrose was excreted in the first twenty-
four hour collection^ of urine.. She was given a diet containing
50 Gm. of protein, 50 Gm. of fat and 150 Gm. of carbohydrate,
and 10 units of protamine zinc insulin was administered each
morning. On the third day the lips were healed and the fissures
at the corners of the mouth were dry and well covered with
epithelium. The original amount of protamine zinc insulin
was found inadequate and the dose was increased on March 8

1700

SUBACUTE BACTERIAL ENDOC ARDITIS— KELSON AND WHITE Jour. a. nr. a.

Nov. 4, 1939

to 30 units. On March 10 the fissures at the corners of the
mouth reopened and were quite painful ; the tongue had remained
red and fissured. On March 11 riboflavin was given intra-
venously, 10 mg. in 200 cc. of physiologic solution of sodium
chloride, and on March 12, 25 mg. was administered by the
same route. The lips healed during the ensuing three days
and the patient felt much better; no change was noted in the
tongue (fig. 7). During this time the dose of insulin had been
increased to control glycosuria and hyperglycemia until 50 units
was being given daily. March 19 there was a sudden recurrence
of the cheilitis and painful fissures at the corners of the mouth.
Riboflavin was given by mouth in doses of 20 mg. a day for
five days, and again the lips healed, though small fissures per-
sisted in the right corner of the mouth. Nicotinic acid was
then started, 25 mg. four times a day. Glossitis, which had
persisted, was healed on the third day of treatment, but slight
excoriation persists at the corners of the mouth.

Case 0. — L. H., a white woman aged 68, was admitted
March 8, 1939, with the diagnosis of chronic endemic pellagra.
She was emaciated, pale and slightly disoriented. There was
slight scaly dermatitis of the nose and nasolabial folds, small
fissures were present at the corners of the mouth, the lips
seemed normal and the tongue was bright red and atrophic.
The skin over the dorsal surfaces of the hands was atrophic but
no dermatitis was present. General physical examination
showed arteriosclerosis and moderate hypertension, moderate
cardiac hypertrophy and the residua of a left hemiplegia. The
blood showed 9 Gm. of hemoglobin per hundred cubic centi-
meters, 3,800,000 red cells and 8,400 white cells per cubic
millimeter. The gastric contents were achlorhydric. The
patient had been seen on several occasions with various mani-
festations of pellagra. She was given a pellagra-producing diet,
and nicotinic acid was administered intravenously, 100 mg. a
day from the day of admission until March 20. Disorientation
and glossitis were absent on the third day of treatment but the
fissures at the corners of the mouth grew rapidly worse and
by March 11 were so painful as to interfere with eating (fig. 8).
Ten mg. of riboflavin was given subcutaneously on March 11,
and because no effect was observed 50 mg. was given by the
same route on March 13. On the second day there was much
improvement in the oral fissures but by March 17 they had
recurred and were painful. Riboflavin was then given by
mouth, 20 mg. daily from March 17 to March 23, with some
improvement. The fissures became dry and less painful but
did not heal. March 20 a soft diet was given and oral admin-
istration of 100 mg. of nicotinic acid was substituted for intra-
venous injection. During the nine days no change has occurred
in the fissures at the corners of the mouth, though there has
been considerable improvement in the patient’s condition.

COMMENT

Five patients who presented lesions corresponding
with those described by Sebrell and Butler as being
due to riboflavin deficiency have been observed ; another
with atypical dermatitis of the hands is included in
this report. Five of these patients either showed evi-
dences of pellagra or were known to be chronic pel-
lagrins. Patient 2 was cured of cheilitis as well as of
pellagrous lesions while under treatment with nicotinic
acid and an ample diet. It seems likely that adequate
intake of food containing ample amounts of riboflavin
explains her recovery. Patient 4 had no sign or symp-
tom of pellagra but showed severe cheilitis and con-
junctivitis; she recovered under riboflavin, given by
various routes, and twice relapsed soon after treatment
was discontinued. Patient 3. who was a known pel-
lagrin, showed no definite signs of pellagra but had an
atypical dermatitis of the hands, which was apparently
cured by large doses of riboflavin. Attempts to produce
pellagra’ by severe dietary restriction were later unsuc-
cessful. The other three patients showed much
improvement of cheilitis and fissures in the corners
of the mouth under riboflavin therapy, though there
was a tendenev to rapid relapse when treatment was

stopped. Large doses of riboflavin were, much more
effective in all cases and parenteral administration
seemed much more efficient than oral. In every instance
response to riboflavin was relatively slow, and in the
presence of an inadequate diet nicotinic acid given con-
currently seemed to have no adjuvant effect. One
patient developed cheilitis while under treatment with
nicotinic acid.

Particular interest was aroused by cases 3 and 4, in
which dermatitis, cheilitis and conjunctivitis seemed to
be cured by riboflavin.

A NEW METHOD OF TREATMENT OF
SUBACUTE BACTERIAL ENDO-
CARDITIS

USING SULFA PYRIDINE AND HEPARIN IN COM-
BINATION : PRELIMINARY REPORT

SAUL R. KELSON, M.D.
With the Assistance of
PAUL D. WHITE, M.D.

ROSTON

Analysis of 250 cases of subacute bacterial endo-
carditis with positive blood cultures for alpha (viridans)
and, rarely, gamma streptococci in Boston hospitals 1
stressed the ineffectiveness of all varieties of therapy
prior to the new chemotherapeutic drugs. Sulfanilamide,
used in twenty-four cases, and prontosil, used in five,
temporarily improved a few; used in four cases, sulfa-
pyridine, although not curative, appeared far more
effective. Data that we have collected from other clin-
ics and from one case report concerning sixty-six well
studied cases in which intensive treatment was given
with sulfapyridine confirm our experience that in most
instances the drug lowers the temperature and sterilizes
the blood stream but that these effects pass off in from
a few days to a month or, rarely, more. Only in one
reported case, 2 in which the blood cultures were posi-
tive for gonococcus and a nonhemolytic anaerobic strep-
tococcus, was there a recovery; the disease followed
its usual course in the other sixty-five.

Blood of patients with subacute bacterial endocarditis
usually has a high titer of antibodies for the organisms; 3
despite this fact, these bacteria will grow in the serum,
hut the)- die quickly, even in normal serum, when
leukocytes are present.' 1 The streptococci lie as a rule
near the periphery of the vegetation, a mass chiefly of
fibrin, an ideal culture medium and protective harrier,
and of platelets. Polymorphonuclear leukocytes are
scarce or absent in the vegetation , 5 At its base, fibrosis
is a nearly constant finding.

By present means it appears impossible to increase
the number of phagocytes and draw them into contact
with the bacteria, to dissolve the vegetations or to
induce granulation within them. One can attempt, how-
ever, to prevent further thrombotic deposition on their
surface in order to (1) restrict the nidus and culture

From the Medical Department (Cardiac Laboratory) of the Massa-
' l 'l? t Ke1son? r 's. R° SP am!’ White, P. D.: The Diagnosis, Prognosis, and

eccvery After Sulfapyridine, New England J. Med. 321: 167 (Aug. )

’1: Kinsella. K. A.: Bacteriological Studies in Subacute Bacterial

rulocarditis. Arch. Int. Med. 10:367 (March) 191 / . \\ 1 it, £

4. Friedman, Meyer; Katz. L. N., and Howell, Kathenne- Expcr
ental Endocarditis Due to Streptococcus ViridansjBioIo^c Factors

s Development, Arch. Int. Med. 61: 9a (Jan.) 1938- , . Fndo*

5 Wright If. D.: The Bacteriology of Subacute Infective r..
rditis, J. Path. & Pact. 2S;5H (No. 4) 3925.

Volume 113
Number 19

SUBACUTE BACTERIAL ENDOCARDITIS— KELSON AND WHITE

1701

medium for bacterial growth, (2) prevent embolism
from the freeing of fresh thrombus, and (3) check the
growth of the vegetations so that proliferating fibro-
blasts may fill in the areas thus limited.

These considerations have led us to treat the disease
not only with sulfa pyridine, for its bacteriostatic and
perhaps bactericidal action, 0 but also with an anticoagu-
lant, crystalline heparin, 6 7 which had been shown effec-
tive and in other conditions nontoxic, was chosen. 8

METHOD

The contents of a 10 cc. vial of heparin (10,000 units)
is added to 500 cc. of physiologic solution of sodium
chloride, and such a solution is given by uninterrupted
intravenous drip day and night for fourteen days. The
rate of flow (usually from 15 to 25 drops a minute)
is carefully regulated to maintain, as well as possible,
the venous clotting time (normally below twenty min-
utes) at approximately one hour. Clotting time is
measured before treatment, twice or more the first day
and then at least daily by the five tube method of Lee
and White. 9 Heparin is begun from four to seven
days after sulfapyridine has been started, when nausea
and vomiting have subsided and before “escape” from
its effects has occurred. From 4 to 6 Gm. of sulfa-
pyridine (with desired blood levels of 5 mg. per hundred
cubic centimeters or more) is given daily by mouth
before and during the use of heparin and for one week
afterward — a total of about four weeks. Blood trans-
fusions are given if there is anemia of 3,500,000 red
blood cells or below. Persisting infections (including
this one *) predispose to vitamin C deficiency. 10 which
interferes with fibrous repair; 11 all patients, therefore,
are saturated with 200 mg. of ascorbic acid by mouth
four times a day for three days and continued on
100 mg. a day. Other added vitamins and iron are
not essential to the therapy.

RESULTS

Six of our patients with subacute bacterial (Strepto-
coccus viridans) endocarditis and one patient with the
rarer condition of acute bacterial endocarditis caused
by the same organism have received the combination of
sulfapyridine and heparin. Each had had four or more
positive blood cultures. They were treated in the fol-
lowing order :

Case 1. — F. G., a man aged 21 with advanced disease com-
plicating patency of the ductus arteriosus, had severe recurrent
pulmonary infarction after three days of heparin (April 1939)
and both drugs were omitted. He died two weeks later.

Case 2. — E. S., a man aged 22 with a history of five attacks
of rheumatic fever, resulting in great heart damage, had been
ill two and one-half weeks with characteristic manifestations
of subacute bacterial endocarditis. Because of a red tender
joint, migratory arthralgia, prolonged auriculoventricular con-
duction and epistaxes, concurrent rheumatic fever was diag-

6. Marshall, E. K. : Bacterial Chemotherapy: The Pharmacology of
Sulfanilamide, Physiol. Rev. 10:240 (April) 1929 (sec pp. 255-258).
Keeler, C. S., and Rantz, L. A.: Sulfanilamide: A Study of Its Mode
of Action on Hemolytic Streptococci, Arch. Int. Med. 63: 957 (May)
1939.

7. Heparin is obtained from the Connaught Laboratories, University
of Toronto, Toronto, Canada, at a cost of $2.72 a vial.

8. Murray, D. G. W., and Best, C. H.: Heparin and Thrombosis:
The Present Situation, J. A. M. A. 110:118 (Jan. S) 1938: The Use
of Heparin in Thrombosis, Ann. Surg. 10S:163 (Aug.) 1938. Mason.
£v. i • : Heparin: A Review of Its History, Chemistry'. Physiology ami
Clinical Applications, Surg. 5:451 (March) 1939; 5:618 (April) 1939.

9. Hunter, F. T. : Laboratory Manual of the Massachusetts Genera!
Hospital, Philadelphia, Lea & Febiger, 1939, p. 25.

. Paulkner. J. M. : The Effect of Administration of Vitamin C on

eticulocytes in Certain Infectious Diseases, Neiv England J. hied.
= 13: 19 (July 4) 1935.

,, J L Lanman, T. H., and Ingalls, T. H. : Vitamin C Deficiency and
Wound Healing, Ann. Surg, 105:616 (April) 1937.

nosed 12 and further indicated by later onset of auricular
fibrillation following rheumatic pleuritis. The rectal tempera-
ture (104.6 F.) fell sharply on administration of sulfapyridine
(April 1939) ; cultures became negative. He was given two
transfusions. After receiving a total of 260 cc. of heparin in
fourteen days he gained strength and weight, and his tempera-
ture stayed under 100 F. for forty-five days (except for one rise
of 0.5 degree F.), then rose for three days with the pleuritis.
Since then, signs of rheumatic infection have recurred, and he
has been kept in bed since fibrillation appeared, with persistent
congestive heart failure. He has shown no evidence of bacterial
endocarditis, however, since shortly after the specific treatment
was stopped; since sulfapyridine has been omitted (May 19)
nineteen consecutive blood cultures have been negative. 1211

Case 3. — A. C., a woman aged 23 with rheumatic fever at
9 years and a slight mitral lesion, had a slowly progressing
bacterial endocarditis for six months, with an oral temperature
to 102 F. and splenic and cerebral embolism. Blood cultures
became negative on administration of sulfapyridine (April 1939).
She received 290 cc. of heparin in fourteen days. Since sulfa-
pyridine has been omitted (May 26) all blood cultures have been
negative, she has gained strength and weight (26J4 pounds
[12 Kg.) in three months) and has shown no evidence of the
disease. She has walked since June 14, is active and at work
and has no complaints.

Case 4. — M. S., a girl aged 19 years, with three attacks
of rheumatic fever and severe heart damage, had been ill three
weeks. After two transfusions, sulfapyridine was begun (June
1939; the rectal temperature fell sharply from 102-104 to 100 F.
or less but rose after eight days. Cultures remained positive.
Heparin was omitted after forty hours because of sudden head-
ache, vertigo and amblyopia. These conditions cleared, but five
days later, after thirteen hours of heparin, she had a chill and
fever and died. Autopsy showed large occipital and subdural
hematomas. These were probably embolic and occurred, we
believe, spontaneously, though the drug very likely increased
the hemorrhage and hastened death.

Case 5. — E. L., a man aged 41 with rheumatic aortic and
mitral regurgitation, entered the hospital July 8, 1939, because
of chills, high fever and prostration for one week following
six weeks of malaise. The rectal temperature of 104.5 fell to
normal on administration of sulfapyridine but rose after two
days; blood culture remained positive. An hour and a half
after beginning heparin he had a chill and high fever and went
into collapse. He died seventeen hours later. Autopsy showed
the typical lesion of acute bacterial endocarditis on the aortic
valve. His reaction after administration of heparin, and the
reactions in cases 6 and 7 were later traced to a faulty lot of
the drug, which caused similar reactions in several patients
with other conditions. Such reactions had not occurred pre-
viously and have not occurred since.

Case 6. — R. M., a man aged 25 with well borne aortic regurgi-
tation. which followed rheumatic fever at the age of 8 years,
entered the hospital July 21, 1939, with bacterial endocarditis
of one week’s duration. The temperature fell to normal on
sulfapyridine and blood cultures became negative. A chill and
high fever occurred after one and one half hour’s use of
heparin of the same toxic lot as that noted in case 5 and after
two further trials of the drug. He was therefore continued as
a control case on sulfapyridine alone, but emboli occurred from
time to time, anemia progressed, fever recurred and a blood
culture, taken thirty-eight days after treatment was started,
was positive. Ten days later sulfapyridine was discontinued
and a new lot of heparin was begun without reaction; to date
there has been little change in his condition.

Case 7.— J. H., a man aged 41 with well compensated mitral
regurgitation following rheumatic fever at 16, entered the

12. While, P. D. and Kelson, S. R.: The Clinical Relations Between
Subacute Bacteria! Endocarditis and Rheumatic Fever, to be published
l.a. This patient died in congestive failure Oct. 12, 1939. Autonsv
revealed an area of clearcut definitely healed bacterial endocarditis with
typical vegetations, fibrous and calcified, on the chronically scarred (rheu-
™' ra ,, va '4' This healed lesion is consistent in time relationship
with apparently effective treatment six months earlier. The aortic valve
showed also extensive, rheumatic scarring, but without any vegetations of
bodies!* 1 cndocard ' i1 '- _ The myocardium is being examined for Aschoff

1702

Jo us. A. SI. A.
Nov. 4, 1939

ENDOCARDITIS— FRIEDMAN ET- AL.

hospital July 20, 1939, severely ill with bacterial endocarditis
of seven months* duration. The rectal temperature, tvhich
had been spiking to 103 F., fell to normal, and blood cultures
became negative following the use of sulfapyridine. He received
two transfusions. Heparin of the same toxic lot noted in
case 5 was begun but omitted after one hour because of a
chill and fever. On the eighteenth day of sulfapyridine medi-
cation, heparin of another lot was resumed without reaction;
he received 18S cc. over a seven and one-half day period (a
larger supply was then lacking). Sulfapyridine was continued
for two weeks longer, until September 7. His improvement
has been striking. He began to walk four days later (after
having been bedridden for three months) and still remains free
of evidence of the disease, four weeks after stopping treatment.

Sulfapyridine was continued despite nausea and
vomiting, which were severe in two cases ; these symp-
toms gradually subsided. Lymphangitis in the region
of the intravenous injection in two cases cleared with
change of the site of injection and hot packs.

COMMENT

We have administered sulfapyridine and heparin to
six patients with subacute and one patient with acute
Streptococcus viridans endocarditis. Two of these
patients, one with subacute (patient 6) and one with
acute (patient 5) endocarditis, were able to take the
heparin for only an hour and a half because of reactions
to a toxic lot of the drug, too short a time to expect
any lasting effect on thrombus formation. Two other
patients (1 and 4) were able to continue the heparin
for only three days and two days respectively because
of the serious course of the disease itself, which termi-
nated fatally in a short time (two weeks or less).

The remaining three patients were able to take the
heparin for more than a week, a length of time probably
adequate to produce an important effect on thrombus
formation. All these three patients showed striking
improvement and have been free from evidences of the
disease for nineteen weeks, eighteen weeks and four
weeks respectively after discontinuing treatment. With
these results we contrasted 246 follow-up control cases:
afebrile intervals were rare for as long as five weeks
once fever had set in, and no patient, so far as we
could determine, remained free from signs and symp-
toms for that length of time except one boy, who without
specific therapy did so for a full year before he died
of rheumatic fever. 13 Our three subjects, moreover,
lack the characteristics of “bacteria-free” cases. 14

We recognize the possible danger of excessive bleed-
ing incident to embolism in these cases but believe it
fair to accept this risk in the face of the hopeless prog-
nosis of the disease. The chances of healing the vege-
tations would seem best early in the disease when they
are small. In this infection, in which exacerbations
with crippling and fatal embolism strike suddenly, the
earliest possible diagnosis and an attempt at early
therapy are important.

The" treatment which we have recounted is new and
still in the experimental stage; it is not to be advised
except under close and careful observation and prefer-
ably in the earlier cases or less seriously ill, and there
must be no doubt about the diagnosis. It can do harm,
but the possible benefit may well outweigh the risks,
we believe, in this almost universally fatal disease.

13. In a recent article Dr. Joseph A. Capps (Subacute Bacterial Endo-
carditis Due to Streptococcus Viridans with Special Reference to Prog-
nosis, Ann. Int. Med. 13:280 [Aug.} 1939) states that be has seen no
recovery from subacute bacterial endocarditis since 1924. Kelson and
White ®

14. Libman. Emanuel: A Consideration of the Prognosis in Subacute
Bacterial Endocarditis, Am. Heart J. 1:25 (Oet,) 1925.

Time will show how much more effective, if any, the
combined sulfapyridine and heparin therapy may be
than the use of either drug alone; there are likely to
be infrequent recoveries from the administration of the
single drug sulfapyridine or even sulfanilamide; heparin
has not yet, so far as we know, been employed alone
m the treatment of this disease. Neither blind to the
failures nor prematurely boastful of the apparent suc-
cesses, we shall continue patiently to gather further
experience to learn just how good our combined therapy
may prove to be and to better its technic. This pre-
liminary report is presented because of the interesting
method of attack and because that attack has in these
first few months given more promise than any other
method that we have ourselves used or heard of in the
past.

USE OF HEPARIN IN SUBACUTE
BACTERIAL ENDOCARDITIS

A PRELIMINARY- REPORT

MEYER FRIEDMAN, M.D.

SAN FRANCISCO

W. W. HAMBURGER, M.D.

AND

L. N. KATZ, M.D.

CHICAGO

Recent studies from this department 1 on experi-
mental Streptococcus viridans endocarditis in dogs
indicated clearly that the infection persisted because the
constant deposition of platelets and fibrin on the vege-
tation exceeded the rate at which the vegetation
implanted on the valve could be sterilized. Further
studies on both dogs and human beings suffering from
subacute endocarditis of the Streptococcus viridans
variety revealed that the blood did not lack the ability
to destroy the organism in vitro and that its inability
to do so in vivo was due to the fact that the effective
agent in the blood, the white blood cell, was unable to
reach the focus of infection because of the relative
avascularity of the valve leaflets and the dynamics of
the blood stream flowing past the vegetations.

Because of these facts it was thought possible that
the prevention of new fibrin and platelet formation by
the use of an anticoagulant might allow the valvular
processes of repair and sterilization to gain the
ascendancy and thus terminate the infection.

With this in mind, a patient was treated with new
concentrated heparin, which has been shown by Murray,
Jaques, Perrett and Best 2 to be effective in the P rc '
vention of thrombosis in animals and possibly in man,
following surgical procedures. These workers have
given this heparin by continuous intravenous infusion
for days to many patients with no noticeable ill effects.

The following case report deals with our observations
on a single patient having subacute bacterial endocar-
ditis. who died of cerebral hemorrhage before the treat-

From the Cardiovascular Department, Michael Reese Hospital-
Read by title at the Central Society for Clinical Research, C<n ' ■
ring November 1938.

The cost of the heparin was defrayed by a grant from an anon}
nefactor. Dr. Best, Dr. Murray and thefr abates
ming the utilization of heparin. Mr. Hutchison, of the Connaugm
tories, cooperated in facilitating the shipments of heparin. p „ r ;.

T Friedman, Meyer; Kate. L. N., and Howell. Katharine M.-. Eafer _
mtal Endocarditis Due to Streptococcus \ indan*. Archlnt-'

(Jan.) 1938. Friedman. Meyer: A Study of the Ffbrin Factor m
lation to Subacute Endocarditis. <53:1/ 3 (June) 1SU • £, If.:

2. Murray, D. W. G.; Jaques, L. B.; rcrrttt, T. S., and Lei., u
irgcry 2: 163 (Aug-) 1937.

Volume 113
Number 19

ENDOCARDITIS— FRIEDMAN ET AL.

1703

ment had been continued sufficiently long to evaluate
the worth of the procedure :

REPORT OF CASE

History. — A. H. was admitted to the Michael Reese Hospital
March 5, 1938, complaining of weakness, fever, loss of weight
and loss of appetite of several months’ duration. His illness
began insidiously in October 1937 with a vague feeling of
malaise, and as it progressed there developed a continuous
fever, loss of weight and strength, and embolic accidents. Before
coming to the hospital, he had been unsuccessfully treated with
quinine, sulfanilamide, antistreptococcus serum and blood trans-
fusions. The essential pathologic changes on admission were
(1) evidence of weight loss, (2) anemia, (3) clubbing of the
fingers, (4) a Corrigan pulse with a capillary pulse, (5) an
enlarged heart with a diastolic murmur at the base and a
short systolic murmur at the apex and (6) a temperature and
pulse rate elevation.

Laboratory examination revealed hemoglobin 65 per cent,
red blood cell count 3,150,000, white blood cell count 12,500,
sedimentation time 44 mm. in an hour, Weltman reaction 5,
blood sugar 88, nonprotein nitrogen 35, occasional red blood
cells in the urine, normal stool, Streptococcus viridans in three
successive blood cultures, and evidence of myocardial damage
shown in an electrocardiogram.

Following a blood transfusion, the new concentrated heparin
was added to physiologic solution of sodium chloride and 5 per
cent dextrose solution so that each liter contained 30,000 units
of heparin. A needle was fixed in the vein and, by means
of a rectal drip, the solution was given continuously for ten
days. The coagulation time of the blood was maintained after
the second day of treatment at twenty-five to thirty minutes
(five times normal for this patient).

The intravenous heparin treatment was begun on March 8
and was discontinued on the morning of March 18 because the
patient at this time began to show projectile vomiting. At
the same time his blood pressure began to rise and his tem-
perature to fall, suggesting a cerebral hemorrhage. He gradu-
ally lost consciousness and in the afternoon he died. In the
ten days during which he received treatment he experienced

no symptoms other than a transitory diarrhea until the final
episode. No petechiae were observed during the hospital stay.
No hemorrhage was noted following the withdrawal of the
intravenous needles, if pressure was applied for a few seconds.

Autopsy (by Dr. Otto Saphir). — There was no evidence of
internal hemorrhage in any organ other than the brain. In
this organ the lateral ventricles and the third and fourth
ventricles were seen to be filled with blood and there was
some blood in the subarachnoid space. The source of this

hemorrhage was found to .be an area of encepbalomalacia
(fig. 1) in the frontal lobe that had probably resulted from
a previous infected embolus from seven to ten days before.
The heart, particularly the left ventricle, was enlarged. The
tricuspid and pulmonic valves were normal but the mitral and
aortic valves showed an old healed endocarditis, and the aortic
valve leaflets were seen to be the site of a vegetative process
that had partially ulcerated the leaflets (fig. 2). The size of
the vegetations on the leaflets were not large and were “clean"

Fig. 2 . — Appearance of aortic valve showing ulcerative vegetations.

in appearance. There were two necrotic areas on the vege~
tations, possibly indicating dissolution of some of the fibrin.
Immediately beneath the aortic valves on the wall of the left
ventricle there was a minute vegetation, arising apparently by
contact. There were several infarcts in the spleen in various
stages of healing. The kidneys appeared normal grossly.

Microscopic sections of the brain lesion confirmed the opinion
made from the gross examination. The aortic leaflet vegeta-
tions were observed to be fairly well organized, bacteria being
present in the outer fringe of the thrombus, which had not yet
become organized. No polymorphonuclear leukocytes in the
valvular area immediately adjacent to the vegetation were
observed. Small focal accumulations of round and polymorpho-
nuclear cells were found in the myocardium. The kidneys
showed an acute, disseminated glomerular nephritis.

COMMENT

We are placing this note on record in order to stimu-
late further clinical investigation of this method of
therapy in subacute bacterial endocarditis. We are
aware that there are theoretical dangers to its use, since
in a disease prone to hemorrhage, as subacute bacterial
endocarditis occasionally is, the use of heparin by inter-
fering with the physiologic process of clotting may lead
to intractable or even fatal hemorrhage following the
rupture of a blood vessel after embolization, as might
have occurred in this case. The sudden liberation of
large quantities of bacteria should the vegetation disin-
tegrate may cause an overwhelming bacteremia. The
acute glomerular nephritis found in this case might
have been caused conceivably by the heparin. Further,
it has not been shown conclusively that heparin actu-
ally prevents the deposition of platelets and fibrin in
man, although the evidence is highly suggestive. It is
possible too that the promptness of instituting treatment
becomes an important and vital factor. However, these
contraindications to the use of heparin are not sufficient
to discourage its use, since the disease itself is almost
inevitably fatal and the possibility exists that some '
definite good may result. We therefore feel that the •
further trial of heparin in subacute bacterial endocarditis
is warranted. Further studies are being projected in
this department both on the experimental animal and
on human beings.

1704

TISSUE CULTURE— KING ET AL.

Jour. A. M. A.
Nov. 4, 1939

THE BACTERIOSTATIC AND ANTITOXIC
ACTIONS OF SULFANILAMIDE

TISSUE CULTURE STUDIES

JOSEPH T. KING, M.D.
AUSTIN F. HENSCHEL, Pii.D.

AND

BERYL S. GREEN, M.A.

MINNEAPOLIS

The bacteriostatic theory explains the curative effects
of sulfanilamide in infections in small laboratory ani-
mals as due primarily to the bacteriostatic action of the
drug. As a consequence of the reduced number of
organisms, there is secondary reduction in the elabora-
tion of toxic substances (leukocidin, hemolysin and the
like). The theory states that under these conditions
the natural defense mechanism of the bod)' frees the
tissues of the infecting organisms.

Bliss and Long/ basing their conclusion chiefly on
the results of experiments with mouse peritonitis caused
by the Welch bacillus, reported that the only demon-
strable effect of sulfanilamide on this organism was
bacteriostasis. Gay and Clark, 2 working with rabbit
empyema caused by a hemolytic streptococcus of human
origin, concluded that the primary effect of the drug
was bacteriostasis.

Colebrook, Buttle and O’Meara 3 had earlier noted
that the blood and serum of human beings and lab-
oratory animals possessed increased bacteriostatic and
bactericidal power after the administration of sulfanil-
amide and the prontosils. They regarded it as prob-
able that this factor might be important in human
infections but expressed surprise that the very low
bactericidal power of the blood of mice should be asso-
ciated', with. such, marked curative effect.

Osgood 4 reported early in 1938 that the major effect
of sulfanilamide appeared to be toxin neutralization.
However, his conclusion was promptly criticized. In an
exchange of papers, Hemmens and Dack 0 attacked the
conclusion that sulfanilamide acted by toxin neutrali-
zation ; while Osgood and Brownlee a admitted that
they were not able to demonstrate toxin neutralization
with ordinary methods, they expressed the belief that
conditions in tissue cultures are more comparable to
conditions in the body than is true of the other in vitro
tests.

The basis for criticism by Hemmens and Dack was
the fact that bacteriostasis, as a factor in reducing toxin

From the Departments of Physiology and Bacteriology, University of
Minnesota Medical School.

The sulfanilamide was furnished by the Department of Medical
Research, Winthrop Chemical Co., Inc., under the trade name “Prontylin.*’
Read before the Section on Pathology and Physiology at the Ninetieth
Annual Session of the American Medical Association, St. Louis, May 18,

3939.

Aided by grants from the Committee on Scientific Research, American
Medical Association, and the Medical Research Fund, Graduate School,
University of Minnesota.

Assistance in the preparation of these materials was furnished by the
personnel of the Works Progress Administration, official project No.
665-71-3-69, subproject No. 237, and the National Youth Administration.

1. Bliss, Eleanor A., and Long, P. H. : Observations on the Mode of
Action of Sulfanilamide, J. A. M. A. 109: 1524-1527 (Nov. 6) 1937.

2. Gay, F. P., and Clark, Ada R.: On the Mode of Action of Sulf-
anilamide in Experimental Streptococcus Empyema, J. Exper. Med. 66:
535-547 (Nov.) 1937.

3. Colebrook, Leonard; Buttle, G. A. H., and O’Meara, R. A. Q. :
The Mode of Action of p-AnunobenzenesuIfonamide and Prontosil in
Hemolytic Streptococcal Infections, Lancet 2: 1323-1326 (Dec. 5) 1936.

4. Osgood, E. E. f and Brownlee, Inez E.: Culture of Human

Marrow: Studies on the Mode of Action of Sulfanilamide, J. A- M. A.
110:349-356 (Jan. 29) 1938. , , , A .

5. Hemmens, Elizabeth S., and Dack, G. M.: Mode of Action of
Sulfanilamide, J. A. M. A. HO: 1209-1210 (April 9) 1938.

6 Osgood, E. E.. and Brownlee. Inez E.: The Mode of Action of
Sulfanilamide, J. A. M. A. llO: 1770 (May 21) 193S.

formation, had not been properly evaluated. Osgood
failed to record the size of the colonies showing smaller
hemolytic zones in plates containing sulfanilamide. His
data on cell suspensions could not be used to support
his conclusion, since these were not in any sense
quantitative.

Gross, Cooper and Lewis 7 reported that, in the
presence of serum, sulfanilamide failed to neutralize
streptococcus hemolysin. Huntington 8 reported that
he was unable to neutralize hemolysin, fibrinolysin or
scarlatinal toxin with sulfanilamide. Long, Bliss and
Feinstone 9 found that sulfanilamide failed to protect
guinea pigs and mice inoculated with lethal doses of
botulinus toxin. They noted also that high concentra-
tions of the drug in the blood of human beings did not
alter positive reactions to the Dick test. Kemp 10 tested
the neutralizing power of sulfanilamide for hemolysin,
fibrinolysin and dennotoxin with negative results. In
discussing his observations, Kemp states: “But there
is something in these observations of more importance
than this disagreement [with Osgood], and that is:
whatever the action of sulfanilamide, the in vitro
methods fail to reveal it . . .” He was probably

led to this conclusion as a result of his failure to dem-
onstrate an antiheinolytic effect of sulfanilamide on
blood agar plates. It is not clear why the excellent
work of English and American investigators showing
beyond reasonable doubt that the drug possesses power-
ful antibacterial properties in vitro was not considered
by Kemp. Elis methods are not described in sufficient
detail to enable one to decide why he failed to observe
an antiheinolytic effect secondary to bacteriostasis. It is
not stated whether he observed a bacteriostatic effect.

It is now realized that several factors may prevent
any considerable bacteriostatic effect of the drug. For
instance, the size of the inoculum is important, as
shown by Colebrook, Buttle and O’Meara, 3 who found
that in the presence of very large numbers of organisms
the drug was practically without effect. As Garrod 11
and Hoare 12 point out, this factor may account for
Domagk’s conclusion that there is little correlation
between the in vivo and the in vitro effect of sulf-
anilamide.

Another factor that may have influenced Kemps
results is the type of strains used. Hoare 12 found
nineteen of twenty-one strains of human origin respon-
sive to sulfanilamide in vitro. The other two strains
were from cases which did not respond to the drug.
Also Bliss and Long 13 and Bliss, Long and Feinstone 14
felt that there was a significant correlation between
in vivo and in vitro response. Since half of Kemps

7. Gross, Paul; Cooper, F. B., and Lewis, Marion: of

Streptococcal Hemolysin by Sulfonamide Compounds, Proc. Soc. r-xt
Jiol. & Med. as: 275-279 (March) 1938. „ .

8. Huntington, R. W„ Jr.: Fa, lure of Sulfanilamide to Pretcnt

lemolysis. Fibrinolysis and Production of Erythrogmic i Toxin H m
ytic Streptococci in Vitro, Proc. Soc. Exper. Biol. & Med.

Al 9.'Lom?! 8 p. H.; Bliss, Eleanor A., and Feinstone, W. II. ( Mode of

Action, Clinical Use and Toxic Manifestations of Sulfanilamide, J-
L A. 112:115-121 (Jan. 14) 1939. .

10. Kemp, H. A.: On the Action of Sulfanilamide: Failure to
nstrate Antiheinolytic, Antifibnnolytic and Antitoxic Effect ot tii V h
'exas State J. Med. 34:208-211 (July) 1938. f .■ lancet

11 Garrod, L. P.: The Chemotherapy of Bacterial Infections, Lance;
1125-1129 (May 14), 1178-1182 (May 21) 1938 . . ^

12. Hoare, E. D.: Bactericidal Changes Induced in Human hiwjl*
erum by Sulfamidochrysoidtne and Sulfanilamide, Lancet 1.

Eleanor A., and Long, P. II.: The Failure of ram-Amino-
enzenesulfonamide Therapy in Urinary Tract InfceDons Due to G O
l (Lancefield) Beta Hemolytic Streptococci, New England J. Men.

S li! Kiss, ^Eleanor A.; Long, P. If., and Feinstone, A',
'ifferentiation of Streptococci and Its Relation to Sulfandam
outh. 31. J. 31 : 303-308 (March) 1938.

Volume 113
Number 19

TISSUE CULTURE-KING ET AL.

1705

strains were from cases which showed good clinical
response, it seems unlikely that this factor explains his
results,

A further factor of importance has been emphasized
by Lockwood. 15 who finds that peptones interfere
with the antibacterial power of sulfanilamide in vitro.
Thus the composition of the culture medium must be
taken into account.

Kemp’s methods of measurement are not described.
Hence, it is not clear whether these are sufficiently
refined to detect slight differences in the size of the
colony and the hemolytic zone in experimental and
control sets.

As will be shown later, it is possible, when using a
suitable medium and suitable quantitative methods, to
demonstrate the bacteriostatic property of sulfanilamide
in dilutions as high as 1 : 1,000,000 even when the -
medium contains as many as 150,000 colonies per cubic
centimeter. With fewer colonies bacteriostasis is more
pronounced.

Osgood 10 seems reluctant to grant any importance
to the bacteriostatic effect of sulfanilamide as a mecha-
nism whereby toxin formation is reduced. This is espe-
cially difficult to understand in view of his own clear
demonstration of the antibacterial power of sulfanil-
amide in vitro. This property of the drug is well shown
in his table 2.' 1 Moreover, he noted and measured the
smaller areas of hemolysis around colonies of beta
streptococci grown in the presence of three different
concentrations of the drug. He recorded regular and
significant decreases in the diameter of the hemolytic
zones. These observations he interpreted as evidence
of toxin neutralization without recording the diameter of
the colonies. It is obviously impossible to arrive at any
conclusion as to the cause of the observed reduction in
hemolysis without considering the bacteriostatic effect
of the drug.

The question of decreased toxin production secon-
dary to the decrease in the number of organisms is one
of fundamental importance. This is the question raised
in the criticism of Hemmens and Dack. 5 In their reply,
Osgood and Brownlee 0 state : “The word ‘neutrali-
zation’ was poorly chosen and ... we should have
said ‘The major action of sulfanilamide appears to be
on the production of toxins or aggressins. We do not
know to what this is due.’ ” In a later paper Osgood lr
states that “sulfanilamide’s major action is prevention
of formation of, or neutralization of, toxins.” Here it is
not clear what he means by “prevention of formation.”
He seems to imply inhibition of toxin formation out
of proportion to inhibition of bacterial growth. In the
same issue, in discussing Kemp’s paper, 10 Osgood
states: “The major action of sulfanilamide appears to
be on the toxins or aggressins. We do not as yet
know whether this is due to destruction of some sub-
stance necessary for the formation of these toxins or
aggressins, to a direct action on the organism pre-
venting the formation of toxins or aggressins, to the
destruction of the nascent toxins or aggressins, to
destruction of toxins or aggressins after they are
formed, to catalysis of an antitoxin-toxin reaction or
to a sufficiently slow rate of production of toxins or
aggressins so that they are destroyed by the natural
processes of oxidation as rapidly as they are formed.”

Lockwood, J, S.: Studies on Mechanism of Action of Sulfanil*
arm tic; Effect of Sulfanilamide in Serum and Blood on Hemolytic Strepto-
Coc . c > >n Vitro. J. Immunol. 05: 155-193 (Sept.) 193S.

Osgood and Brownlee (footnotes -4 and 6).

E. E.: Culture of Human Marrow, Texas State J, Med.
34:206-20$ (Jul>) 1938.

In an effort to resolve this detailed and somewhat
speculative list of possibilities into a smaller number
of general propositions which can be tested experi-
mentally, we list three obvious possibilities involved
in the relation between bacteriostasis and inhibition of
hemolysis (hemolysin being the only toxin considered
in this paper). Decreased hemolysis in the presence of
sulfanilamide might be (a) secondary to bacteriostasis
caused by the drug, as demanded by the bacteriostatic
theory ( b ) caused by neutralization of toxin, i. e., inacti-
vation or destruction of toxin, or (c) due to "prevention
of formation” of toxin, i. e., a reduction of toxin in
excess of what might reasonably be regarded as secon-
dary to the smaller number of organisms resulting from
the bacteriostatic effect of the drug.

By the use of ordinary methods, it has now been
established beyond reasonable doubt that sulfanilamide
does not neutralize toxin. The latest paper on this
phase of the problem is by Osgood and Powell. 18 They
confirm the results of other investigators on this point.
They do not, however, discuss the bearing of their
observations on Osgood’s previously published opinions
on toxin neutralization, or the bearing of either on
the bacteriostatic theory which demands reduced toxin
formation as a consequence of bacteriostasis. In dis-
cussing this paper, it was stated in The Journal 10

Fig, l . — Control (a) and experimental cultures ( b ). Sulfanilamide
1: 1,000; ninety-six hours; approximately 125 colonies per cubic centi-
meter; strain 2; no erythroctes in clot. Direct photograph, X 1^.

that “The results of these experiments, therefore, fail
to support, although they do not disprove, the earlier
experiments with cultures of human bone marrow
reported by the senior author.”

Evidence is offered later to show that, in tissue cul-
ture mediums composed chiefly of rabbit plasma and
serum, sulfanilamide exerts a bacteriostatic effect on
the three strains of beta hemolytic streptococci studied ;
that the effect varies directly with the concentration
of the drug and inversely with the number of bacteria
present ; that a decrease in hemolysis is observed when
bacteriostasis is observed ; that the extent of the decrease
of hemolysis does not suggest either toxin neutraliza-
tion or “prevention of formation” of toxin beyond what
might reasonably be expected as a result of the observed
bacteriostasis, and that the drug inhibits the develop-
ment of diffuse peripheries around colonies of beta
streptococci.

MAILKIALS AND METHODS
The routine tissue culture methods used have been
described previously by King. 00 The method as applied

IS Osgood, E. E. and Powell, H M.: Failure of Sulfanilamide to
Inactivate Preformed Hemotoxms. Diphtheric Toxin or Tctanal Toxin
Pr ?S- S°e .Exper .Biol. & Med. Of): 37 -A0 (Oct.) I93S. '

currc,,t comme “‘> j‘ A. M. A.
, , f 0 ,- , I‘, 7\ : „ ™ 5 5 V e Cu’ture Technic. Arch. f. exper. Zellforsch. 9:
Pla'sma ibid! Mt Wcft $j, . &lratt for Heparin-

1706

Jour. A. M. A.
Nov. 4, 1939

TISSUE CULTURE— KING ET AL.

to the study of neoprontosil has been described by
King, Henschel and Green. 21

The Maximow technic is used, the culture being
planted on a 22 mm. round cover slip. This slip is
fastened to a large cover (with saline solution), which
is then inverted over a deep hollow ground slide and
sealed with petrolatum and afterward with a petrolatum-
paraffin mixture. Cultures are incubated as lying-drop
preparations at 37.5 C. in a special down-draft incu-
bator previously described by King. 22 Under these
conditions there is no vapor in the dome of the chamber
even in the early hours of incubation. The culture is
composed of one drop of heparinized rabbit plasma and
two drops of tissue extract made by extracting six day

•

Table 1 . — Effect of Varying the Number of Organisms on
the Bacteriostatic Effect of Sulfanilamide 1: 1,000;

Twenty-Four Hours; Strain 2

Average Average ~

Dilution of Colony Colony w

Bacterial Diameter, Diameter, Inhibition,

Culture Control Experiment perCent

1:100,000 7.09 5.12 27.8

1:1,000,000 24.29 11.40 53.1

1:10,000,000 49.01 12.40 74.7

to sulfanilamide was prompt. Strain 2 was isolated
from the blood in a fatal case of septicemia. Strain 40,
Lanceneld group C, was isolated from a culture taken
on material from the throat.

Colony diameter is used as an index of the bacterio-
static effect of the drug. The diameter of the hemolytic
zone is used as an index of the hemolytic activity of
the colony. The term “hemolytic index” is used to

Fi*3. Control (a) and experimental (6) colonies. Sulfanilamide
irl.OOO; twelve hours; strain 2; 5 per cent erythrocytes in clot. Slightly
reduced from a photomicrograph with a magnification of 37 diameters.

chick embryos with rabbit serum. The properties of
this extract have been previously described by King
and Henschel. 23

When hemolysin is to be studied, sufficient rabbit
erythrocytes are introduced to make a 5 per cent sus-
pension in the final clot. Sulfanilamide is dissolved in
0.9 per cent saline solution and sterilized by filtration.
A sufficient amount of this solution is added to the
tissue extract to give the required concentration in the
final medium. A corresponding amount of saline solu-
tion is added to the control medium.

Organisms are added to the tissue extract after suit-
able dilution of the original culture in Tyrode’s solution
to give the required concentration in the final medium.

Fig. 2. — Control (a) and experimental (fc) colonies. Sulfanilamide
1: 1,000, ninety-six hours; from 5 to 10 colonies per cubic centimeter;
strain 2; no erythrocytes in clot. Slightly reduced from a photo-
micrograph with a magnification of 37 dianjeters.

The streptococci are grown in veal infusion broth.
Cultures are approximately 18 hours old when used.

The three strains of beta streptococci used are all
of human origin. These strains are mouse virulent.
The strain BG was isolated from the cerebrospinal
fluid of a patient with meningitis. The clinical response

21 King. J. T.; Henschel, A. F„ and Green, Beryl S.: Influence of
Prontosil Soluble on Beta Hemolytic Streptococci Growing m Tissue
Culture Media, Froc. Soc. Exper. Biol. & Med. 3S: 810-S12 (June) 193S.

2 2 King , J. T-: Special Incubator for Tissue Cultures, Arch. f. exper.

Zellforsch. 20 : 208-212 (No. 2) 1937- .

■>3 King, J, T., and Henschel, A. F.: Comparison of Serum and
Saline Extracts as Nutritive Media for Mammalian Lymph Node Cultures,
Froc. Soc. Exper. Biol. & Med. 32: 1224*1226 (May) 1935.

describe the amount of hemolysis in relation to the size
of the colony ; i. e., the diameter of the zone of hemolysis
divided by the diameter of the colony.

Measurements are made at a magnification of 60
diameters, with a standardized ocular micrometer (114
units — 1 mm . ) . With a mechanical stage, accurate
measurements can be made of the diameter of the
colony and zone of hemolysis.

Photomicrographs are made on process film. Expo-
sure is kept down to the minimum required to register
the lysed area adjacent to the colony. In this manner
maximal contrast is obtained between lysed and unlysed
portions of the clot. Films are developed for strong
contrast. Direct photographs of cultures containing no
erythrocytes are taken against a black background on
process film. Panchromatic process film is used for
cultures containing erythrocytes.

RESULTS

Streptococci grow rapidly in this medium, colonies
usually becoming visible between the fourth and the
sixth hour when the medium contains no erythrocytes.
Although some strains are fibrinolytic, those used in

Table 2. — Bacteriostatic Effect of Sulfanilamide 1: 1,000; at
Txvcnty-Four Hours; Strain BG; 150,000
Colonics per Cubic Centimeter

Sulfanilamide Concentration Colony Diameter Inhibition, per Cent

Controls 5.C7 —

1:1,000 4.52 20.3

1:10,000 4.67 17.6

1:100,000 4 .81 15-2

1:1,000,000 4.02 13.2

this study showed no lysis of the clot. Hie usual
inverse relationship between the number of colonies
and the size of the colonies is observed.

The time at which colonies attain maximal size
depends on the number of colonies present. When J >e
medium contains 150,000 colonies or more per cubic
centimeter, growth is essentially complete in twelve
hours. When the colony count per cubic centimeter is
10 or less, growth continues for at least five days.

Volume 113
Number 19

TISSUE CULTURE— KING ET AL.

1707

The inhibition caused by a given concentration of
sulfanilamide varies inversely with the number of colo-
nies present. Table 1 shows the result of three dilu-
tions of a culture of strain 2 in the medium without
erythrocytes.

Figure 1 shows the effect of sulfanilamide with
approximately 125 colonies per cubic centimeter and
figure 2 with from 5 to 10 colonies per cubic centi-
meter.

With a constant number of bacterial colonies the
inhibitory influence of the drug varies directly with
the concentration. Table 2 shows the bacteriostatic
effect on strain BG when a heavy inoculum is used.

Table 3. — Effect of Sulfanilamide 1:1,000 on Colony Sice
and Hemolysis; Strain 2

Controls Sulfanilamide

r

Diam-

'

t

Diam-

Inhibi-

cter

cter

Colony

tion of

Diam-

of

Diam-

of

Inhibi-

Hemol-

etcr

Hemo-

I-Iemo-

cter

Hemo-

Hemo-

tion.

ysis,

of

lytic

lytic

of

lytic

lytic

per

per

Time

Colony

Zone

Index

Colony

Zone

Index

Cent

Cent

IS lirs.

39. S

65.0

1.63

12.4

32.4

2.62

6S.8

50.1

24 hrs.

7S.5

132.9

1.69

13.7

57.4

4.17

S2.4

56.8

■IS hrs.

211.7

354.0

1.64

33.7

20S.1

6.20

S4.3

41.2

3 days

252.4

399.5

1.5S

43.2

245.7

5.69

82.9

38.5

The data in table 2 are based on measurement of
between 225 and 300 colonies (in three cultures) iri
each concentration of sulfanilamide and control set
(three cultures). With this number of colonies, strain
BG shows little, if any, qualitative difference between
experimental and control colonies.

In strong contrast to the very moderate inhibition
shown in table 2 in the presence of a large number of
colonies, this strain regularly shows more than 80 per
cent inhibition with 25 colonies or less per cubic centi-
meter (sulfanilamide 1:1,000).

Fig. 4. — Control (a) and experimental (2>) colonies. Sulfanilamide
1: 1,000; forty hours; strain 2; 5 per cent erythrocytes in clot. Slightly
reduced from a photomicrograph with a magnification of 37 diameters.

TOXIN NEUTRALIZATION

When 5 per cent rabbit erythrocytes are added to
the medium before clotting takes place, it is possible
to determine the size of the colony at the time at
which hemolysis becomes evident. Subsequent mea-
surements of the diameter of the colony and of the zone
of hemolysis make possible a correlation between these
two factors.

Early observations and measurements show that,
when a colony attains a given size, hemolysis com-
mences whether sulfanilamide is present or not.
Hemolysis starts when the colon}'' attains a size of
approximately 10 units.

Figure 3 shows a twelve hour control and experi-
mental colonies of approximately the same size. There
is no evidence that a high concentration (100 mg. per
hundred cubic centimeters) of sulfanilamide has reduced
the hemolytic activity of the colony. As is evident
from tables 3 and 4, there is a lag in the develop-
ment of experimental colonies due to the bacteriostatic
effect of the drug. This results in less hemolysis in

Fig. 5. — Control (a) and experimental ( b ) cultures. Sulfanilamide
1:1,000; twenty-four hours; strain 2; 5 per cent erythrocytes in clot.
Direct photograph, X 1 l A.

experimental cultures at a given time. However, when
experimental colonies are compared with control colo-
nies of the same size, there is no evidence of hemolysin
neutralization.

Study of the subsequent development of the cultures
likewise fails to reveal any evidence of neutralization
of preformed hemolysin. Figure 4 shows well devel-
oped colonies from experimental and control sets (forty
hours).

Figure 5 is made from direct photographs of experi-
mental and control cultures of strain 2 (sulfanilamide
1 : 1,000). In this figure the lysed areas are dark while
the unlysed portion of the clot is light.

Detailed observations on two experiments with strain
2 are shown in tables 3 and 4. In the experiment
shown in table 3 the control colonies showed the usual
diffuse peripheries. In the other experiment (table 4)
the control colonies grew as compact masses.

In both experiments typical inhibition of both colony
and hemolytic zone is shown. '

Table 4. — Effect of Sulfanilamide 1:1,000 on Colony Size
and Hemolysis ; Strain 2

Controls Sulfanilamide

A _ ~ X

Diam-

eter

Diam-

eter

of

Hemo-

Hemo-

Diam-

eter

Diam-

eter

of

Heino-

Hemo-

Colony

Inhibi-

tion,

Inhibi-
tion of
Hernol-
ys is.

of

lytic

lytic

of

lytic

lytic

per

per

Time

Colony

Zone

Index

Colony

Zone

Index

Cent

Cent

9 hrs.

10

5

50.0

11 hrs.

13

25

1.92

6

53.9

14 hrs.

3S

91

2.39

11

32

2.91

71.1

C4.8

22 lirs.

57

232

4.07

21

82

3.90

G3.2

01.7

24 brs.

59

264

4.47

27

110

4.07

54.2

58.3

35 hrs.

67

316

4.72

41

215

5.24

3S.8

32.0

44 hrs.

76

327

4.30

49

26G

5.43

35.5

18.7

2& days

SI

352

4.35

60

300

5.00

25.9

14.8

In all cases it has been noted that the hemolytic
index rises to a maximum and then declines somewhat.
The experimental cultures reach the maximum later
than the controls.

The hemolytic index is higher in the cultures con-
taining sulfanilamide than in the controls. As will be
noted later, the significance of this fact is not entirely
dear at present.

1708

TISSUE CULTURE-KING ET AL.

Jour. A. JI. A,
Nov. 4, 1939

BACTERICIDAL PROPERTIES OF SULFANILAMIDE
In this medium there has been no consistent reduc-
tion in the number of colonies in experimental cultures.

qualitative changes caused by sulfanilamide

With large inoculums no characteristic change is
noted. Sometimes experimental colonies appear less
dense. When the inoculum is sufficiently small to per-
mit colonies to attain any considerable size, the drug
causes qualitative change in those strains which show
diffuse peripheries. The drug regularly inhibits the
development of such peripheries. The resulting colonies
are small and compact. The strains studied have not
shown a characteristic qualitative response to the drug
when they failed to develop diffuse peripheries.

It has been noted that colonies whose diffuse periph-
eries have been inhibited by sulfanilamide frequently
show heavy chains invading the dot. The amount of
chain formation is quite variable. In our experience,
from three to twelve chains can be regarded as typical.
When chains are present they are not evenly distributed
around the colony but are grouped in a loose net in a
rather limited area.

Rarely a colony may develop a complete periphery
composed of this typical loose network of heavy chains. '
We have seen only a few such colonies and those
developed rather late.

' We wish especially to emphasize the difference
between this type of periphery and the normal, diffuse
-periphery seen around control colonies. In the latter
- the organisms are widely scattered, singly and - in
-groups of two or three. In the presence of sulfanil-
amide, however, the normal mechanism of division is
so modified as to produce long chains.

Gay and Clark 2 had observed earlier that when-
streptococci were grown in serum containing sulfaiii)--
arnide the organisms grew in long chains of pleo--
morphic and metachromatic forms. Later, Meyer 24
described "great masses of markedly deformed, swollen
streptococci, growing in endless chains,” in relation to
the “clumping reaction,” which he observed in serum-
broth cultures of streptococci containing a sulfanilamide--
sugar compound. - . -

Lockwood 15 described long chains of abnormal strep-
tococci growing in mediums containing sulfanilamide.
This tendency to form long chains in the presence of
the drug was also noted by Chandler and Janeway. 2 "

COMMENT

Of the many factors having a probable bearing on
the mechanism of action of sulfanilamide, we are
concerned in this paper with the following: (1) the
bacteriostatic action in vitro as influenced by the con-
centration of the drug and the size of the inoculum;
(2) the correlation between the bacteriostatic effect and
the amount of hemolysis; (3) the qualitative changes
caused by the drug.

It is now realized that certain experimental condi-
tions are required to demonstrate the effects of sulfanil-
amide in vitro, and all failures to demonstrate such
effects when therapeutically responsive strains of beta
streptococci are used must be examined in the light of
this knowledge.

Colebrook, Buttle and O’Meara 2 reported that the
drug was almost without effect in the presence of very
large numbers of organisms. Lockwood 12 also found a

2d. Meyer, Fritz: Kew Studies in Sulfanilamide Therapy, Quart. Bull.
Sea View Hosp. 3: 380-404 (July) 1938.

25. Chandler, C. A., and Janeway. C. A.: Observation on the Mode
of Action of Sulfanilamide in Vitro, Proc. Soc. Exper. Biol. & Med. 40.
179-1S4 (Feb.) 1939.

greater effect when using a smaller inoculum. Recently
Cliandler. and Janeway - 5 reported the same experience
I hese investigators worked with fluid mediums.

In tissue culture clots we have found the bacterio-
static effect of the drug to vary inversely with the
number of colonies present (table 1). That it is pos-
siole,. however, to demonstrate moderate bactenostasis
in this medium, even in the presence of relatively large
numbers of organisms, is shown in table 2.

Lockwood 15 found that peptones interfere with the
action of sulfanilamide and pointed out the importance
of avoiding the use of mediums containing such sub-
stances if one wished to obtain the full effect of the
drug.

Lockwood, Coburn and Stokinger reported, on the
basis of clinical experience, that “the presence of debris,
human or bacterial, diminished the effectiveness of
sulfanilamide on the hemolytic streptococcus. In each
instance the organisms remaining in broken down
tissue maintained their virulence. It is not known
whether the debris itself had a protective action on the
organisms or whether there was insufficient penetration
of the drug into the locus.”

We 27 have found ; that the presence of a small frag-
ment of tissue in a Tissue culture greatly antagonizes
the effects of sulfanilamide even at a considerable
distance from the fragment. We have observed this
effect with concentrations of sulfanilamide as high as
140 mg. per hundred cubic centimeters. We believe
that the products of tissue disintegration exercise a
protective effect on the organisms.

Since the extracts used in making the clots of tissue
culture were made by shaking six day chick embryos
in serum, the question might be raised whether enough
peptone-like substance would be extracted to cause a
"peptone effect"; i. e., a reduction in the effect of
sulfanilamide.

It was pointed ' out by Colebrook, Buttle and,
O’Meara 3 that the effect of sulfanilamide was much
less marked in the blood of the small laboratory ani- -
inals than in human blood. Except for very small
inoculums, they found the drug to be bacteriostatic but
not bactericidal in the blood of these animals. Gay and
Clark 2 observed only bacteriostasis in rabbit serum
containing the drug. In neither of these cases was
there any addition of peptone-like substance. In view
of these facts and of the further fact, already noted,
that the drug is much more effective in the cell-free
medium than in the medium containing a small tissue
fragment, we assume tentatively that the meditun
reacts as though free of any significant amount of
peptone-like material.

As pointed out earlier, Bliss and Long 13 and Bliss,
Long and Feinston'e 14 obtained satisfactory correlation
between in vivo and in vitro, response, and Hoare
found 100 per cent 'correlation in a study of twenty-
one strains. •

In the present study we have used only LancencM
group A and C strains. -The strains reported, and
others less intensively studied, proved responsive to
the drug in the tissue culture medium. _

It now seems safe to assume that all therapeutical)
responsive strains of beta hemolytic streptococci are
inhibited by sulfanilamide in vitro if the experiments
conditions are suitable. : '

26. Lockwood. J. S.;'.CobuhG'A:.F: and StokmsM. H- ,
the Mechanism of Action of ' Sulfanilamide, J. A. M. A. J »
54 (Dec. 1?) 1938. . .

17. Kinfr. J. T., and Henschel. A. F„ to he published.

Studies
: 2219 -

Volume 113
Number 19

TISSUE CULTURE-KING ET AL.

1709

In view of the well known ability of the streptococ-
cus to produce destructive toxins, it is natural that
considerable interest has attached to the possibility that
sulfanilamide might either reduce the amount of toxin
formed or neutralize toxin. The bacteriostatic theory
assumes that there is a reduction in the amount of toxin
formed secondary to the reduction in the number of
organisms brought about by the drug. In the tissue
culture medium we have always found that when the
drug causes a decrease in the size of the colony it also
causes a decrease in the size of the hemolytic zone.
Typical results are shown in tables 3 and 4.

We have observed that hemolysis starts when the
colony reaches a certain size whether or not sulfanil-
amide is present. There is a lag in the development
of experimental colonies as compared with the controls.
Otherwise the sequence of events is fundamentally alike
in the two. Study of the subsequent development of
the colony shows that the drug continues to exert a
bacteriostatic effect and that the amount of hemolysis
is less in experimental cultures. On the basis of
colony size, however, colonies growing in 100 mg. per
hundred cubic centimeters of the drug produce a larger
rather than a smaller zone of hemolysis ; i. e., they
show a higher hemolytic index. Possible explanations
for the higher hemolytic index observed in experimental
cultures will be considered after the qualitative changes
caused by the drug have been discussed.

It is clear that if the drug neutralized hemolysin or
reduced the formation of hemolysin out of proportion
to the reduction in the number of organisms, the hemo-
lytic index of experimental colonies would be lower.
This is not the case, however. Consequently, we can
only conclude that such reduction in hemolysis as is
observed is secondary to the bacteriostatic effect of the
drug.

Most of the strains available to us grow with dif-
fuse peripheries in this medium, provided the inoculum
is not too large. Some strains, for example strain 2,
are not constant in this regard, at times showing periph-
eries and at other times growing as compact colonies.

We have never seen a normal diffuse periphery in
a culture containing sulfanilamide unless the effects
of the drug were antagonized by the presence of tissue. 27
The drug inhibits the rapid invasion of the clot usually
seen around control colonies.

As already noted, an inhibited colony may show a
variable number of long, heavy chains projecting from
some point on the periphery or, rarely, a complete
periphery composed of a loose network of such chains.

In considering possible explanations for the higher
hemolytic index observed for colonies growing in cul-
tures containing sulfanilamide, the qualitative change in
colony form usually caused by the drug must be taken
into account. It has been pointed out that the drug
inhibits the development of the wide, diffuse periphery
usually seen around colonies of beta streptococci in this
medium. As may be seen by comparing the control
colonies shown in tables 3 and 4. this diffuse periphery
is not as active in producing hemolysis as the more
dense central part of the colony. In the experiment
detailed in table 3, strain 2 grew with the usual
peripheries. The hemolytic index reached a maximum
of 1.69. An experiment with the same strain is shown
in table 4, in which the colonies are of the compact
type showing a maximum hemolytic index of 4.72.
From these facts it is evident that a more compact
colony has a higher hemolytic index.

It is possible that the higher hemolytic index
observed in cultures containing sulfanilamide is due to
the formation of a more compact colony. It is clear
that this factor is important when the controls grow
with the usual diffuse peripheries, as in the experiment
shown in table 3. The interpretation is complicated
however by the fact that, even when the control colonies
fail to develop diffuse peripheries, sulfanilamide causes
a higher hemolytic index. In this case it is not evident
that the drug causes the development of more compact
colonies, but the possibility cannot be ruled out.

We have considered the possibility that erythrocytes
might be more vulnerable to lysis by streptococcus
hemolysin in the presence of sulfanilamide. There is.
however, no experimental evidence to support this theo-
retical possibility.

Another possible explanation is based on the fact
that sulfanilamide is known to form numerous conjuga-
tion products. Czarnetsky and his associates 28 have
found that certain derivatives of the streptococcus will
conjugate with the drug to form hemolytic products.
It is therefore possible that the drug combines with
some product of bacterial metabolism to form a hemo-
lytic agent. Should this ultimately prove to be true,
it is interesting to speculate what bearing it might , have
on the cause of the severe anemias now known .to occur,
occasionally during administration of the drug. . •

SUMMARY

A tissue culture study has. been made of the bacterio-
static and antihemolytic properties. of sulfanilamide..' -

All strains of beta streptococci studied. were’ inhibited.'

The bacteriostatic effect varied directly with the con-
centration' of the drug and inversely with -.the 'number'
of bacterial colonies.

Reduction in hemolysis was observed to accompany
bacteriostasis.

Correlation of the reduction in hemolysis with -the
observed bacteriostasis leads to the conclusion that the
antihemolytic effect is secondary to bacteriostasis.

The drug regularly inhibits the wide, diffuse periph-
eries usually seen around colonies of beta streptococci
growing in clots of tissue culture.

The drug causes the development of abnormal, long
chains of streptococci.

CONCLUSIONS

Sulfanilamide is bacteriostatic for the strains of beta
streptococci studied. The effect varies directly with the
concentration of the drug and inversely with the num-
ber of bacteria.

The antihemolytic effect is secondary to the bacterio-
static effect. There is no evidence that the drug neu-
tralizes hemolysin or reduces its formation beyond what
can be accounted for on the basis of the reduced number
of organisms involved.

The drug modifies the normal mode of division and
reduces the ability of the organisms to invade the clot.

28. Czarnetsky, E. J., and Calkins, H. F.: Some Reactions of Sulf-
anilamide with Nucleoprotcins and a Suggested Mechanism of Action of
Sulfanilamide, J. Bact. 26: 330 (Sept.) 1938.

Life History of the Housefly.— The housefly passes
through a complex metamorphosis, i. e. egg, larva (maggot),
pupa and adult or fully winged insect. Under warm summer
temperatures the egg stage requires about twenty hours, the
larval stage about five days, the pupa about four days, a total
of about ten days from egg to adult insect. This allows for
the development of from, ten to twelve generations in one
summer.— Herms, William B.: Medical Entomology, New York,
Macmillan Company, 1939.

1710

EXPERIMENTAL CHEMO THERAPY— ROSENTHAL

EXPERIMENTAL CHEMOTHERAPY WITH
SULFANILAMIDE AND RELATED
COMPOUNDS

SANFORD M. ROSENTHAL, M.D.

Senior Pharmacologist, Division of Pharmacology, National Institute
of Health, United States Public Health Service

WASHINGTON, D. C.

Bacterial chemotherapy has emerged from the labora-
tory. It is primarily in the laboratory that progress
must be made in the development of more effective
compounds and of compounds active against diseases
as yet not influenced by chemical treatment. It is
also in the laboratory that a better understanding of
the mode of action of these drugs and of their toxic
effects can be obtained.

I wish to discuss some aspects of the problem from
a laboratory point of view. This new field has been
characterized by too hasty clinical application of experi-
mental results. Some shortcomings in our knowledge
and some of the difficulties encountered in transferring
results from one species to another will be brought
out. This paper is not intended to be a comprehensive
review of the field of bacterial chemotherapy but a dis-
cussion of certain phases of the subject with which I
have had experience in the laboratory.

PHARilACO LOGIC CONSIDERATIONS

The acute toxicity of sulfanilamide for several species
of higher animals has been adequately established.
Given in single doses by mouth, it is tolerated in
amounts of from 1.5 to 3 Gm. per kilogram, depending
on the species. The work of Marshall 1 and his col-
leagues has added much to an understanding of the
acute toxicity, absorption, distribution in the body and
excretion of sulfanilamide. It must be pointed out that
these toxicity values were established on normal ani-
mals. My associates and I have observed that in mice
rendered extremely ill by infection and toxins, such
as is seen following the injection of large numbers
of meningococci of low virulence to mice, deaths were
often encountered following one third of the maximum
dose normally tolerated.

Of more importance to the clinician is the question
of chronic toxicity, and in this our knowledge is inade-
quate. Marshall, Emerson and Cutting 2 found sulfanil-
amide well tolerated over a period of weeks by the
rat and dog. Molitor and Robinson 3 have quite
recently studied the acute and chronic toxicity of sulf-
anilamide and benzysulfanilamide in mice, rats, dogs
and rabbits. With large doses of sulfanilamide cumu-
lative toxicity and pathologic changes were manifest.
Their chronic toxicity studies on rabbits were unsatis-
factory. Contrary to prevalent opinion, water increased
the toxicity of sulfanilamide in their experience. We 4
have found that in the rabbit under certain dietary
restrictions from 0.5 to I Gm. per kilogram for two
weeks produced toxic symptoms and frequent deaths.

Read before the Section on Pathology and Physiology at the Ninetieth
Annual Session of the American Medical Association, St. Louis, May 18,
1939

L Marshall, E- K.: Bacterial Chemotherapy : The Pharmacology of
Sulfanilamide, Physiol. Rev. 19 : 240 (April) 1939.

2. Marshall, E. K.; Emerson, Kendall, and Cutting, W . C.: I he
Toxicity of Sulfanilamide, J. A. M. A. XlO:2o2 (Jan. 2-) 1938.

3. Molitor, Hans, and Robinson, Harry: Some Pharmacological and

Toxicological Properties of Sulfanilamide and Benzyls ulfanilamide,
J. Pharmacol. & Exper. Therap, 65:405 (April) 3939. Q Tnv!( .
J 4 . •« ’ c • c *"dies in Chemotherapy: VIII- Some Toxic

Fffert c '■ ration of Sulfanilamide and Sufanilyl Sulf-

”) to Rabbits and Chickens, Pub. Health

Rep. 54 i sj -■ -

Jour. A. SI. A'.
Nov. 4, 1939

Chickens on this dosage showed emaciation, motor
weakness and a high mortality. Halpern and Mayer 5
and Rich 6 have also noted cumulative toxic effects in
the guinea pig. _ Still another illustration of species
variation in toxicity is seen in that frequent toxic mani-
festations observed in human beings such as fever,
dermatitis and hematologic changes are encountered
rarely or not at all in experimental animals. However,
cyanosis has recently been produced in rats and chick-
ens, and susceptible species may be found in which
the other toxic effects seen in man may be produced.

In dealing with compounds of low water solubility
this discrepancy between acute and chronic toxicity may
be even more marked. Thus with sulfanilyl sulfanil-
amide the enormous single doses tolerated by animals
give a misleading indication of the results obtained on
repeated administration. It must therefore be con-
cluded that the acute toxicity of this group of drugs
is no reliable criterion of the effects to be obtained on
their repeated administration and that considerable vari-
ation in toxic manifestations may be encountered from
one species to another.

THERAPEUTIC RESULTS IN ANIMALS

There is a definite need for some standardization
of the experimental assay of chemotherapeutic activity
of these new drugs. Widely divergent results have
been obtained in different laboratories. Apart from
such factors as toxicity and the rate of absorption and
excretion, therapeutic effectiveness is influenced by the
dosage, the route of administration, the onset and dura-
tion of therapy, the period of observation following
therapy, the strain of organism, the infecting dose and
virulence of the organisms, the species and number of
the animals and the condition of the animals employed.

While there is universal agreement on the activity
of sulfanilamide in experimental beta hemolytic strepto-
coccus infections, the dosage required to bring about
the survival of the majority of infected mice varies
from one third to one tenth of the maximum tolerated
dose. At best this is not an impressive therapeutic
index and emphasizes from the laboratory point of
view the necessity for large doses to bring about good
therapeutic results.

On pneumococcic infections in mice sulfanilamide
has a less marked action, bringing about chiefly a
prolongation of life. 7 That this degree of activity
cannot be accepted as valid for man is shown by the
fact that sulfanilamide has a much better action in
pneumococcic infections in rabbits, and in rats a high
percentage of cures can be effected. 8

The increased effectiveness of sulfapyridine against
pneumococcic infections was first demonstrated by
Whitby.® While preliminary experiments have not

5. Halpern. B. N., and Mayer, R. L.: Toxicite experimental e com-
ree de quelque substances antistreptococciques, Pressc med.

37 6. Rich, A. R., and Follis, R. H-, Jr.: Inhibitory Effect of Suit-
ilamidc on the Development of Experimental Tuberculosis
linea Pig, Bull. Johns Hopkins IIosp. 62:77 (Jan.) 1938. . .

7. Rosenthal, S. M.; Bauer, Hugo, and Branham, ft mnoundf in
emotherapy: IV. Comparative Studies of Sulfonamide Compounds
penmen ta! Pneumococcus, Streptococcus and Meningococcus Infect o s
b. Health Rep. 53 : 662 (May 22). 1937. Cooper, F. B.i ‘ a $

1 Mellon, R. R.: Action of p-.knnnohenrencsulfonamide on Tjp
eumococcus Infections in Mice, Proc. Soc. Exper. Biol. & .Med. -

8 ( Gross 0 PauL and Cooper, F. B-: Efficacy of p-Aminobrnrene-
fonamide'in Experimental Type III Pneumococcus r "'j“ rn 5;} 30 / fg)y.
3C. Soc. Exper. Biol. & Med. 36 : 22a (March), 535 HlaW V"

F fr B n and °r^J,l“s: M d ; i C .- iffid (J 36 , : 3 n '■(April)' 19J7.

aiuiammc, * — * ~

Whitby" L. a E d “"emotherapy of Bacterial Infections, Umeet
095 (Nov. 12) 1938.

Volume 113
Number 19

EXPERIMENTAL CHEMO THERAPY— ROSENTHAL

1711

confirmed the uniformly high curative effects of this
compound reported by him in mouse infections, results
have shown a definite superiority over sulfanilamide.

The effectiveness of sulfanilamide in experimental
meningococcic infections, demonstrated first by Buttle,
Gray and Stephenson , 10 has been amply confirmed. It
should be noted that the two infections most susceptible
to therapy in the laboratory, streptococcic and meningo-
coccic, have given the most encouraging results in the
clinic.

On staphylococcic infections in mice sulfanilamide
has only a slight activity, but more favorable effects
have been obtained with sulfanilyl sulfanilamide , 11 and
recently with sulfapyridine. 1 -

Space will permit only brief mention of the positive
laboratory results in other infections. Following the
successful clinical use in gonorrhea, Levaditi 13 first
demonstrated marked curative action of sulfanilamide
and some related compounds in gonococcic “toxi-

Chart 1. — Eight daily doses of 1 Gm. per kilogram of sulfanilamide to
chickens caused progressive loss of weight, weakness, particularly marked
in the legs, and delayed death.

infection” in mice. Levaditi 14 had also demonstrated
for several bacterial endotoxins a true antitoxic action
for some sulfur compounds, although no effect could
be shown against bacterial exotoxins.

Favorable laboratory results have been reported in
infection with Clostridium welchii , 15 Escherichia coli , 10
brucellosis , 17 Bacillus aertryke, B. typhosus 18 and
B. pestis . 19 An inhibitory but not curative effect has
been found in experimental tuberculosis in guinea pigs . 0

30. Buttle, G. A. H.; Gray, W. H., and Stephenson, Dora: Protec-
tion of Mice Against Streptococcal and Other Infections by P-Amino-
benzcncsulfonamide and Related Substances, Lancet 1: 1286 (June 6)
1936.

11, Mellon, R. R.; Shinn, L. E., and McBroom, Josephine: Therapy of
Experimental Staphylococcus Infections with Sulfonamide Compounds,
Proc. Soc. Exper. Biol. & Med. 37: 563 (Dec.) 1937.

32. Whitby. 8 Slayer. 18

13. Levaditi, Constantin, and Vaisman, Aaron: La toxi-infection
gonococcique experimentale et son traitement chimiotherapique, Pressc
mcd. 45:1371 (Sept. 29) 1937.

14. Levaditi, Constantin, and Vaisman, A.:. Chimiotherapie antiendo-
toxique, Ann. Inst. Pasteur 61:635 (Dec.) 3938.

35. Long, P. H.; Bliss, Eleanor, and Fcinstone, W. H.: Sulfanilamide,
J. A. M. A. 112: 115 (Jan. 14) 1939.

16. Mayer, R. L.: Activity de l'a (P. armnophenyl-suKamido) -pyridine
dans les infections colibacillaire et staphylococcique de la souris, Compt.
rend. Soc. de biol. 129:480, 1938.

17. Chinn, B. D.: The Use of Sulfanilamide in Experimental Brucel-
las. J; Infect Dis. 64:78 (Jan.) 3939. Wilson, G. S., and Maier, I.;
Brit. M. J. 1:8 ()an. 7) 3939. Montogomerie, R. F.: Veterinary' Rec.
5O:3S0 (March 26) 3938.

18. Buttle, G. A. H,; Parish, H. J.; McLeod, Morag, and Stephenson,
Dora: Chemotherapy of Typhoid and Some Other Nonstreptococcal Infec-
tions in Mice, Lancet 1;6S3 (March 20) 3937.

19. Schutze, Harry: Chemotherapy in Plague Infection, Lancet 1:266
(Feb. 4) 1939.

Against malaria some effect has been found in monkeys
but none in bird malaria . 20 Dr. Wooley and I have
recently confirmed our earlier results 21 of a slight pro-
tective action with Domagk’s original prontosil against
infections in mice with the virus of lymphocytic chorio-

PNEUMOCOCCUS

SA. THERAPY

{Mice)

S. A.

2>ays

9 «o

Chart 2. — Sulfanilamide and sulfanilyl sulfanilamide therapy of pneu-
mococcic infections (Mulford strains types I, II and III) in mice. Sulf-
anilamide from 0.5 to 1 Gm. per kilogram given subcutaneously for from
four to six days following intraperitoneal inoculation of organisms.

meningitis. Sulfanilamide was inactive. Among other
virus diseases a definite curative action with sulfanil-
amide and some derivatives has been shown by
Levaditi 22 for lymphogranuloma venereum. Suggestive
results with some sulfanilamide derivatives in influenza
virus infections in mice have been reported by Climenko,
Crossley and Northey 23 and by Oakley . 24 On the virus

Chart 3. — Sulfanilamide therapy of type I pneumococcus in the rabbit.
Infecting dose of organisms 3.5 cc of 10-* intraperitoneaUy. Drug given
subcutaneously as indicated.

of canine distemper conflicting results have been
obtained since Dochez and Slanetz 25 first reported
successes with sulfanilyl sulfanilate.

20. Coggeshall, L. T.: Prophylactic and Therapeutic Use of Sulfanil-
amide Compounds in Experimental Malaria, Proc. Soc. Exper. Biol. &
Med. 38:768 (June) 3938.

21. Rosenthal, S, M.; Wooley, J. G., and Bauer, Hugo; Studies in
Chemotherapy: VI. The Chemotherapy of Choriomeningitis Virus Infec-
tion in Mice with Sulfonamide Compounds, Pub. Health Rep. 52:1211
(Sept. 3) 1937.

. 22. Levaditi, Constantin: Chimiotherapie de la lymphograhulomatcse
inguinale experimentale, Compt. rend. Soc. de biol. 128: 138, 1938.

23. Climenko, D. R.; Crossley, M. L., and Northey, E. IL: The Pro-
tective Action of Certain Sulfanilamide Derivatives in Experimental
Influenza Infections, J. A. M. A- 110: 2099 (June 18) 1938.

24. Oakley C. L.: Chemotherapy of Virus Infections, Brit M. J, 1:

895 (April 23) 1938. J

25. Dochez, A. R and Slanetz. C. A.: The Treatment of Canine
Distemper with a Chemotherapeutic Agent, Sodium Sulfanilyl Sulfate,
Science 87: 142 (Feb. 11) 1938.

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VotUME 113
Number 19

EXPERIMENTAL CHEMO THERAPY— ROSENTHAL

1713

That sulfur is not essential for activity has been
shown by Rosenthal and Bauer 40 in that asymmetrical
arsenic derivatives analogous to the sulfones

4,4'-acety!aminomtro diphenyl 4,4 , -.-tcety i.-munonitro diphenyl

s ul tone arsinic acid

possess antistreptococcic action. We 40 also found
simultaneously with Mayer and Oechslin 41 that p- nitro-
benzoic acid no?

cooh

has a slight action against pneumococcic and strepto-
coccic infections in mice. These brief examples serve
to illustrate the wide chemical front along which the
conquest of bacterial infections may be approached.

A survey of the numerous derivatives brings out the
importance of an amino or nitro group in the para
position in the benzene ring. Substitutions in the amino
group of sulfanilamide are much more prone to diminish
antibacterial activity than substitution in the sulfon-
amide group. Mayer 42 has found that an intermediate
oxidation product of the amino group, the hydroxyl-
amine (NHOH) derivative of sulfanilamide, is highly
active in the test tube against streptococci. Mayer
has postulated the slow formation in the body of this
derivative as the basis for activity of sulfanilamide.
The hydroxylamine derivative as such (/> -hydroxy 1-
amino-benzene sulfonamide) is unstable when injected
into the body; the feeble therapeutic activity shown
when this compound itself is employed is believed by
Mayer to be due to its rapid breakdown. Mellon and

Chart 6. — Three experiments with meningococcic infections showing the
marked curative effects of combated drug and serum therapy when each
alone yielded poor results; treatment subcutaneously two hours after infec-
uon with 0.8 Cm. per kilogram of sulfanilamide and 0.5 cc. of 1:5
dilution of meningococcic scrum.

bis co-workers 43 have also suggested that the hydroxyl-
amine derivative may be the active agent by virtue of
its anticatalase activity.

_ 40, Rosenthal, S. M., and Bauer, Hugo: Studies in Chemotherapy;
Ia. Antibacterial Action of Some Aromatic Arsenic, Sulfur and Nitro
Compounds, Pub. Health Rep. 54: 131? (July 21) 1939.

41. Mayer, R. L., and Oechslin, C.: Sur une nouvelle clnsse de corps
antihactcricnnes; Vacid p-nitrobenzoSque et ses esters, Compt. rend. Soc.
de Biol, 130: 211, 3939.

42. Mayer, R. L: _ Recherche*? sur 1c mecanUmc de Taction anti-
strep! ococciquc de l'aminobenrenesulfamide ct ses derives Bull. Acad, de
med. 117:727 (June 22) 1937.

43. ^ Shinn, L. £.; Main, E. R., and Melton, R. R.: Anticatyla.se
Activity of Sulfanilamide and Related Compounds: II. Relation to

Inhibition in Pneumococcus, Proc. Soc. Expcr. Biol. & Med, 39:
591 (Dec.) 393S.

Following the administration of. sulfanilamide, not
ail of the compound can be recovered as the free or
acetylated derivative. 1 It is thus of importance to
know more of the fate of that portion of the drug
which is unaccounted for.

Chart 7 . — The increased effectiveness of combined drug and serum
therapy in type I pneumococcic infection in mice. Treatment subcuta-
neously begun five and one half hours after inoculation. Units of serum
(Felton) and dosage of sulfanilamide are indicated by arrows on the chart.

We 44 have recently devised tests for the estimation of
aromatic hydroxylamines and for further oxidation
products of aromatic amino groups, that can be carried

Presence in Urine of an Hydroxylamine Derivative o{ Sulf-
anilamide Polloiving Oral Administration of 1.5 Gnu
of Sulfanilamide in 100 Cc. of Water to Tsvo
Rabbits of 2.S and 2.65 Kg. Weight

Free Total Hydroxj’laralne

Urine Sulfnnil- Sulfanil- Sulfunil-'

Volume amide amide amide

2 hr? SO cc. SO mg. CO mg. 0,43 mg,

4 brs 93 cc. 93 mg. 177 mg, 2.14 mg.

c brs 25 ec. 87 rag, 1SS mg. 2.4 mg.

2 brs 52 cc. 52 mg. 7S mg, 1.0 mg.

4 brs 45 cc. 45 mg. 93 mg. 2.1 mg,

Ohrs 2S cc. 50 mg. 320 mg, 2.8 mg.

out in the presence of sulfanilamide or other aromatic
amino compounds. Following the administration of
sulfanilamide to rabbits, it has been possible to demon-
strate from 1.5 to 5 per cent of the free sulfanilamide
in the urine present as a compound giving the reactions
characteristic of the hydroxylamine derivative (shown
in the accompanying table). 45 This of course does not
finally^ prove that the hydroxylamine derivative is the
active agent, but it should now be possible to correlate
the presence of this compound with bacteriostatic effects
and to investigate further the relation of hydroxylamine
derivatives and of further oxidation products of the
amino group to toxicity and to therapeutic activity.

SUMMARY

The acute toxicity of sulfanilamide and related com-
pounds is no reliable index of the toxicity to be
encountered on continued administration, particularly
under adverse conditions of infection or dietary restric-
tion. Variations in the toxic manifestations of sulf-

7’. i -yuso: siuates in Chemotherapy : X.

Lolonraetric Tests for Aromatic Hydroxylamines and for Further Oxida-
]«9 lr ° dUCtS ° f • Arom:,tlc • An > !nes > ■Puii- Health Rep. H4-. ISSO (Oct. 20)

rc ‘l c 5| ons . hav'c, also been obtained in the urine of dogs, of
rats ana ot man following sulfanilamide administration.

1714

DISCUSSION ON SULFANILAMIDE

Jour. A. M. A.
Nov. 4, 1939

anilamide occur in different species of animals. There
is inadequate knowledge of the chronic toxic effects
on laboratory animals.

Relatively large doses of sulfanilamide and repeated
therapy are required to bring about a high percentage
of cures in streptococcic infections in mice.

With pneumococcic infections, marked variation in
response to therapy occurs with different species of
animals.

Combination of sulfanilamide therapy with specific
antiserum in pneumococcic, meningococcic and strepto-
coccic infections in mice brings about more favorable
results than those obtained with either type of therapy
used alone.

It has been shown that sulfur is not essential to thera-
peutic activity. Antibacterial properties have been
demonstrated for some aromatic arsenic compounds, as
well as for />-nitro benzoic acid.

Following the oral administration of sulfanilamide to
rabbits, a small percentage of an oxidation product of
the amino group (hydroxylamine) has been detected
in the urine. Other investigations have suggested the
possible significance of this derivative in the mechanism
of action of sulfanilamide.

ABSTRACT OF DISCUSSION

ON PAPERS OF DR. KING ET AL. AND DR. ROSENTHAL

Dr. Charles L. Fox Jr., Boston : The paper of Dr. King
and his co-workers is interesting but I would make one obser-
vation to be considered in evaluating some of his facts. Hourly
bacterial counts of cultures with sulfanilamide (10 mg. per
hundred cubic centimeters) and controls without sulfanilamide
show these three features : For the first three hours growth
is equal in the two. Then the control proceeds along the loga-
rithmic phase of growth whereas the sulfanilamide culture grows
but slightly until the eighth or ninth hour. Then this period of
bacteriostasis (from the third to the ninth hour) ends and the
sulfanilamide culture grows out equaling the control. If, there-
fore, one has not observed the culture between about three hours
and about eight hours, one is likely not to see any bacteriostatic
effect whatever. In table S which Dr. King showed, and in all
his observations, I believe the first observation of the colony was
at nine hours. His other observations were at about twelve
hours. If one considers this fact, one will recognize that the
major effect of the drug occurs between about the third and the
ninth hour, but after nine hours one is not going to see so much
effect. It may be possible to recognize that a culture the growth
of which has been held up for three or four hours here at this
time, at about seven or eight hours, is a younger and possibly
a more actively growing culture than the control which has
been growing vigorously during that period. There may be a
possibility that this increased hemolytic effect of the organism
grown in sulfanilamide is due to the fact that his observations,
beginning at about nine hours, are on cultures with controls
which are not growing as actively at this stage as the sulf-
anilamide cultures. In evaluating all sulfanilamide studies, I
think it must be realized that the major effect of the drug
occurs between about the third and the ninth hour.

Dr. Sanford M. Rosenthal, Washington, D. C. : I think
we are all on the right track in mechanism, but I just want
to add that most of our work has been in the test tube and
that all mechanisms of action based on in vitro experiments
remain theories until they are demonstrable in the living organ-
ism. I feel that we now have to take our test tube work
over into the animals to see whether the same thing applies.

I should like to ask Dr. Shinn whether he has studied the
blood of animals or human beings under sulfanilamide for the
catalase activity or for peroxide content.

Dr. Joseph T. King, Minneapolis: The question was raised
by Dr. Fox whether with this method one might overlook an
important phase of the bacteriostatic action of sulfanilamide

during the early part of the incubation period. Since the
diameter .of the colony is used as the index of growth rate in
this medium, no information exists concerning growth until
the colonies can be measured microscopically. In the medium
without erythrocytes the colonies usually appear between the
fourth and the sixth hour of incubation. On the basis of
colony diameter the maximal bacteriostatic effect of the drug
occurs at a point in time later than that at which colonies
become measurable in both experimental and control cultures.

. Dr. Fox also pointed out that, although the growth curve of
cultures containing sulfanilamide is usually greatly retarded in
the early part of the incubation period, it may eventually rise
above the control and he raised the question whether this might
account for the higher hemolytic index observed in our cul-
tures. . With my . technic I usually observe a decrease in the
bacteriostatic action of the drug following the maximum,
which usually occurs somewhere near the twenty-four hour
period. This tendency is probably more pronounced when the
cultures contain erythrocytes. I have never observed the bac-
teriostatic action to fail completely — the experimental colonies
never become larger than the controls in this medium. This
fundamental difference between fluid mediums and tissue cul-
ture clots where the organisms grow as colonies must be kept
in mind when interpreting results. In any event this sugges-
tion could hardly account for the fact that a higher hemolytic
index is found in cultures containing sulfanilamide, since this
term expresses the hemolyzing power of a colony in relation
to its size, i. e. the diameter of the hemolytic zone divided
by the diameter of the colony. The absolute amount of hemol-
ysis is less in experimental cultures than in controls. The
experimental colonies produce wide zones of hemolysis in rela-
tion to their size.

L. E. Shinn, Ph.D., Pittsburgh: With regard to the paper
of Dr. Rosenthal, I am glad to see some one embark on a
study of compounds other than the interminable ringing of
changes on the amino attached to the sulfur. So far as I
know, no one has made any systematic efforts to get at the
real fundamentals of the structure, replacing the sulfur with
other substances and making the changes in the heart of the
molecule, so to speak. We have begun work similar to that
which he has discussed with regard to the benzoic acid. I am
preparing to do some work on arsenicals in the belief that
that group, the group which is now the sulfonamide group, is
not in itself particularly important or critical. From my point
of view, the action of that group probably lies in its influence
on the amino group. Its effect is indirect, unstabilizing the
amino group to just the right degree. Dr. Rosenthal asked
whether I had examined the tissue fluids of animals or human
beings with regard to the anticatalase mechanism, production
of hydroxylamine, and so on. I must say that I have not. I
had considered it hopeless to hunt for the hydroxylamine
derivative in vivo. The question was raised as to what is
going to be done with some other organisms — the staphylo-
coccus, the diphtheria bacillus, B. coli and the gonococcus.
On that question I cannot say very much. I feel that we
are going to find in those organisms factors which will allow
the application of this or a very similar theory in explanation
of mechanism. For example, the gonococcus is presumed to
be a producer of an appreciable amount of catalase and, since
it is a producer of catalase, one must presume that that cata-
lase serves some purpose. The indication would be that the
organism is extremely susceptible to hydrogen peroxide and
therefore that interference with catalase may be even more
effective.

Dr. I. S. Ravdin, Philadelphia: The workers who believe
that anticatalase activity is responsible for the mode of action
of sulfanilamide must explain why this drug is effective against
the colon bacillus, which grows well in the presence of hydro-
gen peroxide. The explanations advanced this morning must
not be accepted as proofs of the mode of action of these very
interesting and useful substances but further work must be
awaited.

Dr. Fox : Dr. Rosenthal said he would like further evi-
dence as to the presence in the blood of patients or animals
of some of these compounds which assumed!}' arc formed from
sulfanilamide in vivo. That evidence has been difficult to get.

Volume 113
Number 19

SEROLOGIC DISCREPANCIES— CRAWFORD AND RAY

1715

We have taken specimens of blood of sulfanilamide treated
patients and, by using the recording spectrophotometer at the
Massachusetts Institute of Technology, have been able to get
a smooth line curve of the transmission spectrum of the blood
of these patients. Such blood almost always contains methemo-
globin, as many others have shown, and sometimes sulfhemo-
globin, but, in addition, in the red end of the spectrum,
where hemoglobin absorbs but slightly, there is a residual
absorption. The human eye is but slightly sensitive, and the
ordinary spectrophotometer is less accurate in the region above
650 millimicrons. With the recording spectrophotometer we
have gone from 400 to 700 millimicrons. From about 650 to
700 millimicrons there is definite absorption strikingly similar to
the absorption by the products of the ultraviolet irradiation of
sulfanilamide. Important additional evidence for the presence
of these oxidation products in patients’ blood is that, added in
vitro, these products convert hemoglobin to methemoglobin.
Sulfanilamide itself has absolutely no such effect. Dr. Rosen-
thal said that the compound nitrosobenzene, the oxidized form,
is bacteriostatic. I have found that addition of a paradimethyl-
amine group produced a compound 100 times more bacteriostatic
than nitrosobenzene. These substances are reversible oxidizing
systems and in vitro, in mice, produce fatal methemoglobinemia
so that therapeutic tests were unsuccessful.

SEROLOGIC DISCREPANCIES IN
SYPHILIS

THE POSITIVE HINTON-NEGATIVE WASSERMANN
PROBLEM

G. MARSHALL CRAWFORD, M.D.

AND

LEON F. RAY, M.D.

PORTLAND, ORE.

The occurrence of a positive Hinton with a negative
Wassermann reaction in patients with late syphilis
gives rise to delicate problems of diagnosis as well as
to the question of activity in old cases and the advisa-
bility of further treatment. The first technic of the
Hinton test 1 was adopted for routine use at the Massa-
chusetts General Hospital in 1929. The present method, 2
which is comparable to the Eagle, Kahn, Kline and
Kolmer tests as to specificity and surpasses them in
sensitivity, 3 is similar in principle to the Eagle, Kahn
and Kline tests. When the Hinton test was first used
at the Massachusetts General Hospital it was applied
to all bloods in conjunction with the Wassermann test.
The technic of the latter test is a modification of the
standard Wassermann test. 4 A general agreement
between the two tests led to the practice of omitting the
Wassermann test unless the Hinton test was positive.
When an additional check was desired, a portion of the
specimen was sent to the Massachusetts State Board
of Health Laboratory, where the Hinton technic is
under the supervision of its originator. With the pas-

From the Massachusetts General Hospital, Department of Dermatology
and Sy philology, Dr. C. Guy Lane, chief.

Read before the Section on Dermatology and Syphilology at the
Ninetieth Annual Session of the American Medical Association, St. Louis,
May 18, 1939.

1. Hinton, W. A.: A Glycerol-Cholesterol Precipitation Reaction in
Syphilis. Boston M. & S. J. 196:993 (June 16) 1926-

2. Hinton, W. A.: Syphilis and Its Treatment, New York, Mac-
millan Company, 1936. p. 293.

3. Cummings, H. S.; Hazen, H. H., and others: The Evaluation of
Serouiagnostic Tests for Syphilis in the United States, Report of Results,
\en. Dig. Inform. 1G: 1S9 (June) 1935 (first evaluation). Parran,
1 nomas; Hazen, H. H., and others: The Efficiency of State and Local
Laboratories in the Performance of Serodiagnostic Tests for Syphilis,

(Jan.) 1937 (second evaluation). Parran, Thomas; Hazen,
nt }& others: A Comparative Study of Serodiagnostic Tests for
Syphilis, ibid. IS: 273 (Aug.) 1937 (third evaluation).

and 'X risht > H - : Pathological Technique,
Philadelphia, W. B. Saunders Company, 1924, p. 533.

sage of time, however, cases exhibiting a disagreement
between the two tests gradually accumulated.

In new infections, the development of increased sensi-
tivity in tests for syphilis facilitated diagnosis. In late
syphilis, however, more delicate tests increased the
importance of demonstrating clinical evidence of the
disease. The specificity of blood serologic reports might
otherwise be open to question. The results of nation-
wide serologic conferences for evaluation by the United
States Public Health Service indicate that these highly
sensitive technics are accurate. The extensive appli-
cation of such methods of blood examination has given
rise to many intricate and perplexing problems. Some
doubts arose when new technics produced a positive
reaction accompanied by a simultaneous negative report
with an older standard test. In early syphilis “serologic
cures” were delayed, with a corresponding increase in
serofast cases. In late syphilis, especially the asymp-
tomatic group, still more difficulties appeared. It was
questioned whether persistently positive serologic exami-
nations by such delicate technics meant continued
activity of the disease. Criteria of adequate therapy
were consequently open to further consideration. Many
old Wassermann-negative cases exhibited positive reac-
tions to the new tests. Likewise, numerous unsuspected
cases appeared which were negative by older methods.
Some clinicians doubted that a positive report by such
sensitive procedures meant syphilis in the face of a
negative Wassermann reaction unless other evidence
was provided. Cannon 5 stated that a properly con-
trolled “4 plus” Wassermann reaction meant active
syphilis in need of treatment, with certain exceptions
including yaws and leprosy. Can his statement be
applied as well to the more sensitive tests ? Kolmer 0
expressed the opinion that serologic positivity in an
apparently healthy person, even with previous adequate
therapy, indicated the persistence of syphilitic infection.
He further stated that serologic relapse meant renewed
activity of foci of the disease. Kolmer also indicated
that therapy was needed to aid immunity and prevent
progression of the disease. Can such beliefs be applied
to cases exhibiting a positive serologic reaction by
sensitive methods when the Wassermann reaction is
negative? The questions are partially answered by the
ratings of accuracy attained by many of the sensitive
tests in the reports of serologic congresses. We have
attempted to clarify some of these problems from the
clinical aspect by the following work.

DATA

In the period from July 1936 to July 1938 there
were 2,862 new admissions to the syphilis clinic at the
Massachusetts General Hospital. Excluding early syph-
ilis, there were 335 cases (11.7 per cent of the 'total)
which were found to have a positive Hinton and a
negative Wassermann reaction on the first blood sero-
logic examination. During the same period 1,078 cases
of syphilis were diagnosed, so that these 335 patients
comprised 31 per cent of the actual cases of syphilis
admitted. This group was chosen for the present stud;'
without further criteria of selection. Early syphilis of
less than two years’ duration was excluded because such
cases would present more of a question of adequacy
of therapy than a serologic problem. During the same
period of time approximately 40,000 specimens of blood

in. tto Jr syphilis iiirough Common

roems j. A. M. A. 100:148 (July 31) 1937.

™* j *• . Ser ®Iopc Reactions and Immunity in Relation to

22 : 426 (M ° f S5Thilis - Ara - Syph - Conor. & Vcn.° Dis!

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Volume 113
Number 19

1717

SEROLOGIC DISCREPANCIES— CRAWFORD AND RAY

The average age of group B patients was 47.1 years.
Since the history and physical evidence were not con-
clusive, cases of congenital syphilis could not be defi-
nitely segregated. A suggestive history consisted of
dubious genital lesions, indistinct eruptions, possible
iritis, and miscarriages or stillbirths of doubtful sig-
nificance. There was a suspicion of syphilis in some
member of the family in one fifth of these cases.

Table 5.— Group B: Additional Studies

Cases

1. Corroboration of positive Hinton by other laboratories 25

2. Spina! fluid examinations (ail negative) 19

3. Cardiovascular x-ray studies (2 suspicious and 8 negative)... 10

Table 6. — Group C: Additional Studies

Cases

1 . Corroboration of positive Hinton reaction by state labora-

tory 35

2. Spinal fluid examinations (all negative) 28

3, Cardiovascular x-ray studies (nil negative) 12

Indecisive physical lesions were inconclusive scars,
osseous changes, dental changes, facies, pupillary aber-
rations, dubious old choroiditis or optic atrophy, other
suspicious neurologic lesions, questionable cardiovas-
cular damage and gastritis. Additional investigations
are given in table S.

Group C. — The fifty-four cases included here were
diagnosed as syphilis on the basis of persistently posi-
tive Hinton reactions alone. This seemed justified in
the light of such observers as Moore, T who stated that,
if a precipitation test is reliable, a series of positive
reactions must be considered of the same significance as
a series of positive Wassermann reactions. The Hinton
test appeared to fulfil this criterion and should mean
syphilis when persistently positive, regardless of nega-
tive Wassermann reactions. Five or more positive
reactions were obtained here in each case; no evidence
other than this was afforded. The average age in this
group was 46.3 years. Additional investigations are
given in table 6.

After having studied and tabulated the first two
groups of cases (A and B) there was no hesitancy
in our minds about making a diagnosis of syphilis in
group C. Yaws and leprosy could be eliminated without
difficulty; malaria was ruled out as far as possible by
the anamnesis. The five blood examinations which
gave consistently positive results were done over an
average period of 9.S months in all cases. This time
factor should rule out the few diseases which are
thought to cause a temporary positive reaction. The
cases in this group comply with the criteria generally
used to denote true latent syphilis.

Group D.— - In this group there were forty-two cases
that have not been classified. It was impossible to
decide whether these patients had syphilis or were free
of the disease. After the initial positive Hinton reaction
the reports vacillated repeatedly. There was nothing
in the personal or family history to suggest syphilis,
nor was there a story of any disease which might have
given rise to a “false positive” report. No physical
evidence was found to suggest syphilitic damage. The

/. Moore, J. E.: The Modern Treatment of Syphilis, Springfield,
11!., Charles C. Thomas, 1933, p. 465.

average age was 40.2 years. These patients have been
followed for an' average period of 10.2 months each.
A summary of the data in this group appears in table 7.

Disagreements in the blood serologic reports were
pronounced in this group. Additional checking by
sending split samples simultaneously to two laboratories
did not settle the question in these cases because of the
failure of the results to coincide. This fact is demon-
strated in table 8.

An example of the type of case encountered in this
group is given in table 9.

It is possible that many of these patients had syphilis
and perhaps some did not. From the clinical standpoint
there was no way to decide. From a purely serologic
aspect the discrepancies in reports precluded an accu-
rate decision. It seemed that ten months should be long
enough in which to decide whether most patients had
syphilis, but when the data given were considered front
the practical point of view the problem was not always
clear.

Group E. — It was felt that in all probability the
forty-eight patients in this group did not have syphilis.
In each case there was a single positive Hinton reaction
followed by several negative reactions. The initial posi-
tive reaction was followed by three or four negative
reactions over a period of 10.5 months average time.
Here again there was no history or physical evidence
of syphilis in any case. The average age was 38.4
years. Every attempt was made to rule out any con-
dition which might possibly have given rise to a tem-

Table 7. — Group D: Forty-Two Undecided Cases with
Serologic Discrepancies

Average Xo.

Blood Serologic Data per Case

1 . Positive Hinton reactions 2,1

2 . Doubtful Hinton reactions 0.0

3. Negative Hinton reactions 3.1

Total average number of tests j.S

Additional Studies Cases

1. Hinton test done by state laboratory 31

2. Spinal fluid examinations (all negative) 10

3. Cardiovascular x-ray studies (all negative) 4

Table 8. — Comparison of Discrepancies in Tivo Laboratories
in Group D *

Cases

State laboratory (31 cases)

1 . Hinton positive 7

2. Hinton negative 24

3. Subsequent disagreement in the same laboratory 5

Massachusetts General Hospital laboratory (42 cases)

1. Hinton positive 40

2. Hinton negative 2

3. Subsequent disagreement in the same laboratory DO

* Discrepancies between reports irom the two laboratories occurred
in twenty-four eases.

porary false report, since haptens or “partial antigens”
are thought to cause such reactions in some diseases.
Table 10 presents the data on these patients. Serologic
discrepancies were less pronounced in this group, as is
reflected in table 11.

The question of “false positive” reactions arose in
this group, and the series of subsequent negative tests
in these cases indicated such a situation. These forty-
eight patients comprised 13.7 per cent of the 335 cases

1718

SEROLOGIC DISCREPANCIES— CRAWFORD AND RAY

Jour. A. M. A.
Nov. 4, 1939

studied, which was an undue number of false positive
reactions for a test which has stood high in the con-
ferences on serologic tests recently held. When com-
puted on the basis of the state laboratory reports alone,
in which only three positive reactions were obtained,
less than 1 per cent of false positive reactions would
exist. This was in agreement with the accepted status
of the Hinton test. Some degree of error exists, how-
ever, in that not all cases were checked by the state
laboratory. This situation implies that the Hinton test

Table 9. — Example of Case in Group D

History: L. A., a man aged 42, in February
193S complained of discomfort in the lower
part of the abdomen of 4 years’ duration;
the past, family and marital histories were
entirely negative for syphilis

Physical examination: Three complete physi-
cal examinations by three different physi-
cians over a period of 10 months were
entirely negative for clinical evidences of
syphilis

Laboratory studies:

Spinal fluid:

Cells 0

Total protein 21
Wnssermann reaction negative
Colloidal gold curve 0000000000
Blood counts, urine and stool were normal
Gastrointestinal and cardiovascular x-ray
studies were negative

Gastroscopic examination showed superfi-
cial and hypertrophic gastritis
Serologic examination on wife negative

Serologic Tests

Date

Hinton

TVnsser-

inann

2/ 8/38

Pos.

Neg.

2/11/33

Pos.

Ncg.

3/ 5/38

Pos.

Neg.

3/ 5/38

(State)

Nog.

3/10/38

Pos.

Neg.

3/31/3S

Neg.

Ncg.

7/ 7/3S

Pos.

Neg.

12/10/38

Neg.

Neg.

as done in the laboratory at the Massachusetts General
Hospital was lacking in specificity. A tabulation of the
chronologic occurrence of these false positive reactions,
compared with the number of reports received per
month, showed a direct ratio of incidence. That is,
more were found in those months during which most
of the cases were picked up.

This group showed the value of comparative sero-
logic data between laboratories, even for the better
hospitals. It also emphasized the absolute necessity of
checking and rechecking a positive serologic reaction of
the blood when other evidence is lacking.

“false positives”

In order to compute the true percentage of false
positive reports it was necessary to use the total number
of new bloods tested in the laboratory during the

Table 10.— Group E: Forty-Eight Patients Not
Having Syphilis

Average No.

Blood Serologic Data

per Patient
1.0

0.2

4.0

Total average number of tests

5.2

Additional Studies

Cases

1 .

Hinton test done by state laboratory

34

2. Spinal fluid examinations (all negative)....

3. Cardiovascular x-ray studies (all negative)

twenty-four months which this study included. There
were 21,073 new patients who had serologic examina-
tions of the blood during this time. To allow for the
widest possible margin of error, all of both groups D
and E were included, which made a total of ninety
possible cases, which would be 0.42 per cent of false
positives. The total number of positive and doubtful

reports on these ninety patients was 171. If computed
on the basis of this number of tests against the total
number of blood specimens examined by the laboratory
during this period, approximately the same percentage
of false positives is calculated.

The occurrence of false positive reactions can be
attributed with certainty to such oriental diseases as
yaws, relapsing fever and trypanosomiasis. Leprosy
and malaria show false positive reactions less often.
Hyperpyrexia, hemorrhagic diseases and jaundice are
highly controversial. All these conditions were ruled
out as far as possible in the present study. When a
case showed occasional positive results interspersed
among several negative ones, it may have been due to
a fluctuating and very low reagin titer. Some good
authorities construe such cases as being definitely syphi-
litic. Other observers feel that these serums contain
some unknown substance which may be detected by a
given test and that in the absence of clinical corrobo-
ration there is no syphilis present. There were nineteen
cases in group D which exhibited this vacillating type
of serologic status. Perhaps these were the only truly
false positive cases. The rest of group D showed two

Table 11. — Comparison of Hinton Reports from
Two Laboratories

State laboratory (31 cases)

1. Hinton positive 3

2. Hinton negative 31

8. Subsequent disagreement in the same laboratory 2

(Two positives inter negative, one not repeated at state
laboratory)

Massachusetts General Hospital laboratory (18 cases)

1 . Hinton positive 10

2. Hinton negative 2

3. Subsequent disagreement in the same laboratory 16

(All positives inter repeatedly negative)

Discrepancies between the two laboratories 34

No case positive in both laboratories

Only 2 cases positive at state laboratory and negative at
Massachusetts Genera] Hospital laboratory

or more positive or doubtful reactions followed by
several negative reactions. It is possible that such
patients showed a fading reagin titer just at the time
at which it passed below a detectable level. A mistaken
report or technical error occurring twice per case
seemed most unlikely in so many instances.

The cases in group E, however, were in all proba-
bility merely falsely positive in the sense of “technical
errors.” A single positive reaction was followed by
repeated negative reactions in each instance. Possible
disease causes of a temporary false positive reaction
were ruled out. Technical errors in such cases may be
due to improper technic in the performance of the test,
the skill of the individual technician, human fallibility
in reading the tests, errors in labeling the tubes and
mistakes in reporting the results. The occurrence of
only forty-two such cases among 21,073 new serologic
examinations provided the extremely low figure of 0.2
per cent in the two year period. Other situations that
give rise to false positive or anticomplementary reac-
tions in the complement fixation tests do not need to
be considered here. These include bacterial or chemica
:ontamination, the presence of a high concentration ot
a drug in the serum and an excess of native anino-
:eptor. Many such factors which may inhibit com-
plement fixation have no effect on the flocculatio
phenomenon and hence may be disregarded.

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1720 ACUTE PERFORATIVE

least three of these tests, and incidentally the technic is exactly
as described by the originators, namely Kolmer, Kahn and
Kline, and in the last two years we have added to that the
Eagle complement fixation test and Eagle flocculation test.
Now our routine procedure is to do not two or three sero-
diagnostic tests on the blood but five in parallel. This has
taught us a few things. It has taught us much about the rela-
tive sensitivity of these various tests. It has taught us some-
thing about false positive tests in what we think are apparently
normal individuals. I am talking from the standpoint of the
clinician and not from the standpoint of the serodiagnostician.
At the serologic conference in Hot Springs last fall the clini-
cians were in the minority. Here the laboratory diagnosticians
are in the minority. So I think it is a matter of one’s point of
view as to whether we regard group C, D and E the authors
had on slide 1 in the doubtful group, or whether we include
just group D and E. Group C was the group in which the
diagnosis of syphilis was made solely on a positive Hinton test
or a very sensitive flocculation test for syphilis. It will take
observation over a long period of years to determine whether
group C, as the authors presented it, did have syphilis or did
not. The group of individuals that Dr. Ryan spoke about indi-
cating that it all depends on how sensitive a serologic test is
as to whether or not it has prognostic import, with special
reference to early syphilis, I think can be placed to one side.
We, have dark field examination to help us there make a definite
diagnosis. The important group to consider is not the early
syphilitic patient who is beginning to go into serologic positivity,
but the enormous group that Dr. Lane spoke of. In my experi-
ence it is at least 60 per cent of our entire clinic clientele, and
in the last two years we have thoroughly examined, not merely
serologically and cursorily speaking from a clinical standpoint,
5,400 new patients with syphilis.

Dr. G. Marshall Crawford, Boston: Thank you for this
generous discussion. Dr. Lane brought out two points that I
didn’t have time to emphasize: the matter of having several
tests to establish the diagnosis and also to use different labora-
tories. I am also indebted to Dr. Kulchar for mentioning the
reagin-lfke substance. I covered that in one sentence, saying
that some men believe there is a substance which will occa-
sionally show positives by certain tests. The elaboration by
Dr. Kulchar was quite enlightening. I should like to repeat
that the observation of these cases extended over a period of
nine to ten months, so that temporary causes of an increase in
their reagin-like substance should be eliminated. Whether a
positive Hinton reaction means activity of syphilis and whether
these patients should be treated were points I expected to see
raised and was glad to hear. We do not feel that all these
patients should be given intensive therapy. It has been our
policy to treat only definitely active syphilis intensively and the
others on an intermittent plan. Some very notable observers
say that the human mechanism is not capable of conquering the
syphilitic infection without help. We usually give them a short
course once or twice a year. The hazards of the complement
fixation test were also mentioned; they are largely avoided by
the flocculation or precipitation test. I was glad to hear Dr.
Rein mention the possibility that there is no seronegative stage.
As long as there is some reagin present there must be some-
thing going on to produce that reagin. Dr. Rein may be fore-
casting the day when we shall simply mak; a diagnosis of
syphilis and disregard stages except for infectiousness. Dr.
Schoch’s comments were very apropos. We are envious of him,
having five serologic tests at his command. We do a routine
Hinton and when that is positive always do a Wassermann;
when there is a question we get as many checks as possible in
another laboratory. While we don’t think that some of our
conclusions are far fetched on a few tests, they certainly could
be improved if we had more. I should like to quote a few
figures, as yet unpublished, from the last Serologic Congress.
The Hinton test was done by five laboratories and there was not
a single false positive or false doubtful from any of the five
laboratories. There was no other test showing a complete
absence of false positives. The Hinton test was 83.9 per cent
sensitive on known positive specimens. The Kline exclusion
test was close to that and the other five tests submitted to that
congress were grouped in the 70 s of percentage.

DIVERTICULITIS— BEARSE J°”*. a. m. a.

Nov. 4, 1939

ACUTE PERFORATIVE DIVERTICULITIS
OF -THE COLON IN YOUNG
PERSONS

CARL BEARSE, M.D.

BOSTON

Based on reports of unselected postmortem exami-
nation 1 and on x-ray studies of the gastrointestinal
tract of patients with abdominal symptoms, 2 the inci-
dence of diverticulosis of the colon averages about 5.9
per cent. The average incidence under the age of
30 years is about 0.31 per cent of all diverticulosis
patients ; 3 therefore, the frequency of diverticulosis in
persons under 30 years of age would be about 18 pei-
liundred thousand of population.

In an average of about 15 per cent of patients with
diverticulosis diverticulitis develops, 4 and approximately
21 per cent of these require surgical intervention, 5 or
about 3 per cent of diverticulosis patients. For the
entire population the incidence of operation would be
about 186 cases per hundred thousand of population,
and for persons under 30 years of age, diverticulitis
requiring operation would occur in no more than 5.7
patients in 1,000,000 of population.

It is possible, however, that diverticulosis and diver-
ticulitis occur more frequently in young adults than
has been indicated by these reports. Postmortem
studies do not portray the true incidence of diverticulosis
in young persons, since there is only an approximate
mortality of 0.4 per cent of the population who are
under 30 years of age. 0 Likewise, the facts obtained
from x-ray studies of the gastrointestinal tract are open
to criticism. The average age of patients who have
x-ray examinations made of the gastrointestinal tract
has been given as 45 years. 20 Diverticula may not be
visible unless special efforts are made to demonstrate
them, and repeated x-ray examinations of the gastro-
intestinal tract may be necessary. To ascertain the
approximately correct incidence of diverticulosis in per-
sons under 3C it would be necessary to have x-ray
studies of the gastrointestinal tract made for diverticula
of all persons during their first three decades of life.

Furthermore, Judd and Pollock 7 reported that of 118
operations for diverticulitis two, or 1.7 per cent, were
performed on patients under 30 years of age. Also, in
the course of my own private practice I have operated
on three young adults for perforated diverticulitis with
abscess, two of these patients being operated on within
a period of two years.

1. (a) Koncour, E. J.: Colon Diverticula, Am. J. Surg. 37|

Sept.) 1937. (i>) Rankin, F. W., and Brown, P. W.: Diverticulitis

be Colon, Surg., Gynec, & Obst. 50: 836 (May) 1930. c no.

2. (a) Mayo, W. J.: Diverticula of the Sigmoid, Ann. Sure. u .

39 (Oct.) 1930. (fr) David. V. C.: Diverticulosis and Dt'ertic , ‘
/ith Particular Reference to the Development of Diverticula of the L
>urg., Gynec. & Obst. 56: 375 (Feb., No. 2A) 1933. (e) Sjj S| s ;

i I., and Marxer, O. A.: Multiple Diverticula of the Colon, Lancet x.
067 (May 21) 1927. (d) Rankin and Brown. 11 ’ . n . erlicu-

3. (o) Brown, P. W., and Mardey, D. M. : Prognosis of Diverticu

:tis and Diverticulosis of the Colon, J. A. M. A. ^

937. (&) Spriggs and Marxer. 1 ' (c) Rankin and Brown. . ,,. .

4. Abell, Irvin: The Diagnosis and Treatment of D ‘': c r tl0 "‘ l<15 .„, s
livertieulosis, Surg., Gynec. & Obst. CO : 370 . (Feb. , No. 2A>
layo, W. J.: Diverticulitis of the Sigmoid, Brit. M. J..2. 574 (» I I
8) 1929. Ochsner, H. C., and Bargen. J. A.: Diverticulosis i of “
arge Intestine; An Evaluation of Historical and Personal Ohsenalion,
,nn. Int. Med. 9:282 (Sept.) 1935. Rankin and Brown * b and Mareley.

5. (o) Friedenwald, }., in discussion on Brown and Marciey.

Iayo. la (c) Rankin and Brown. Ib . , r, ...

6. Vital Statistics: Special Reports (Summary of the United St a .

.egistration Area. 1936), Dept, of Commerce, Bureau of the Census .
57-958 (April 29) 193S. Estimated Population i of the United t States uy
ge as of April 1. 1935, ibid. Truesdell, L. E.. Chief Statutician
opulation, ,U. S. Dept, of Commerce, Bureau of the Census. I erso
3mm unicat ion to the author. - . «

7. Judd, E. S., and Pollock, L. \V.: Diverticulitis of the Colon, Ann.
urg. 80:425 (Sept.) 1924.

Volume 313
Number 19

ACUTE PERFORATIVE DIVERTICULITIS — BEARSE

1721

report of cases

Case 1 —Mrs. J. P., aged 30, a housewife, admitted Jan. 21,
1925, had been taken ill five days previously with vomiting
and constant abdominal pain, which was localized to the left
lower quadrant. The patient was rather short and obese. The
temperature was 102 F. There was considerable tenderness
but no spasm in the left lower quadrant of the abdomen; no
masses could be felt. Directions were given regarding the
nonsurgical management of acute diverticulitis of the colon.
Three days later the temperature was 102 F. and the pulse
rate 120. An exquisitely tender mass the size of a large grape-
fruit was palpated for the first time in the left lower quadrant
of the abdomen.

Operation was done the following morning. The mass con-
sisted of omentum, adherent to the sigmoid, which was greatly
thickened, particularly on the mesenteric border, and was cov-
ered with much fibrin. Associated with the mass was an
abscess cavity containing about 8 ounces (240 cc.) of foul
smelling pus. This was aspirated, and drainage was instituted.
The patient made a satisfactory convalescence and was dis-
charged from the hospital thirty days after operation. Gastro-
intestinal roentgenograms three and one-half months after the
operation showed a diverticulum of the sigmoid.

Case 2. — -J. M., a man aged 23, admitted June 12, 1936,
complained of intermittent abdominal pain of three weeks’
duration which came on suddenly in the region of the umbilicus.
He complained of diarrhea and vomiting on the day of the
consultation as well as the day before. X-ray studies of the
gastrointestinal tract showed moderate dilatation of several loops
of small intestine; no diverticula of the colon were visible but
the pattern of the mucosa seemed to be accentuated. A barium
sulfate enema had been given and fluoroscopic examination
showed tenderness at the junction of the descending colon
and sigmoid. The patient was well developed and well nour-
ished. The temperature was 99.6 F. Examination of the
abdomen revealed exquisite tenderness and resistance at the
left lower quadrant. Rectal examination disclosed a mass that
could just be reached by the examining finger.

At operation a moderate amount of straw-colored fluid was
found in the peritoneal cavity. The descending colon was
adherent to the lateral parietal peritoneum, where there was a
mass the size of a baseball. Within this mass was an
abscess cavity from which about 4 ounces (120 cc.) of fout
smelling pus was aspirated. A cigaret wick was placed into
the cavity. The convalescence was fairly uneventful and the
patient left the hospital on the thirty-seventh postoperative
day. Roentgenograms of the gastrointestinal tract six months
after the operation showed a diverticulum of the descending
colon.

Case 3. — Miss E. G., aged 19, a bookkeeper, admitted March
26, 1937, complained chiefly of abdominal pain, which after
onset four days previously had localized to the right lower
quadrant. Two days before admission she had an evening
temperature of 101 F. There was no nausea and no vomiting.
The patient was well developed and well nourished. The tem-
perature was 100.5 F. Examination of the abdomen revealed
tenderness, resistance and an indefinite fulness to the right of
the umbilicus. Rectal examination was negative.

Operation revealed a mass the size of a tennis ball in the
region of the ascending colon. Within the mass was an
abscess cavity from which about 1 ounce (30 cc.) of thick,
foul smelling pus was aspirated. A cigaret wick was placed
into the cavity. The convalescence was relatively uneventful,
and the patient was discharged from the hospital three weeks
later. Roentgenograms of the gastrointestinal tract ten months
after the operation showed a diverticulum of the ascending
colon.

COMMENT

The causation of diverticulosis is still obscure.
Although various explanations have been offered for
the development of diverticulosis, such as old age,
constipation with increased gaseous pressure within
the colon, excessive fat or emaciation, and even a dis-
turbance of the sympathetic nerves of the colon, =a it

seems that the most applicable cause in young persons
is an inherent weakness in the structure of the colon,
which is usually at the point of entrance or exit of the
blood vessels. 8 The possibility of diverticula being
congenital should also be considered, since cases have
been reported in children and even in infants."

In young adults, as in older patients, diverticula
rarely give rise to symptoms until there are inflamma-
tory changes. These changes may be brought about by
trauma, 10 such as repeated straining at stool, enemas
given at high pressure, the use of drastic cathartics, and
strenuous exercise. Food may also be a factor in caus-
ing diverticulitis ; - a red meats, for instance, may
increase the bacterial activity within the intestine, and
potatoes and milk may cause irritation by forming a
relatively large mass. The possibility of an infection
from a distant focus 11 should also be considered.

In diverticulitis the symptoms may closely resemble
those of acute appendicitis. Pain, the outstanding symp-
tom, may vary' in intensity and may be intermittent or
constant. Nausea and vomiting may be present. There
is always localized abdominal tenderness and at times
rigidity as well as distention. The temperature is
usually elevated and there is an accompanying leuko-
cytosis.

When diverticulitis involves the ascending colon, as
in case 3, the diagnosis may be confused with an
appendical abscess until the abdomen is opened. If,
however, the lesion is on the left side a correct pre-
operative diagnosis is frequently made. At times an
abscess associated with diverticulitis can be felt by
rectum. Fluoroscopic and sigmoidoscopic examinations
may be of help in making an accurate diagnosis but
are not without risk; if too vigorous, rupture of the
abscess may result.

In early diverticulitis, that is, before perforation and
abscess formation, inflammation may subside under
nonsurgical management. This treatment should con-
sist of rest in bed, practically nothing by mouth for a
day or two, and ice bags or heat to the seat of pain. The
heat may include short wave diathermy, electric pads,
hot packs, Elliott treatment or rectal irrigation of warm
physiologic solution of sodium chloride or olive oil.
After the inflammation begins to subside, olive oil (2
or 3 ounces) or liquid petrolatum may be given by
mouth, and later food, the diet at first being practically
free of residue. Subsequently the patient should be put
on an anticonstipation diet and given oil or agar by
mouth.

If an abscess is present when the patient is first
seen, as in the cases reported, or if in spite of medical
treatment perforation and abscess formation take place,
operation for the drainage of the abscess is indicated.
If obstruction is present, cecostomy should also be done
and, if the obstruction persists after the acute inflamma-
tion has subsided, resection of the obstructed area may
be necessary.

Following recovery from an operation for perforated
diverticulitis, the patient should be advised that

8. Hansemann and Klebs, cited by Judd and Pollock 7 and by David. 2U
Rankin and Brown. ,lJ Judd and Pollock. 7 David. 2b

9. Hartwell, J. A and Cecil, R. L.: Intestinal Diverticula, Am. J.
Sc. 140: 174, 3910. Ashhurst, A. P. C. : Sigmoid Diverticulitis

(Mesosigmoiditis) in a Child. Ann. Surg. 47: 300, 1908. Ransohoff T,:
Acute Perforating Sigmoiditis in Children, Ann. Surg. 58: 218, 3913
Goebel, cited by Ransohoff. Erdmann, J. F.: Acute Diverticulitis of
tH^Colon. A civ \ork State J. Med. 109:969 (June 7) 1919. Judd' and

10. Telling, W. H.; Acquired Diverticula of the Sigmoid Flexure
Lancet ^84 3, 3908; Multiple Diverticula of the Sigmoid Flexure, Brit!

Diverticulitis of the Colon, Minnesota Mcd.‘6:35
Uan.) 1923. Spnggs and Marxer. 5c

/ 1722

EPIDEMIC ENCEPHALITIS— BRESLICH ET AL.

Jove, A. M. A.
Nov. 4, 1939

diverticulosis is still present. In order to avoid further
development of diverticula or a recurrent diverticulitis,
large doses of kaolin, 511 bismuth subnitrate or barium
sulfate 12 once or twice a week may be helpful. Par-
ticular attention should be given to regularity at stool ;
agar may be taken for bulk and soft stools. 35 An
effort should be made to improve the intestinal flora. 2b
It would be well for the patient to exclude from the diet
coarse and indigestible foods and to include cooked fruits
and finely chopped vegetables. 311

SUMMARY

1. Diverticulosis and diverticulitis of the colon prob-
ably occur more frequently in young persons than
reports would indicate.

2. In this report young adults required operation for
perforated diverticulitis of the colon with abscess.

483 Beacon Street.

EPIDEMIC ENCEPHALITIS IN
NORTH DAKOTA

PAUL J. BRESLICH, M.D.
PAUL H. ROWE, M.D.

AND

WILLIAM L. LEHMAN, M.D.

MINOT, N. D.

During July, August, September and October 1938
an epidemic of acute encephalitis, which clinically
resembled the St. Louis type, was observed in North
Dakota. According to information supplied by Dr.
John Cowan, of the North Dakota Department of
Health, 101 instances were reported, of which fifty-
two occurred in Minot and the surrounding rural
territory, which includes the ten counties in the north-
western portion of the state. Twenty-three of these
patients were cared for in Trinity Hospital by the mem-
bers of the medical staff, and the material of this report
was obtained from their clinical records. Nine entered
the hospital from Minot, while fourteen came from
farm homes located within a. radius of 65 miles of the
city. The rural patients lived from 10 to 120 miles
apart, and in only two instances did more than one
patient come from any single locality.

Nineteen patients were adults and four were children.
Arranged according to age groups, the incidence among
adults was evenly distributed from 20 to 70 years. Nine
of the adults were men and ten were women. The four
children ranged from 2 months to 8 years in age. Two
were boys and two were girls. Most of the city patients
were engaged in business or professional pursuits, and
one was a nurse who had cared for patients ill with
encephalitis. The severity of the symptoms was mot
related to age and was just as marked in the younger
as in the older patients. Five died of the illness and
were respectively 25, 26, 36, 57 and 60 years of age.

The illness was characterized by an acute onset with
generalized severe headache and fever. The tempera-
ture when first taken at home ranged from 101 to 105
F., the average being about 102 F. The commonly
used analgesics gave no relief from headache. The
patients complained of severe generalized muscular
pains and backache. Chills and chilly sensations

io. FrietJemvald, J., in discussion on Lynch, J. M.: Diverticula and
Diverticulitis, J. A. M. A. OSj /93 (March 19) 1932. . ,

From the Medical Sendee and Laboratory of Trinity Hospital and the

Xorthwest Clinic.

occurred when the temperature elevation was marked.
Nausea and vomiting occurred in about one half of
the patients early in the illness. Dizziness and drowsi-
ness appeared within the first three days, but in spite
of the drowsiness the patients were unable to sleep.
After the fourth day, coarse or fine muscular tremors
of the arms and face were present in about three
fourths of the adult patients. The tremors were of the
intention type and were absent at rest.

The symptoms of individual patients varied con-
siderably. One became comatose on the first day of
the illness while the mental symptoms of ten others
did not progress to a state of delirium. Eight of the
adult patients became irrational and delirious on the
fourth or fifth day, and this condition was followed by
coma within two days of all but one of these patients.
For a time they could be aroused momentarily to take
food, but later coma became deeper and incontinence
of urine and feces occurred. Coma was a grave prog-
nostic sign and five of the eight comatose patients died,
four within two days after the onset of coma and one
after eleven days.. Two of the five had repeated con-
vulsions before death and one had a right hemiplegia
which could not be explained by cerebral hemorrhage or
thrombosis at the postmortem examination. A third
patient died of paralysis of the respiratory center, the
respirations gradually slowing to 4 or 5 a minute. In
only one instance was there a terminal bronchopneu-
monia.

In the children the onset was sudden with high
fever. Vomiting, nervous irritability and convulsions
were the most frequent symptoms, while coma of only
one patient occurred. Spasmodic muscular contrac-
tions of the right arm and leg of one infant were noted.
Recovery of children was rapid, and the course of the
illness was several days shorter than that of adults.

Most of the patients had been ill three or four days
before admission to the hospital. Physical examination
disclosed no constant changes in the heart, lungs or
abdomen. Rigidity of the neck, the most characteristic
physical finding, appeared early in the illness and was
present in fifteen cases. This sign was elicited by any
passive effort to bring the head forward on the chest.
Coarse intention tremors of the hands and face, par-
ticularly of the lips, were observed in all but seven
cases, and in four there was slurred speech, apparently
related to the tremor of the lips and tongue. The
abdominal reflexes were absent in ten instances and
later became absent in two more. The Kernlg sign
was positive in six of the cases in which there was
rigidity of the neck. The Babinski reflexes were posi-
tive in only four cases and varied from time to time.
There were no characteristic abnormalities of the patel-
lar and achilles tendon reflexes. Lateral nystagmus
was present in two cases, and in two others a fixation
nystagmus was demonstrated. In one of the latter
there was a transient divergent squint.

The temperatures on admission to the hospital ranged
from 100.6 to 105.6 F., most of them being between
102 and 104 F. In those cases in which recovery'
occurred the temperature remained elevated from three
to seven days after the onset and then subsided to
normal within two or three day's. The average dura-
tion of fever was about eight days. The pulse anu
respiratory' rates were increased proportionately' to the

temperature. .

Recovery' from delirium, somnolence, muscular
tremor and rigidity of the neck were complete witlim

Volume 113
Number 19

EPIDEMIC ENCEPHALITIS— BRESLICH ET AL.

1723

one week after the temperature became normal. In one
instance muscular tremor persisted for about six weeks.
The average duration of the illness before convalescence
was well established was fifteen days.

LABORATORY EXAMINATIONS

The average white blood cell count was 12,200, the
lowest being 5,200 and the highest 22,700. The dif-
ferential blood counts disclosed no constant change.

Fig. 1. — High power microscopic field demonstrating perivascular round
ceil infiltration.

Examination of the urine revealed albuminuria in
eleven instances, the amount varying from 10 to 800
mg. per hundred cubic centimeters, but in most cases
it was not more than 50 mg. per hundred cubic centi-
meters. Two patients showed traces of dextrose in
the urine, and a third showed a large amount of dex-
trose with acetone and diacetic acid. This patient’s
blood sugar was 240 mg. per hundred cubic centimeters
and death occurred on the ninth day of illness, although
hyperglycemia and glycosuria were controlled by insulin.

In one fatal instance, the blood culture was repeatedly
positive for the hemolytic streptococcus, and in four
cases in which typhoid was suspected the Widal test
was negative.

The average white cell count of the spinal fluid was
130, and it varied from 2 to 525 cells in individual
instances. In adults about 80 per cent of the cells were
lymphocytes and the rest polymorphonuclear leuko-
cytes, while in children about 50 per cent of the cells
were polymorphonuclear leukocytes. The spinal fluid
sugar content, not including that of the diabetic patient,
ranged from 45 to 104 mg. per hundred cubic centi-
meters, the average concentration being 72 mg. per
hundred cubic centimeters. The cerebrospinal fluid
pressure with the patient lying on the side ranged from
100 to 230 mm. of spinal fluid. The Nonne test was
faintly positive in seven cases, and Lange’s colloidal
gold test was negative in five. The spinal fluid was
cultured in seven instances and found sterile.

PATHOLOGY

Postmortem examination was performed on all five
patients who died. The characteristic pathologic
changes were limited to the central nervous system, and
examination of the thoracic and abdominal tissues dis-
closed only such changes as might have been found in
any severe toxic illness. When the dura was reflected
from the brains a marked hyperemia of the leptomen-
ingcs was the most noteworthy change. There was

some flattening of the cerebral convolutions and nar-
rowing of the sulci, and on surfaces made by cutting,
the tissue of the brains was pink.

Histologically the leptomeninges were diffusely infil-
trated with lymphocytes, although plasma cells and
epithelioid cells were occasionally seen. The infiltra-
tion was most marked over the base of the brain, while
over the vertex the cellular exudate was most abundant
opposite the cerebral sulci. The small blood vessels
of the brain and of the leptomeninges were widely dis-
tended with erythrocytes. Thrombi were found in a
few small arteries in the basal ganglions of one brain
and were associated with small recent hemorrhages in
the surrounding tissue.

The most striking microscopic change was a marked
perivascular round cell infiltration. This occurred in
all parts of the brain but was less marked in the cere-
bral cortex and medulla than in the basal ganglions,
pons and medulla oblongata. Occasional lesions were
found in the cerebellum. The round cell exudates occu-
pied the so-called Virchow-Robin spaces and only rarely
were round cells found between the blood vessels and
the brain substance. The cells were chiefly lympho-
cytes but plasma cells, epithelioid cells and polymorpho-
nuclear leukocytes were occasionally identified.

A second characteristic change consisted of aggre-
gates of mononuclear cells widely distributed in the gray
and white matter of the brain. These lesions varied
in size but ordinarily were not more than 250 microns
in the greatest diameter. The mononuclear cells were
apparently of glial origin. Their nuclei were rather
large, round or oval, and often indented. The cyto-
plasm was scanty, irregular in outline and poorly
defined. In the larger cell aggregates occasional lym-

phocytes were identified. The cell masses were not
related to the vascular lesions and occurred indepen-
dently of them.

In all five brains degenerative changes of the large
nerve cells were observed in the basal ganglions and
pons, medulla oblongata and occasionally the cerebral
cortex. The changes consisted of swelling and round-
ing off of the cell bodies with disappearance of the
Nissl granules. The nuclei of these cells stained more
deeply than normal, and the nuclear outlines were indis-
tinct. In some no nuclear substance was visible and the
rounded or irregular cell remnants were stained deep
pink in hematoxylin and eosin preparations. Such cell

Fig, 2. — High power microscopic field from region of glial proliferation.

1724

EPIDEMIC ENCEPHALITIS— BRESLICH ET AL.

Jour. A. M. A.
Nov. 4, 1939

remnants were most frequently found in or near the
regions of glial cell proliferation but were also found
.in the more normal tissue.

An unusual feature of the histologic preparations
from the basal ganglions, pons and medulla oblongata
was the presence of foci of demyelinization in which
the normal brain tissue was replaced by a pale staining
spongy fibrillar mass. These lesions were no larger
than a miliary tubercle. Many of them were densely
infiltrated with mononuclear cells similar to those found
in the regions of glial proliferation, but it was not
unusual to find foci containing almost no mononuclear
cells. The lesions were irregularly distributed in the
tissue. Some were arranged along the course of the
blood vessels, but others occurred as isolated lesions
unrelated to the blood vessels. Foci of demyelinization
were not observed in the medulla or cortex of the
cerebrum or cerebellum. The lesions were found in
all five brains but the frequency with which they
occurred varied considerably. They were numerous in
three, while in the other two many microscopic sections
were carefully examined before the lesions were dem-
onstrated.

Fig. 3. — Low power microscopic field from lcntiform nucleus, demon-
strating region of demyelinization.

In three brains marked glial proliferation, perivas-
cular round cell infiltration and degenerative changes
in the nerve cells were noted in the olfactory bulbs.

Serums from six patients who recovered were exam-
ined in two laboratories. Dr. Edwin H. Lennette, of
the Department of Pathology of Washington Univer-
sity School of Medicine, St. Louis, reported that four
of the serums failed to neutralize the virus of Western
equine encephalomyelitis or of lymphocytic choriomen-
ingitis. Three of the four failed to neutralize the St.
Louis encephalitis virus, while the fourth on repeated
tests gave equivocal results.

Serums from the same four patients in addition to
two others were examined in the laboratories of the
National Institute of Health, of the U. S. Public Health
Service in Washington, D. C., and Dr. Charles Arm-
strong was kind enough to report that in only one
instance were neutralization tests with St. Louis enceph-
alitis virus strongly positive. This serum was from
the same patient in whom equivocal results had earlier
been obtained by Dr. Lennette. Serum from four of
these six patients was found to contain neutralizing
antibodies against the Western virus of equine enceph-
alomyelitis.

COMMENT

Acute epidemic encephalitis, as it was observed in
North Dakota in the summer of 193S, resembled that
i eported in the St. Louis region in 1933. 1 The symp-
toms, physical manifestations and clinical course were
similar. The seasonal incidence and the distribution
of the cases in the community were much the same. 2

The pathologic changes in the central nervous sys-
tem, however, differed from those occurring in the St.
Louis patients 3 in that small regions of demyelinization
were found in the basal ganglions, pons and medulla
oblongata. Because of the difference in the pathologic
condition it was suspected that the illness in North
Dakota patients might be caused by a virus different
from that responsible for the St. Louis epidemic. As
already stated, the serum from only one of six patients
who recovered neutralized St. Louis encephalitis virus.

In view of the fact that encephalitis in human beings
has been reported as caused by the virus of both Eastern
and Western equine encephalomyelitis,' 1 it is interesting
to note that Western equine encephalomyelitis was pre-
valent in North Dakota in the summer of 1938. Serums
from six of our patients who recovered were tested
against the Western virus of equine encephalomyelitis,
and Dr. Armstrong reported that the neutralizing anti-
bodies w’ere moderately positive in two instances and
positive in two others.

The mortality in our series of patients was about 22
per cent. This figure is probably too high, since only
seriously ill patients were brought to the hospital. The
incidence of less severe acute encephalitis in the com-
munity could not be determined. The increased severity
in the older age groups noted in St. Louis was not
apparent in our patients.

In children the illness was first thought to be acute
anterior poliomyelitis without paralysis, but later,
because of the marked similarity of the clinical course
to that in adults, the diagnosis was changed to acute
encephalitis. Since all the children recovered, the path-
ologic changes could not be investigated.

SUMMARY

Twenty-three instances of acute epidemic encephalitis
not previously observed occurred in North Dakota.

Clinically the illness resembled the St. Louis type of
acute encephalitis.

Pathologically the North Dakota encephalitis differed
from the St. Louis type in that foci of demyelinization
occurred in the basal ganglions, pons and medulla
oblongata.

Serum from only one of six patients who recovered
neutralized the virus of St. Louis encephalitis, while
serum from four of these six patients neutralized the
Western equine encephalomyelitis virus. The virus of
lymphocytic choriomeningitis was not neutralized by
serum from these six patients.

The mortality in the reported series was 22 per cent.

1. Leake, J. P.: Encephalitis in St. Louis, J. A. Al- A ■ 101 : 978

sept. 16) 1933. Hemplemann, Theodore: Symptoms and Dia^nosM
ncepbalitis, ibid. 103: 733 (Sept. 8) 1934. Barr, D . , V.:

ncephalitis Epidemic in St. Louis, Ann. Int. Med. 8 1 37 (July J u •

2. Leake, J. P.; Musson, E. K., and Chopc. if. D. : EpidcnuofoffX «
pidemic Encephalitis, St. Louis Type, J. A. M. A. 103:728 (Sept. I

3. McCorrlock, H. A.; Collier, -William, and Gray, S. }[.: T j! c
athologic Changes of the St. Louis Type of Acute Encephalitis, J- *

A. 102 : 822 (Sept. 15) 1934. Weil, Arthur: Histopathology of
entral Nervous System in Epidemic Encephalitis, Arch. Aeuro.
sychiat. 31:1139 (June) 1934. , ^.„ nrr ty

'■*. Fothergi), L. D.; Dingle. J. II.; Earlier. Sidney, and Cmmtlt
. L.: Human Encephalitis Caused l.y the Virus oTiTl rV/nt 23)
quine Encephalomyelitis, New- England J. Sled- 210. 4 L [ |i un ian
US. Wesselhoeft, Conrad: Smith. E. C„ and Branch, C. I.. I
acephalitis: Eight Fatal Cases tilth Four Due to the Wrus of
iccphalomyelitis, J. A. St. A. 111 : 1735 CNoy. 51 JUun n

AL. and Blumstein, Alex: The Relation of Human Encephalitis

iccphalomyelitis in Horses, ihid. Ill : 1/34 {Nos. 5) 1 •

Volume 113
Number 19

ADDISON’S DISEASE— FERREBEE ET AL.

1725

DESOXYCORTICOSTERONE ESTERS

CERTAIN EFFECTS IN 'THE TREATMENT OF

addison’s disease

JOSEPH W. FERREBEE, M.D.

CHARLES RAGAN, M.D.

DANA W. ATCHLEY, M.D.

AND

ROBERT F. LOEB, M.D.

NEW YORK

During the past decade there have been two material
advances in the treatment of patients suffering from
Addison’s disease. The first of these was the recog-
nition of the abnormalities of electrolyte metabolism
present in addisonian patients and the correction of
these disturbances primarily through the addition of
large amounts of sodium salts to the diet 1 and also
through a reduction in the intake of potassium. 2 The
second advance came through the elaboration of extracts
of the adrenal cortex, 5 which are life sustaining, at least
in adrenalectomized animals.

Despite the progress made through these contribu-
tions, the treatment of Addison’s disease has continued
to be only moderately satisfactory at best. In the past
three years the isolation of a series of crystalline steroids
of great physiologic activity from adrenal cortical
material has been accomplished by Kendall, 4 by Winter-
steiner and Pfiffner 6 and by Reichstein. 0 This work
aroused the anticipation that one of these active steroids
might be synthesized in sufficient amounts to make pos-
sible the treatment of adrenal insufficiency in man. This
hope has been realized in the synthetic preparation of
esters of desoxycorticosterone by Reichstein, 7 and the
present report deals with the results obtained following
their use in a series of thirteen patients with Addison's
disease. These results are in general agreement with
those reported by Thorn s and his associates and by
Cleghorn and his colleagues. 9

From the Departments of Medicine and Neurology, Columbia Uni-
versity College of Physicians and Surgeons, and the Presbyterian Hospital.

Owing to lack of space, this arictle has been abbreviated for publica-
tion in The Jpurnal by the omission of ten case reports. The complete
article appears in the authors' reprints.

1. Loeb, R. F. : Chemical Changes in the Blood in Addison's Disease,
Science 7G:420 (Nov.) 1932; Effect of Sodium Chloride in Treatment
of a Patient with Addison’s Disease, Proc. Soc. Exper. Biol. & Med. 30:
808 (March) 1933. Loeb, R. F. ; Atchley, D. \V.; Benedict, Ethel M..
and Lcland, Jessica: Electiolvte Balance Studies in Adrenalectomized
Dogs with Particular Reference to the Excretion of Sodium, J. Exper.
Med. 57: 775 (May) 1933. Harrop, G. A.; Weinstein, Albert; Softer,
L. J., and Trescher, J. H. : The Diagnosis and Treatment of Addison’s
Disease, J. A. M. A. 100: 1850 (June) 1933. Harrop, G. A.: Diag-
nosis and Treatment of Addison’s Disease, ibid. 101:388 (July) 1933.

2. Wilder, R, M.; Snell, A. M.; Kepler, E. J.; Rynearson, E. II.;
Adams, Mildred, and Kendall, E. C. : Control of Addison’s Disease with
a Diet Restricted in Potassium: A Clinical Study, Proc. Staff Meet.,
Ma>o Clin. 11: 273 (April 22) 1936.

3. Hartman, F. A.; MacArthur, C. G., and Hartman, W. E.: A Sub-
stance Which Prolongs the Life of Adrenalectomized Cats, Proc. Soc.
Exper. Biol. & Med. 25:69 (Oct.) 1927. Rogoff, J. M.. and Stewart,
G. N.: The Influence of Adrenal Extracts on the Survival Period of
Adrenalectomized Animals, Science GG: 327 (Oct.) 1927. Pfiffner, J. J.,
and Swingle, XV. XX.: The Preparation of an Active Extract of the
Suprarenal Cortex, Auat. Rcc. 44: 225, 1929.

4. Kendall, E. C.; Mason. H. C. : McKenzie, B, F., and Myers, C. S. :
The Isolation in Crystalline Form of the Hormone Essential to Life from
the Suprarenal Cortex: Its Chemical Nature and Physiologic Properties,
Proc. Staff Meet., Mayo Clin, 9: 245 (April 25) 1934.

5. Winterstcincr, Oskar, and Pfiffner, J. J.: Chemical Studies on
the Adrenal Cortex: II. Isolation of Several Physiologically Inactive
Crystalline Compounds from Active Extracts, J. Biol. Cliem. 111:599
(Nov.) 1935.

6. Steiger, Marguerite, and Reichstein, T.: Partial Synthesis of a
Crystallized Compound with the Biological Activity of the Adrenal Cortical
Hormone, Nature 139 : 925 (May 29) 1937.

7. Steiger, M., and Reichstein. T. : Dcsoxv-corticosteron (23*Oxy*
prugesteron) aus 5'3-Oxy-atiocholensnure, Heli. chini, act. 20; 3364, 1937.

8. Thorn, G. W.; Howard. R. P.; Emerson, Kendall, Jr., and Firor,
W. M. : Treatment of Addison’s Disease with Pellets of Crystalline
Adrenal Cortical Hormone (Synthetic Desoxycorticosterone Acetate)
Implanted Subcutaneously, Bull. Johns Hopkins Hosp. G4 : 339 (May)
1939.

9. Read before the American Society for Clinical Investigation, May

EXPERIMENTAL

Observations were made of the effects of desoxy-
corticosterone esters 10 on various blood constituents
including sodium, potassium, calcium, chloride, bicar-
bonate, nonprotein nitrogen, serum proteins, sugar and
cholesterol. The effects on the excretion of water,
sodium, potassium, total nitrogen and riboflavin were
studied, and observations were made on changes in
hematocrit, serum volume as measured with the blue
dye method of Gregersen and Gibson, and total inter-
stitial fluid volume as determined by the sodium thio-
cyanate method. Finally, in a number of instances the
effects of desoxycorticosterone on the basal metabolic
rate and carbohydrate metabolism were recorded.

In this study, six patients were placed on standard
regimens in the metabolism service. Their diets were
essentially constant as to the types and amounts of the
various foodstuffs, caloric values and mineral content.
These patients also received a constant fluid intake and

. *»* *• •JuiKin.iry oi cennin enects oi desoxycorticosterone propionate

observed after ten days' treatment of a group of patients with Addison’s
disease maintained on a standard regimen.

\\ ere given in addition to theii* food, which was pre-
paied salt free, ’ a constant intake of sodium chloi'ide.
In addition to these rigidly controlled cases, observa-
tions were made on other addisonian patients who were
allowed to eat and drink as they desired.

After a foreperiod of varying duration, the hospital-
ized patients received, as a rule, 25 mg. of desoxy-
corticosterone acetate or propionate dailv for four days
and then from 10 to 25 mg. daily for five days more.
(The hormone, dissolved in sesame oil. was injected
subcutaneously or intramuscularly once a day and each
cubic centimeter contained 5 mg.) After this time the
patients were allowed to eat as they desired and the
dose of synthetic hormone was continued at a main-
tenance level. We have failed to detect any definite
difference in activity between the acetate or propionate
esters of desoxycorticosterone. The details of treatment
are presented in the individual case histories.

10. The desoxycorticosterone esters use
Roche-Organon, Inc. The term “doca”
the full chemical name.

in this work were furnished by
employed as a contraction of

/

ADDISON’S DISEASE— FERREBEE ET AL.

RESULTS

Ihe results are shown in part in the table and in
figure 1 and can be summarized as follows :

Salt and Water Retention. — Desoxycorticosterone
esters cause a striking retention of salt and water. The
rate of retention of the sodium ion usually exceeds that
of water, so that as a rule the serum sodium concen-
tration increases to normal and is maintained at a
normal level as fluid retention continues. In case 4
(fig. 2) water appeared to be retained more rapidly at
first than the sodium ion, resulting in an actual decrease
in the sodium level of the blood for three days. Fol-
lowing this the concentration rose to normal despite
further water retention. In case 6, of extensive tuber-
culosis, it was never possible to raise the sodium con-
centration above 132 milliequivalents per liter although
the retention of water was sufficient to cause pulmonary

Jour. A. M. A.
Nov. 4, 1939

hours and the chloride excretion underwent a com-
parable change.

As a result of these changes there were marked
increases in the extracellular fluid volume in the various
cases as measured by the sodium thiocyanate method.
These, increases were in general agreement with the
gains in body weight except in case 1, in which repeated
observations suggested an increase in extracellular fluid
volume of 8.0 liters but a gain of only 3.3 Kg. in body
weight. This discrepancy' is not at present explainable.
The data for salt and water retention in this case indi-
cate that the validity' of the thiocyanate figure is ques-
tionable.

Ihe blood. serum volumes increased between 0.3 and
1.2 liters during the first ten days of treatment in the
six cases in which these measurements were made.
These increases are in close agreement with the

Summary of the Maximal Effects of tlic Administration of

Serum Serum Serum

Inter-

Hemato-

Pro-

Albu-

Glob-

Venous

Scrum

stitial

Serum

crit.

Red

tein,

min,

ulin,

Pres-

Circu-

Sodium

Blood

Fluid

Vol-

per

Blood

Grains

Grams

Grains

sure.

Vital

Iation*

m£n.

Pressure,

Weight,

Volume,

ume.

Cent

Cells,

per

per

per

Mm.

Capacity,

’lime.

per

Case

Age

?0X

Alin . He

Kg.

Edema

Liters

Liters

Cells

Millions

ioo Ce.

100 Cc.

100 Cc.

HaO

Cc.

Sec.

Liter

1. S. McD.

35

<s

90/ 52

50.3

0

15.0

2.0

48.0

4.48

0.7

2,250

12

135 8

142 / SGt

53.3

0

23.0

3.0

32.0

4.00

5.7

75

2,450

13

140.8

•2. R. W.

47

a

96/ 64

70.2

0

20.5

3.4

42.0

5.10

G.7

55

2,250

23

134.4

146/108

74.3

+

22.3

4.6

29.0

3.90

5.2

55

2,850

16

139.1

3. M. D.

27

s

78/ 50

50.1

0

15.9

2.3

36.0

4.71

7.2

4.4

2.8

ec§

4,250§

126

96 / 64

64.4

+ + + +

28.3

3.3

27.0

2.88

4.7

2.8

1.9

158

1,250

138 6

i. F. D.

41

e

96/ 5S

66 .8

0

15.1

2.5

44.5

3.70

7.1

130.3

120 / 85

75.1

H-

16.7

3.3

34.0

3.60

6.0

143.2

5. 21. L.

56

9

300/ 68

50.2

0

12.6

2.5

42.0

3.85

6.G

133.0

160 / 92

53.8

++

15.6

3.0

29.0

3.73

5.1

142.2

6. H. W.

30

SO/ 52

0

14.7

2.2

31.0

3.80

6.5

3.9

2.G

7£§

900 §

122.4

120 / 84

++++

15.7

2.5

28.0

3.36

4.7

2.5

2.2

140

600

132.1

7. M. C.

37

9

100/ 70

45.4

0

....

6.2

4.2

2.0

137.7

118 / 80

50.7

0

5.7

4.3

1.4

141.2

8. A. W.

50

cT

100/ 80

55.4

0

4.48

6.8

4.8

2.0

141.1

104 / 65

59.5

+

3.42

5.0

3.5

1.5

75

3,000

143.4

9. H.B.

33

c r

100/ 72

GO.S

0

. ...

4.84

7.0

...

106 / 70

62.1

0

4.70

5.9

10. A. G.

35

cT

105/ 65

51.1

0

...

7.4

132 / 90

55.5

+ +

6.5

11. R. F.

33

c i

94/ 70

61.1

0

7.0

.....

160/110

63.8

+ 4*

6.0

250

143.5

12. G. B.

52

9

82/ 00

50.1

0

7.0

..

132 / 88

54.0

++

6.3

13. M. J.

43

9

04/ GO

3S.6

0

....

...

6.8

...

..

90 / 60

40.0

+ 4-

6.2

* Circulation time with 0.5 Gm. of calcium gluconate. _

t Figures in bold face type arc following desoxycorticosterone propionate or acetate and represent maximal effects.

congestion, hydrothorax, generalized edema and a tem-
porary' elevation of venous pressure to 140 mm. of
water.

The amount of salt and water retained varies greatly
in different cases and cannot be correlated with the
initial sodium or serum protein concentrations or with
the initial plasma volumes. Patient 3 (fig. 3) gained
11 Kg. in ten days, during which time lie received a
total of 190 mg. of the hormone. In contrast, patient 1
gained but 2 Kg. in thirty days, during which time he
received 725 mg. of hormone. Both of these patients
received tire same amounts of sodium and potassium
salts in their diets.

Coincident with the retention of salt and water and
gain in weight, there was in every case a considerable
decrease in the urinary excretion of sodium, chloride
and water. For example, in case 3 the urine output fell
from an average of about 1,500 cc. daily to as little as
410 cc. during the period of administration of 15 mg.
of hormone eacli day. The sodium excretion fell from
tire average control period level of 159 milliequivalents
to as low a value as 28 milliequivalents in twenty-four

decreases in hematocrit and serum protein concentra-
tion and indicate that no significant change in red cell
volume occurred.

No consistent alterations of albumin-globulin ratios
occurred in the four cases in which this determination
of the serum was made. These included the two cases
in which the serum protein concentrations fell respec-
tively from 7.3 to 4.7 and from 5.9 to 4.8 Gm. per
hundred cubic centimeters.

Potassium Excretion. — Synthetic desoxycortico-
sterone esters cause a striking decrease in the concen-
tration of potassium of the serum and frequently reduce
it to abnormally' low levels. Thus, in eight of nine cases
the potassium concentration after treatment was lower
than 4 milliequivalents per liter, the lower limit of our
normal values. In no instance, however, did the potas-
sium concentration fall below 2.9 milliequivalents per

liter. . i (i

The urinary excretion of potassium increased on tne
first day of hormone injection in the six cases in wine >
this was studied. Thereafter the potassium excretion
was extremely variable. For example, in one case t arc

Volume 113
Number 19

ADDISON’S DISEASE— FERREBEE ET AL.

1727

resulted an increase in excretion of potassium far in
excess of that which could be accounted for by a
decrease in concentration in the interstitial fluid and
also greatly in excess of that which might have been
liberated by cell breakdown as judged by a slight
increase in excretion of nitrogen. In another case the
excess potassium excreted could be entirely accounted
for on the basis of that lost from the interstitial fluid
alone. In a third case the excess excretion was even
less than might have been anticipated from the decrease
in serum potassium level.

Nitrogen Excretion —The nonprotein nitrogen level
of the serum decreases even when it is within normal
limits at the beginning of treatment.

Total nitrogen excretion may not be affected, but as
a rule there is a slight increase not exceeding 2 Gm.
in the first two or three days of treatment.

respiratory quotients measured before and after_ two
weeks of hormone treatment in this case were 0.85 and
0.78 respectively— a change of questionable significance.
In another case two hypoglycemic episodes occurred
during which the blood sugar levels were 40_ and 38
mg. per hundred cubic centimeters. This patient had
been receiving 10 mg. of desoxycorticosterone daily for
more than two weeks. This dose was insufficient to
raise the blood sodium level above 122 milliequivalents
per liter, although it was enough to cause excessive
fluid retention.

Blood Pressure. — The effect of desoxycorticosterone
derivatives on blood pressure is undeniable, although it
does not appear as promptly as do the effects on salt
and water metabolism. In all of the thirteen cases the
blood pressure reached normal levels in the course of
two to four weeks and in three cases it has risen gradu-

Desoxycorticosteronc Esters Observed in Patients with Addison’s Disease

Serum

Cnrbon

Serum

Serum

Serum

Dioxide

Potas-

Cal-

Chloride, Content,

sium!

mEq.

cium.

ffiEq.

mEq.

Mg.

per

per

per

per

Liter

Liter

Liter

100 Ce.

99.5

27.6

5.0

10.6

107.7

26.5

3.7

9.1

93.0

31.0

4.8

10.3

103.0

29.0

3,5

9.0

100.0

20.3

7.7

10.1

106.7

25.6

4.0

8.6

100.0

20.0

5.2

....

108.8

27.0

3.9

100.0

22.4

6.3

....

109.4

26

3.9

91.0'

23

5.1

8.7

102.0

27.2

3.9

8.0

10S.O

22.5

3.9

10.1

113.0

25.7

3.6

8.9

106.0

23.6

4.7

10.0

112.0

28.6

3.7

9.0

101.0

108.0

98.8

105.3

10 . 1.0

109.0 2.9

105.0

108.4

100.0

104.0

Scrum

Kon-

Serum

Serum

Basal

protein

Dex-

Choles-

Meta-

Kitro-

trose,

Mg.

terol,

bolic

gen,

Mg.

Rate,

Mg. per

per

per

per

100 Cc. 100 Cc.

100 Cc.

Cent

29

72

172

—14

22

61

151

—17

33

74

188

— 8

29

87

163

± o

41

78

134

24

82

89

31

82

279

21

77

16B

3S

78

212

30

76

*178

27

63

SI

17

35

66

23

70

393

23

71

165

25

85

343

22

88

140

30

03

21

80

27

71

23

71

27

G4

22

83

87

75

20

CD

22

81

Comment

Gained only 3 Kg. in 3 weeks despite 23 mg. Docaf and 11.6 Gm. of salt daily

Gained only 3 Kg. in 12 days despite 25 mg. Doea and 7.9 Gm. of salt daily

Gained 11 Kg. in 10 days with about 20 mg. of Doea daily; gained 0.3 Kg.

regularly with 5 mg. of Doea without salt added to diet

Gained 2.2 Kg. in 10 days on 20 mg. of Doea and 11.6 Gm. of salt daily

Gained 3.7 Kg. in 10 days on 20 mg. of Doea and 6.6 Gm. of salt dally

Died; marked hydrothorax and ascitic fluid; massive edema; extensive tubercu-
losis of adrenals, peritoneum and spine; hod fever and ate poorly in last weeks
Gained 3 Kg. in the hospital on 12.5 mg. of Docn and 10 Gm. of salt daily; main-
tained in office on 35 mg. of Doea every two days and 5 Gm. of salt daily
In hospital, gained 4.5 Kg. in 10 days on 15 mg. of Doea and 10 Gm. of salt
daily

Patient treated in clinic; gave himself 32.5 mg. Doea every other day; taking
2 teaspoonfuls of salt daily

Patient given 13 mg. of Doea daily for 2 weeks and then 32,5 mg. every other
day; taking 5 Gm. of salt daily

Patient treated in clinic; after 2 mo. on 15 mg. of Doea every other day and 10
Gm. of salt dally, he was admitted with marked congestive heart failure; died
Patient treated in clinic; getting 15 mg. of Doea every other day and 10 Gm. of
salt daily; 6 wk. after start she died suddenly at home; death was unexplained
Treated at home with 15 mg. every 2 days and 8 Gm. of salt daily for 2 weeks;
becauso of local reaction. Doea stopped for 2 weeks; last 3 weeks on 10 me. of
Doea every 2 days and 5 Gm. of salt daily

§ After return to normal.

1 Doea = Desoxycorticosterone acetate or propionate (Roehc-Organon).

In the two cases in which determinations were made
it appears that ammonia excretion increases within
twenty-four hours after desoxycorticosterone has been
administered.

Blood Calcium and Cholesterol. — The serum calcium
concentration decreases following administration of the
hormone. This was observed to he true in each of six
cases in which determinations were made before and ten
days after the initiation of treatment. This change may
be attributed to hemodilution with its attendant decrease
in serum albumin concentration.

The cholesterol content of the blood also decreases,
probably as a result of hemodilution.

Carbohydrate Metabolism. — No evidence lias been
found to suggest that desoxycorticosterone esters have
any effect on carbohydrate metabolism. The fasting
blood sugar level is often as low or even lower after
from ten to forty days of treatment. In case 1, in
which 25 mg. of hormone was administered daily for
thirty days, the fasting blood sugar level was 74 mg.
and four hours after the ingestion of 100 Gm. of dex-
trose it was 46 mg. per hundred cubic centimeters. The

ally to 160/92, 160/1 10 and 146/108 respectively. It
does not seem likely on the basis of the history that any
of these patients suffered from hypertensive vascular
disease before the onset of Addison’s disease.

Miscellaneous Effects.— In addition to the objective
changes described, all of the patients feel stronger and
their characteristic early morning asthenia and nausea
disappeared during the course of treatment with the
synthetic hormone. No definite effect on pigmentation
has been noted beyond that attributed to rehydration
and no change in riboflavin excretion has been observed.

. Effect of Progesterone— In view of recent observa-
tions oil the similarity of action of progesterone and
desoxycorticosterone 11 in animals, their relative effects
were compared in three cases of Addison’s disease. The
results in two of these are shown in figures 3 and 4. It
is cleai that the daily subcutaneous administration of

Excretion of Electrolytes/}. Exner/Med ‘fi'q
h[^^iUc’Ac t °on r o{ PreSicraic and xldSof l« Hormm^s'on

mt r c\tZTt S''/ l

Maintain Adrenalcetoraired Rats, il.itl. 40:83 (Jan?) ' 1939 ?” 0 ' l ' Tane " i!1

1728

ADDISON’S DISEASE— FERREBEE ET AL.

Jour. A. M. A.
Nov. 4, J939

progesterone in doses of 30 mg. given for seven or eight
days was entirely without either subjective or objective
effect. Whether larger doses might have had some
effect is not known.

COMPLICATIONS

In view of the high degree of physiologic activity of
desoxycorticosterone esters, it could be expected that
overdosage might result in the appearance of disturbing
complications. Indeed, ten of thirteen patients devel-
oped edema varying from mild and transient puffiness
of the face and ankles to massive anasarca. Patients 3,
6 and 11 developed respiratory distress, tightness in the
chest, a rise in venous pressure and a decrease in vital
capacity associated with x-ray evidence of pulmonary
congestion, as shown in the table. Patient 3 also devel-
oped striking dilatation of the right side of the heart
(fig. 5). In this patient the rapid increase in blood
volume from 3.6 liters up to 4.5 liters was associated
with the development of hypoproteinemia, circulatory

embarrassment and edema. It was necessary to resort
to the restriction of fluid and salt to do away with this
“edema of adrenal origin.” He improved promptly, and
in the course of fourteen days his venous pressure
dropped from 157 nun. to 80 mm. of water, his cardiac
dilatation disappeared ' (fig. 6), his vital capacity rose
from 1,250 cc. to 4,250 cc., and except for slight puffi-
ness of his face and ankles his edema disappeared. It
is of interest to note that after this improvement had
taken place the circulating blood volume was still 4.5
liters.

In case 11, serious cardiac insufficiency associated
with a rise in venous pressure to 250 mm. of water
and a rise in arterial pressure to 160/110 mm. of mer-
cary developed at a time when the patient was taking
only 15 mg. of desoxycorticosterone every other day
arid from two to three teaspoonfuls of salt in his diet.
The difference in the size of his heart before and after
treatment may be seen in figures 7 and 8. Following
phlebotomy and the limitation of salt and water the
venous pressure fell but the patient succumbed with a
terminal pneumonia. The details are described in the
case record. Autopsy revealed no adequate organic

basis for the dilatation of the heart, although mild
hypertrophy was present.

d he mechanism for the development of cardiac insuf-
ficiency in these three cases is not clear. A rapid and
extensive increase in circulating blood volume is a pos-
sible factor, although in case 6 the increase in blood
volume caused by the hormone was only 300 cc. at the
time when the venous pressure was elevated and symp-
toms were most marked. The possibility of vitamin B,
deficiency" as an etiologic factor has been considered but,
with the exception of relatively low excretion of thiamin
in the urine, we have no evidence to support this idea.

REPORT OF CASES

Case 3. — History. — M. D., a man aged 27, unmarried, a
soda clerk, whose history prior to the present illness contained
no significant facts, for about ten years had tanned easily and
noticed that the tan did not fade normally. One year before
admission he consulted a physician because of weakness, anemia
(hemoglobin 75 per cent, erythrocytes 3,700,000) and be
improved following treatment. The present illness
was finally precipitated by a reaction to tetanus
antitoxin given for a hand injury; after consider-
able vomiting he received a saline infusion with
spectacular benefit and the diagnosis of Addison’s
disease was made. In spite of the use of salt
and small amounts of adrenal cortex extract be
continued to fail and a perirectal abscess accelerated
this trend. He lost 19 pounds (8.6 Kg.) in the
four months before coming to the Presbyterian
Hospital. On admission he was thin, markedly
pigmented both in skin and mucous membranes,
and obviously ill ; the blood pressure was 80 sys-
tolic, 40 diastolic, and there was acrocyanosis and
a fistula in ano. There was no evidence of tuber-
culosis. His sedimentation rate on admission was
68 mm. in one hour, but lie was afebrile. The
basal metabolism was — 8 on February 27. Chemi-
cal studies on admission showed the scrum sodium
126 milliequivalents per liter, potassium 7.7 milh-
cquivalents per liter, blood sugar 78 mg. per hun-
dred cubic centimeters and nonprotein nitrogen
41 mg. per hundred cubic centimeters.

This was a typical case of Addison’s disease,
probably due to atrophy of the adrenals and com-
plicated by a rectal fistula.

Treat went svith Desoxycorticosterone . — The pa-
tient was placed on a constant diet with measured
and constant intake of sodium (12.3 Gm.), potas-
sium and water. He was then given 30 mg. of progesterone daily
intramuscularly for eight days and no demonstrable effect was
noted on weight, blood pressure, excretion of urine chloride or
in serum electrolytes. He was then given 25 mg. of desoxycor-
ticosterone subcutaneously for four days. His weight increase
1.7 Kg., the urine volume was halved and there was no markc
change in urinary nitrogen. Urine chloride excretion "as
decreased 30 per cent, sodium excretion 60 per cent, and urine
potassium excretion was increased about 60 per cent. Scrum
cholesterol decreased from 112 to 102 mg. per hundred cu ic
centimeters, serum sodium rose from 126 to 132 milliequivalc" s
per liter, chloride from 100 to 104 milliequivalents per l |tcr >
bicarbonate from 20 to 23 milliequivalents per liter, serum P 0 ’ 35
sium fell from 6.9 to 4.3 milliequivalents per liter, protein ■ °

5.6 per hundred cubic centimeters, nonprotein nitrogen from
to 30 mg. per hundred cubic centimeters. The scrum sugar
not changed. The extracellular fluid volume rose from la.

19.8 liters. The hematocrit reading fell from 34 to -/.a P
cent cells. The blood pressure was not altered. The patien
was then given between 10 and 15 mg. of dcsoxycorticos cr
subcutaneously daily for the next seven days and gamed .
more weight. At this time there was marked cocma o
face, sacrum and ankles. The venous pressure was cer
(158 mm. water), the vital capacity was lowered to h-- j
and he had developed an acute dilatation of the right sic

Fig. Z (case 4 ). — Effects of desoxycorticosterone acetate and propionate.

Volume 113
Number 19

ADDISON’S DISEASE- FERREBEE ET AL.

1729

the heart (fig. 5). During this period the urine output was
about one half of that in the foreperiod. The excretion of urine
chloride varied but was usually below that of the foreperiod
by about 45 per cent. Excretion of urine sodium was 30 per
cent of that during the foreperiod apd urinary potassium was
about 20 per cent less than during the foreperiod. His serum
sodium had risen to 138.6 milliequivalents per liter from 131.6,
chloride to 107 milliequivalents per liter from 104, bicarbonate
to 25.6 from 23.1 milliequivalents per liter. The serum potas-
sium remained about the same after the first four days and
at this time was 4.2 milliequivalents per liter. The serum

Fig. 3 (case 3). — Comparison of effects of progesterone and desoxy-
corticosterone propionate.

protein continued to fall from 5.6 to 4.7 per hundred cubic
centimeters, the nonprotein nitrogen fell to 24 mg. per hundred
cubic centimeters from 30, and the serum sugar continued to
remain the same. The serum volume had risen to 3.3 liters from

2.3 liters at the start of the administration of desoxycortico-
steronc. The extracellular fluid volume had risen from 15.9
at the start to 28.3 liters. The blood pressure remained about
the same. The serum cholesterol had fallen to 89 mg. per
hundred cubic centimeters from 102. The restriction of salt
and water for three days was necessary to stop progressive
gain in edema and cardiac insufficiency. Thereafter the patient
was on an unlimited diet and fluid intake. Salt was restricted
somewhat and he was given 5 mg. of desoxycorticosterone every
two to three days. He gradually lost his edema, his venous
pressure and vital capacity returned to normal, his cardiac
dilatation disappeared (fig. 6) and about six weeks after the
first injection of desoxycorticosterone he had gained 14 Kg.
and had no edema. His serum sodium remained about 135.5
milliequivalents per liter, potassium 4 milliequivalents per liter,
the serum protein bad risen to 6.6 per hundred cubic centimeters
and the serum cholesterol to 134 mg. per hundred cubic centi-
meters. The extracellular fluid volume was 25.5 liters and
the blood volume 4.6 liters as against 28.3 and 4.5 liters respec-
tively at the height of his edema. At this time his blood
pressure had risen about 15 mm. of mercury systolic but the
diastolic had not changed and he still had a blood pressure
consistently under 100. His general clinical status was as
different from his original condition as possible and he felt
perfectly well up and around. He was given a constant diet
again for a six day period and given 25 mg. of desoxycortico-
sterone by mouth for three days. This was five times the
amount needed to maintain him when given subcutaneously
and had no effect cn bis chloride excretion or on his serum
values. He lost weight and the scrum potassium rose from

4.4 to 5.4 milliequivalents per liter on this regimen. He was
returned to his former regimen of desoxycorticosterone 5 mg.

every two to three days and a regular diet with no added
salt and had the fistula in ano repaired. He was under general
anesthesia for an hour and withstood the operation uneventfully
with only one saline infusion postoperative!}'. He is now
still in the hospital, recovering from his operation, and two and
one-half months after the start of desoxycorticosterone admin-
istration he has gained a total of 14 Kg. and has maintained
his serum electrolyte values at nearly normal levels on 5 mg.
of desoxycorticosterone every three daj’s. More than this leads
to edema. His blood pressure after ten weeks of desoxycortico-
sterone remains below 100. A dextrose tolerance curve done
two months after the start showed a flat curve but no hypo-
glycemia four hours after ingestion of 100 Gm. of dextrose.

Case 4. — History. — F. D., a man aged 41, married, an editor,
had a nervous breakdown in 3920 and progressive leukodermia
since 1921. In 1936 he noticed that his summer tan did not
fade in the winter. Beginning in August 1937 he suffered from
increasing weakness, anorexia and loss of weight (20 pounds,
9 Kg.) in all. On admission his blood pressure was 70 systolic,
60 diastolic, and bis nonleukodermic skin was pigmented but
there was no pigmentation of the mucous membranes. The
blood count and urine were normal; the sedimentation rate
was 20 mm. in one hour. Roentgenograms of the chest and
adrenal areas were negative. The serum sodium was 127,7
milliequivalents per liter, potassium 5.6 ’ milliequivalents per
liter, the blood sugar 96 mg. per hundred cubic centimeters and
the nonprotein nitrogen 47 mg. per hundred cubic centimeters.

On salt administration be improved greatly and the addition
of cortical extract made little if any difference. He was fol-
lowed in the hospital and clinic uutil Jan. 5, 1939, when he
was readmitted for desoxycorticosterone administration. During
this time he was able to work at intervals, bis serum sodium
remaining normal most of the time but his blood pressure
usually being below 100 systolic.

A man of 40 with Addison’s disease greatly helped by salt
administration but never returning to normal strength, his
emotional make-up interfered with an accurate appraisal of his
condition at times. There was no evidence of tuberculosis.
Leukodermia was a coexisting condition.

Treatment zaith Desoxycorticosterone . — The patient was placed
on a constant diet containing known amounts of sodium chloride
(11.6 Gm.), potassium and water. He was then given 25 mg.
of desoxycorticosterone intramuscularly daily for four days and
gamed 1 Kg. in weight. The urine volume was decreased by

1730

ADDISON'S DISEASE— FERREBEE ET AL.

about 10 per cent, the urine chloride by 50 per cent, the urine
sodium by 70 per cent. The urine nitrogen was increased by
about 10 per cent and the potassium by about 50 per cent.
The serum sodium rose from 136.3 to 141.6 milliequivalents per
liter, chloride from 100 to 104.8 milliequivalents per liter, bicar-
bonate from 26.3 to 26.7 milliequivalents per liter. The serum
potassium was decreased from 5.2 to 4.4 milliequivalents per
liter, the protein from 7.1 to 5.9 per cent, the cholesterol from
279 to 192 mg. per hundred cubic centimeters, the nonprotein

Fig. 5 (case 3). — Pulmonary congestion
and dilatation of the right side of the heart
associated with a gain of 11 Kg. during ten
clays' treatment with desoxycorticosterone
propionate.

Fig. 6 (case 3). — Disappearance of pul-
monary congestion and dilatation of the
heart two weeks after the cessation of
desoxycorticosterone propionate injections
and the limitation of salt and water in the
diet.

nitrogen and sugar remained about the same and the hematocrit
reading fell from 44.5 per cent to 37 per cent cells. Desoxy-
corticosterone was continued for six more days, from 10 to
15 mg. daily, and he gained another kilogram and had no rise
in blood pressure. The urine volume remained about 10 per
cent less than in the foreperiod, the nitrogen was 10 per cent
less than in the foreperiod, the chloride was about 50 per
cent of that of the foreperiod, the sodium about 50 per cent and
the potassium excretion was increased about 25 per cent. The
serum sodium continued elevated at 143.2, chloride at 108.8
milliequivalents per liter, bicarbonate at 27 milli-
equivalents per liter, nonprotein nitrogen fell
from 32 to 21 mg. per hundred cubic centi-
meters and serum potassium, protein and sugar
did hot change during this' additional six days
on desoxycorticosterone. For the whole ten day
period the extracellular fluid ‘ volume rose 2.3
liters and serum volume rose 800 cc. The
hematocrit reading fell from 44.5 to 34 per cent
cells. He was discharged to the clinic on 12.5
mg. of desoxycorticosterone given subcutane-
ously by himself daily with between 5 and 10
Gm. of sodium chloride added to the diet and
has continued to gain weight. When. last seen,
two months after the start of desoxycorticos-'
t'erone administration, he was feeling well, was
gainfully employed and was maintaining a blood
pressure of 120 systolic, 85 diastolic as well as
a serum sodium of 140 and a potassium of 3.9
milliequivalents per liter. He never developed
any peripheral edema but at times noted that
his face was puffy.

Case 11. — History. — R. F., a man aged 33,
married, an elevator operator, began to notice weakness, ano-
rexia and loss of weight (60 pounds, 27 Ivg., in all) in the fall
of 1937. Over about the same period “brown spots” appeared
on his skin. Following tonsillectomy on May 21, 1938, he began
to have nausea and vomiting and was admitted to Bellevue Hos-
pital, where he remained three and one-half months with the
diagnosis of Addison’s disease. The serum sodium at this time
was 115.9 milliequivalents per liter. He responded well to
sodium chloride but implantation of an adrenal gland into the
ri el it rectus was ineffective.

Jour. A. M. A.
Nov. 4, 1939

Sept. 12, 1938, he began visiting the Vanderbilt Clinic. He
presented the classic picture of weakness, pigmentation of the
skm and mucous membranes and a blood pressure of 95 systolic,
70 diastolic. He had a mild secondary anemia, x-ray examina-
tion of his chest showed, healed tuberculosis at the left apex,
and his adrenal areas contained shadows of calcium density!
The serum sodium was 141 milliequivalents per liter, potassium
4.5 milliequivalents per liter, sugar 83 mg. per hundred cubic
centimeters and nonprotein nitrogen 22 mg. per hundred cubic
centimeters. On approximately 15 Gm. of sodi-
um chloride and a low potassium diet lie
improved greatly.

Jan. 9, 1939, he was admitted to the' Presby-
terian Hospital acutely ill with hemolytic strep-
tococcus sore throat. The serum sodium was
132 milliequivalents per liter. Again on Febru-
ary 20 he came into the hospital with fever.
This lasted for more than a week and was never
satisfactorily explained. Roentgenograms of the
spine showed a destruction of the intervertebral
disks between the fourth and fifth dorsal verte-
brae suggesting tuberculosis, probably inactive.
He was discharged March 11 with a relatively
normal temperature, a blood pressure of 90/60,
sedimentation rate 78 mm. in one hour and a
calculated serum sodium of 137 milliequivalents
per liter. Fie returned to the Vanderbilt Clinic
for Doca administration April 3.

A man of 33, with classic Addison’s disease
due to tuberculosis, he survived two febrile epi-
sodes by the use of sodium chloride. He had
inactive pulmonary and spinal tuberculosis.
Treatment xvith Desoxycorticosterone . — The patient was
treated in the clinic. He was on his usual diet at home with
from two to three teaspoonfuls of salt added to the diet. During
the first week of the administration of desoxycorticosterone (15
mg. every two days) he gained 1.5 Kg. in weight and bis blood
pressure rose from 95/70 to 120/75. Serum chloride showed
no change, his serum protein fell from 7.0 to 6.8 per cent, and
his blood sugar remained constant at 65 to 75 mg. per hundred
cubic centimeters. He was taught to inject the desoxy-
corticosterone himself at home and after seven weeks of 15 mg.

Fig. / (case It). — Appearance . of heart
before treatment with desoxycorticosterone

Fig. 8 (case 11).— Appearance, of heart
after treatment with desoxycorticosteron
acetate.

every other day he gained 2.6 Kg. and maintained his Mood
pressure at the normal level of 120/80. His serum protein had
fallen to 6.4 per cent, nonprotein nitrogen from 27 to 22 mg-
per hundred cubic centimeters and serum chloride remained the
same, about 106 milliequivalents per liter. He felt much
improved, developed a large appetite, and although he slater
that his ankles had been swollen at night, this edema had never
been observed in the clinic in the morning. Three weeks after
his last clinic visit and approximately two months after he ha<
begun to take desoxycorticosterone he was admitted to the war

Volume 113
Number 19

FRAME FOR TURNING— STRYICER

1731

with a story of slowly increasing dyspnea for three weeks,
severe enough in the past two weeks to confine him to his fifth
floor room. This was accompanied by nonradiating squeezing,
substernal pain. Two days before admission he had complained
of nausea, vomiting and epigastric cramps. On examination he
was dyspneic with slight cyanosis, and his face was puffy. Fine
rales and dulness were present at the right base. The pulmonic
second sound was greater than the aortic second sound. A
tender liver was felt two fingerbreadths below the costal mar-
gin. There was no pitting edema. The temperature was 99.4,
blood pressure 130/100, vital capacity 1,300 cc„ venous pressure
140 mm. of water, rising to 200 following an infusion of 200 cc.
of physiologic solution of sodium chloride. The c : -culation time
was 64 seconds (calcium gluconate), serum sodium was 143.5
milliequivalents per liter, potassium 3.2 milliequivalents per
liter, protein 6 per cent, sugar 80 mg. per hundred cubic centi-
meters. X-ray examination of the heart (fig. 8) showed marked
increase in size both to the right and to the left, contrasting
sharply with a normal cardiac contour shown on a roentgeno-
gram taken four months earlier (fig. 7). An electrocardiogram
showed little beyond the voltage lower than that of the record
taken four months previously. The urine contained 3 plus
albumin and no significant cells. Desoxycorticosterone and salt
were withheld. On the day following admission, his blood pres-
sure rose to 150/130 and because of increasing dyspnea and
cyanosis together with a venous pressure of 250 mm. of water,
he was digitalized parenterally, 400 cc. of blood was withdrawn
by phlebotomy, and he was put in an oxygen tent. The follow-
ing morning his temperature had risen to 103 F., venous pres-
sure had fallen to 100 mm. of water and throughout the day
his blood pressure fell from 130/80 to 60/40, responding only
briefly to an infusion of 1,250 cc. of 5 per cent dextrose in
saline solution. The heart sounds became poor, his putse became
irregular and he died the following morning after ten hours of
coma with increasing tachypnea and irregular tachycardia.
Postmortem examination revealed no gross cause for cardiac
failure, although there was slight cardiac hypertrophy and
marked dilatation. Only about 150 cc. of fluid was present in
the pericardium, and a mild bronchopneumonia was also present.
There was also advanced tuberculosis of both adrenal glands.

SUMMARY

1. The use of desoxycorticosterone esters in patients
with Addison’s disease produces striking clinical and
physiologic effects.

2. Clinically there is unequivocal improvement far-
greater than has resulted from any therapy hitherto'
advocated.

3. The most striking physiologic effects are on salt
and water metabolism. The administration of desoxy-
corticosterone esters causes retention of sodium and
water. The result of this retention is an improvement
in the patient’s condition which is qualitatively identical
with that following the administration of salt and water
alone, but quantitatively it is far more marked.

4. No effect on carbohydrate metabolism has been
observed.

5. Patients vary greatly in the amounts of desoxy-
corticosterone esters required to alleviate the manifesta-
tions of adrenal insufficiency.

6. Extreme caution must be exercised in the
administration of desoxycorticosterone esters because
excessive amounts may lead to the development of
hypoproteinemia, marked edema and cardiac insuf-
ficiency.

Addendum. — Since this article was written, it lias been found
that patients do most satisfactorily with small daily doses of
synthetic hormone without the addition of salt beyond that of
the usual diet. It may also be pointed out that patient 7 devel-
oped transient dilatation of the heart, relieved by the withdrawal
of salt. Furthermore, patient 5 died suddenly at home while
under treatment while the blood pressure was normal and
without fever.

Clinical Notes, Suggestions and
New Instruments

A DEVICE FOR TURNING THE FRAME PATIENT
Hosier Stryker, M.D., Axx Arbor, Mica.

Hospitals or physicians who use the anterior and posterior
Bradford frames are confronted with the nursing problem of
changing the patient from one frame to the other. A method
which enables one nurse to turn any patient without lifting
and with a minimum of discomfort to the patient is herein

Fir. 1. — Patient on posterior Bradford frame with foot and arm sup-
ports attached. The frame is supported by the turning devices attached
to the ends of the bed. These also support the overhead frame, from
which is suspended a small cabinet the door of which serves as a reading
board or, when lowered, a writing board.

described. It has been found satisfactory in the daily care of
from fifteen to twenty such patients at the University Hospital.
If a patient who requires frame care is allowed to remain a
part of the day on his abdomen, he is more comfortable and
is less liable to develop decubital ulcers or respiratory or renal
complications.

Fig. 2. — The nurse has removed the cabinet and the arm and foot sup-
ports and is placing the anterior frame down over the patient, where it is
fastened by a wing nut at each end.

METHOD OF TURNING PATIENT

The patient is placed on his back on a posterior frame. This
frame is then suspended about 1 foot from the mattress, each
end being attached to a turning device which clamps on to the

From the Orthopedic Service of Dr. Carl E. Badglev.

thC Department of Surger >'» University of Michigan Medical

L/SZ

FRAME FOR TURNING— STRYKER

Jour. A. M. A.
Nov. 4, 1939

head and foot of the bed. To turn the patient, the anterior
frame is placed over him and pressed down firmly, pressing
him between the two frames. The anterior frame is then locked
in this position. The nurse then releases a spring lock at the
end and revolves the two frames, with the patient between them,
through an angle of 180 degrees, whereupon the frames auto-
matically lock again, leaving the patient face downward on

Fig. 3. — The nurse has released the lock and is turning the frames
with the patient compressed between them. When face downward the
frames automatically lock and the posterior frame is then released and
lifted off. The face support and rubber bands which hold the canvas taut
are shown in this view.

the anterior frame. Since the patient simply revolves on his
long axis without change of the center of gravity, little effort
is required for the turning. The upper frame (posterior) is
now released and lifted off.

While on the anterior frame, the head is supported by an
adjustable face piece which lies on the anterior frame and takes
the weight on the cheeks and forehead. It is padded with
sponge rubber and has flannel covers which may be removed

Fig. 4. — Patient on anterior frame. This is the portable unit in which
the turning devices, instead of clamping on the bed ends, are supported
by a base which sets on the bed. It may be transported as a unit and
rests on any level surface.

for washing. The eyes are about IS inches from the mattress,
a comfortable distance for reading and writing. The anterior
frame is narrowed at the shoulders to allow the arms to be
brought down over the sides for comfort. In some cases fre-
quent turning may be required, but usually the patient remains
on the anterior frame during the day. At night the patient is
turned in the same manner to tlfe posterior frame.

TYPE OF FRAMES

Bv means of turn buckles at each end, the adult frames are
adjustable in width between 12 and 17 inches, children’s from

7 to 12 inches. No patient requires a frame more than 17 inches
in width — over this it becomes a hammock and no longer
effectively supports the spine.

Our frames are made of light weight tubing but gas pipe
frames of proper length may be used with the turners by drilling
a five-eighths inch hole in the center of each end by which they
are fastened to the turning disk. For a standard bed they should
be 6 feet 3 inches long and for the portable unit they are 6 feet
1 inch long.

COVERING OF FRAMES

The frames are covered with heavy canvas, with eyelets at
4 inch intervals along each side, and wide enough to fold over
the sides of the frame when set at its greatest width. Bands of
rubber stretched across the back between the eyelets are used
in place of laces or straps with buckles. This keeps the canvas
perpetually and evenly taut, provides for personal variations in
contour and allows changing the width of the frame without
removal of the frame covers. They are easily applied or
removed and eliminate the necessity of frequent adjustment.
A spreader is placed beneath the center of each frame to main-
tain uniform width. The canvas is padded with celotex or
1 inch sponge rubber, over which a draw sheet is placed and
pinned beneath the frame. A 6 inch opening at the center
allows toilet service. The small (6 inch diameter) chamber

Fig. 5. — Patient on portable unit being transported to ambulance. The
overhead frame, anterior frame and accessories have been detached for
transportation.

mug commonly used for infants will be found more satisfactory
than the conventional bedpan. It can be lifted up through the
opening overlapping the edge of the canvas, which prevents
soiling.

SUPPORTS FOR ARMS AND FEET
Attachments are provided for the support of the feet at right
angles and for the arms at the sides of the frame. These arc
easily applied or removed while the patient is on the frame.
The arm supports may also be used to hold the tray at
mealtime.

TYPE OF BED

The turners fit on the head and foot of any standard hospital
bed of either round or square design. A socket is provided
on top of eath turning device for the insertion of an overhead
frame if desired. The turners may be used for this purpose
with or without the Bradford frames. A cabinet with a reading
board may be suspended from the overhead frame.

PORTABLE UNIT

For those patients who require a continuation of frame care
at home or elsewhere, a portable unit is provided in which the
turning device is fastened to a base which sets on the bed at
the hospital or at home and may be transferred with the patient
as a unit in an ambulance or invalid car. This has been espe-
cially appreciated when there is only one person available in
the home to care for the patient.

1101 Baldwin Avenue.

Volume 113
Number 19

COUNCIL ON PHYSICAL THERAPY

1733

THREE FATAL CASES OF SODIUM NITRITE
POISONING

Louis R. Padbeeo, M.D., and Tiio.mas Martin, M.D.

Coroner and Autopsy Physician, Respectively
St. Louis

Scdium nitrite and other inorganic nitrites are used mainly
in the manufacture of dyestuffs and more recently as anti-
corrosives in automobile anti-freeze mixtures. Inorganic nitrites
are rarely encountered as the cause of human poisoning. It
is therefore considered of value to report the following cases:

Three white men, J. N., aged 55, T. H., aged 65, and A. K,
aged 70, were inmates of a cheap lodging house near the
river front, the location of several wholesale chemical com-
panies, one of which is a large distributor of sodium nitrite.
Oct. 27, 1938, at about noon these three men were observed
preparing a meal consisting of “beef stew” in the room of J. N.
Four hours later the landlady of the house saw A. K. staggering
down the stairs ; when he reached the bottom he collapsed
without making a statement. The landlady stated that the
man’s face was very pale and that his lips and the areas around
the lips were purplish. The City Hospital ambulance was
called, and all three men were pronounced dead on arrival at
the hospital.

The bodies were immediately taken to the city morgue,
where autopsies were performed.

SUMMARY OF AUTOPSIES

Gross examination of the three bodies showed the following
conditions in each body :

The skin was very cyanotic, about the color of slate; the
blood was thin and did not coagulate and was a dark brown,
simulating prune juice. '

Specifically the results of the examination in each are recorded
as' follows ;

■ J. N. was 5 feet 8 inches (173 cm.) tall and weighed 140
pounds (63.5 Kg.). The hair was white and tiie eyes were
blue; the left forearm had been amputated below the elbow.
Dense fibrotic adhesions were seen in the right pleural cavity
and old fibrosis was present throughout the right lung, par-
ticularly in the apex. The capsule of the kidney was adherent
and did not strip readily. Other than this there were no gross
abnormalities.

T. H. was 5 feet 11 inches (180 cm.) tall and weighed 175
pounds (79.4 Kg.). The hair was white and the eyes were blue.
There was edema of the brain and lungs, hypertrophy of the
heart, moderate sclerosis of the vessels and degenerative changes
within the kidney.

A. K. was 5 feet 10 inches (178 cm.) tall and weighed 180
pounds (81.6 Kg.). The hair was white and the eyes were
blue. There was edema of the brain and lungs, hypertrophy
of the heart with atheromatous changes in the aorta and sclero-
sis of the coronary. ’ The arteries were moderately sclerosed
and the kidney showed some parenchymatous changes. Other
than these abnormalities the gross examination of all viscera
except the stomach was negative.

The three deaths occurring almost simultaneously after a
meal might have been suggestive of botulism except that the
time factor was too short and the food eaten was known to have
been cooked. The viscera and blood samples of the three men
together with a portion of the “stew,” a box of salt and pepper
and an ice cream carton containing a yellowish white crystalline
substance were submitted to the coroner’s toxicologist for chem-
ical examination. Within forty-eight hours the following report
was received:

On acid steam distillation of 100 Grn. portions of each portion
of stomach and contents there was chemically detected in the
dilute sodium hydroxide of the receiver the presence of a
nitrite. A portion of this nitrite was subsequently isolated as
silver nitrite and so identified. A quantitative analysis was
performed on steam distillates from weighed portions of stomach
and contents by the method of Lunge. Approximate amounts
of nitrite, calculated as sodium nitrite and based on total weights
of stomach and contents, arc as follows : in J. N., 0.5 Gm. of
sodium nitrite; in T. H., 0.7 Gm., and in A. K., 0.1 Gm.

Samples of the blood of the three men were submitted to
spectroscopic examination for the presence of mcthemoglohiii :

A strong absorption band of methemoglobin (630) was observed
at 1 : 100 dilution, fa 7.1, in all three samples.

A portion of food containing meat and tomatoes was sub-
mitted to acid steam distillation and the presence ot a nitrite
was detected in the distillate.

The sample of salt and pepper was examined and found to
be sodium chloride and finely ground black pepper.

Seventy-five Gm. of a yellowish white crystalline substance
contained in an ice cream carton was submitted to analysis and
found to be' almo'st’chemically pure sodium nitrite. ’

A thorough investigation was made as to the motive, but
up to -the .present- time, these .cases are unsolved, i. e. as to
whether they were accidental, suicidal or homicidal.

1300 Clark Avenue.

Council on Physical Therapy

The Council on Physical Therapy has authorized publication

OF TIIE FOLLOWING REPORTS. HOWARD A. CARTER, SECRETARY.

POLYTHERM SHORT WAVE APPARATUS
ACCEPTABLE

Manufacturer: Polytherm, Incorporated, 707 Broadway,
Paterson, N. J.

The Polytherm Short Wave Apparatus considered in this
report includes the “Advance,” “Standard Cabinet" and “Port-
able” models. These units are identical in circuit and component
parts. They are designed for use in medical
and minor surgical diathermy. Standard
equipment includes pad electrodes, felt
spacers and surgical accessories.

Two tubes (211-B) are employed in a
typical tuned-plate, tuned-grid circuit, operat-
ing at approximately 14 meters wavelength.
There is a ventilator to dissipate heat from
the tubes by convection. The bipolar sur-
gery which is optional on any unit is the
introduction of one terminal which is a tap
on the output or pick-up coil.

The Council tests showed that with an
input of 610 watts and an electromotive force
of 120 volts, the maximum output obtain-
able was 245 watts. After two hours of
operation at a maximum input of 610 watts the Council tests
demonstrated a final temperature in the outside windings of the
transformer which stayed within allowable limits.

Tiie firm submitted evidence to substantiate the efficacy of
the machine in producing a temperature rise in the human thigh

Polytherm Short
Wave Apparatus.

Oulpui

with the cuff technic. A reliable investigator was secured by
the firm to perform these tests. Six tests were carried out and
three normal male subjects were used. Cuffs measuring 17)4
bv 4)4 inches were wrapped about the thigh, 7)4 inches apart.
The average spacing was l'/a inches for the right and V/ A inches
for the left. Temperature measurements were taken by thermo-
couples before and after twenty minute treatments. The thermo-
couples were inserted into the subcutaneous and intramuscular

/

COUNCIL ON PHARMACY AND CHEMISTRY

Joint. A. M. A.
Nov. 4, 1939

/ 1734

I

tissue in the usual manner, Rectal temperatures were observed.
The average room temperature was 76 F. The room humidity
was 72 per cent.

Average temperatures (F.) of six observations after applying
heat for twenty minutes are given in the accompanying table.

Average Temperatures of Six Observations

Deep Muscle

Rectal

Initial Final

Initial

Final

97.9 107.2

99.5

99.6

prolonged as to cause weakness. Some restlessness and fatigue
also were shown by those who were treated over four hours.
It was found further, as might be expected, that there was a
drop of temperature of about 15 or 20 F. from the original
before the air reached the joints of the extremities.

In the light of the foregoing report, the Council on Physical
Therapy voted to include the Tropidores in its list of accepted
devices.

Council on Pharmacy and Chemistry

The unit was investigated clinically by the Council and found
to give satisfactory service.

In view of the foregoing report, the Council on Physical
Therapy voted to accept the Polvtherm Short Wave Apparatus,
“Advance,” “Standard Cabinet” and "Portable” Models, for
inclusion in its list of accepted devices for use with the cuff
technic.

TROPIDORES ACCEPTABLE

Manufacturer : Hill Laboratories Company, 128 Lancaster
Avenue, Wayne, Pa.

The Tropidores is a device for continuous, local, heated air
therapy. The system consists of the moving of warm air
through flexible garments that may be applied locally and
worn for as long as desired on the affected parts of the body.
The unit is portable, the machine being small enough to be
put on an ordinary bedside table. The complete assembly con-
sists of (1) the motor, intake fan and heating coil chamber,
(2) master conveying tube and connecting tubes, (3) two boots

for the legs (hip length), (4)
one sleeve and (5) jacket for
the treatment of thorax and
torso regions, supplied sepa-
rately and made up according
to specifications.

The manufacturer states that
the Tropidores is designed to
induce heat controllable at any
desired degree up to 145 F.,
which temperature is claimed
to be safe when constantly
applied on the full length of
the extremities without danger
of shock or evidence of rise of
temperature in the mouth. Heated air by means of a fan with
a capacity of 30 cubic feet per minute is blown through a tube.
The total consumption of electricity when a standard coil is
used is 230 watts an hour. The apparatus may be attached to
an ordinary electric light socket by a 12 foot cable and will be
supplied for alternating or direct current as specified.

The large hose from the machine is fitted into a three way
connection leading to smaller hose and to the vestibules, which
are at one end of each garment and allow the passage of air
into the garments through numerous holes. All vestibules are
removable to permit sterilization. The garments are of canvas
and supplied with flannel trimmings at all body contact points,
slide fasteners and draw strings. They are supposed to pro-
vide freedom of arm and leg movement and to allow the patient
to turn in bed without readjusting the apparatus. The hose
are also flexible. Heavy woolen stockings and gloves should
be worn under Tropidores garments for tire purpose of absorb-
ing perspiration, which acts as a humidifier of inducted air.
Slide fasteners should be left partly open to permit a constant
flow of air.

An investigation of the unit was conducted by the Council,
from which study it appeared probable that the Tropidores
offers a convenient form of heated air therapy for those who
are bedfast. It is necessary that an attendant, trained in the
use of this apparatus, supervise the treatments, because it is
possible to create unduly heated areas close to the entrance or
the heated air into the garment. If the treatments are of long
duration, caution must be exercised lest the sweating be so

REPORTS OF THE COUNCIL

The Council has authorized publication of the following report.

Paul Nicholas Leech, Secretary.

DILANTIN SODIUM

Sodium 5, 5-diphenyl liydantoinate, originally presented to the
Council under the name “Dilantin” and marketed as “ICapseals
Dilantin” by Parke, Davis & Company, has been redesignated
“Dilantin Sodium” and is now marketed as “ICapseals Dilantin
Sodium.” Dilantin Sodium is an active anticonvulsant and
relatively feeble hypnotic, used in the treatment of epilepsy.
H. H. Merritt and Trace J. Putnam studied the anticonvulsant
action of a number of drugs, including Dilantin Sodium, 1 and
later they reported 2 the results of the treatment of 150 epileptic

The Comparative Effectiveness of Various Anticonvulsant
Drugs in 595 Epileptic Patients

Drug or Drags Most Effective

K.

A and B Neither No Ana-
Equally AnorB lyznble Total

Investigator

A

B

c

D E

Effec-

tive

Effec-

tive

Com-

ment

No. of
Patients

Weaver ct nl

0

2

G

14

Wexberg

2

2

,,

2

1

7

Spurting et nl

7

3

It..

1

3

35

Bigler

9

i

1

O

4

1

1

39

Reese

. 42

4

2

3 1

4

2

3

G1

Fetterman

. 10

1

1

s

20

Taylor

. 14

G

20

McNeil

4

32

, ,

1G

Kimball

. 100

20

129

Dixon

22*

2

2

3 J

41

Osgood

. 24

4

13

2

43

Philips

8

s .

Merritt

. luG

3

27

io

202

-

— — . .

— .

— —

—

—

—

TotaD

.. 404

27

S

G 1

2G

70

53

593

A, Dilantin Sodium; B, phenoTmrbftnl; C, dilantin plus phenobarbltaJ;
D, phcnobarbitaJ plus bromides; E» bromides.

* The Council’s referee accepted this figure* without verifying ft.
t Dilantin plus bromides.

patients with this drug. The Council also received a report of
the treatment of fifty-two epileptic children by Dr. 0. P.
Kimball of Cleveland. While these clinical studies pointed to
the therapeutic value of Dilantin Sodium the Council requested
additional information, with especial reference to the toxicology,
the side actions and the limitations of its usefulness.

Pharmacologic studies were conducted in the laboratories of
Parke, Davis and Company, and clinical investigations were
made in a number of institutions, five of them in institutions
for the treatment of epilepsy and kindred conditions.

The pharmacologic studies show that Dilantin Sodium is of
relatively low toxicity when administered orally to rats, rabbits
and dogs, and much more toxic when injected intravenously.
A special investigation was conducted to show whether Dilantin
Sodium interferes with the utilization of ascorbic acid._ after
Kimball had reported hyperplasia of the gums suggestive ot

J. Merritt. II. H-. and Putnam. T. J.: A New , Sc V c \.°[, j” &
avulsanl Drugs Tested by Experiments on Animals, Arch. Neurol.

'fjl'errin. It IlS Sa T. J.: PoctiumDiphrayl IDdantomate

the Treatment of Convulsive Disorders, J. A. M. A. 1X1. 1065 ( P
) 1938 .

Volume 113
Number 19

COUNCIL ON PHARMACY AND CHEMISTRY

1735

scurvy. The results of the experiments on animals did not
indicate that the drug: lias any influence on the utilization of
ascorbic acid.

Physicians who studied Dilantin Sodium therapeutically were
furnished with forms for recording; data. Some sixty pages of
these forms were submitted to the Council by the firm, which
received them from ten observers who had treated 437 patients.
The headings of the forms included history, age, sex, age at
onset, etiology, type of attacks, reactions and treatment, includ-
ing dosages and a comparison of results with phenobarbetal and
Dilantin Sodium.

The side actions reported by one or more include dizziness,
dry skin, dermatitis, rash, itching, tremors, fever with tempera-
ture of 104 F. in one case, nausea, vomiting, blurred vision,
fatigue, apathy, difficult breathing and swallowing, nervousness,
mental confusion and active hallucinations. Hyperplasia of the
gums has been reported by Kimball.

It would require much space to present a summary of the
work of every one of the clinical investigators, but it is believed
that the accompanying table submitted by Parke, Davis and
Company (and confirmed by the Council's referee) affords a
fair statement of the chief points of interest.

The Council voted that the firm be informed (1) that the
available evidence justifies the recognition of Dilantin Sodium
as a therapeutic agent of promising value in the treatment of
many cases of epilepsy and (2) that Dilantin Sodium will be
accepted for inclusion in N. N. R. provided the firm will agree
to market it under rigid restrictions, including those which
further experience shall indicate, as well as the following:
(a) It shall not be recommended for use by the general prac-
titioner unless he is able to maintain a close (daily) supervision
of the patient, until the scope of its usefulness as well as its
side actions have been determined more accurately; (6) it is not
to be recommended for the treatment of those patients whose
seizures occur only at long intervals unless moderate doses of
phenobarbital are ineffective or induce disagreeable side actions.
The firm has agreed to these conditions. The A. M. A. Chemi-
cal Laboratory has found the composition of Dilantin Sodium
satisfactory.

NEW AND NONOFFICIAL REMEDIES

The following additional articles have been accetted as con-
forming to the rules of the Council on Pharmacy and Chemistry
of the American Medical Association for admission to New and
Nonofficial Remedies. A coi>v of the rules on wmen the Council

RASES its ACTION WILL EE SENT ON AT PLICATION.

Paul Nicholas Leech, Secretary.

DILANTIN SODIUM. — Sodium 5,5-diphenyl-hydantoinate.
— Sodium 2,4-diketo-5,5-diphenyl-tetrahydroglyoxaline. — The
mono-sodium salt of 5,5-diphenyI-hydantoin,

Na(GsHs)-C.NH.CO : N.C : O.

i i

Actions and Uses . — Dilantin sodium is an anticonvulsant with
a relatively weak hypnotic action. It, is used in the treatment
of epileptic patients who are not benefited by phenobarbital or
bromides and those in whom these drugs induce disagreeable side
actions. Dilantin sodium appears to be more effective in con-
trolling seizures of the grand mal type than in those of the petit
mal. It does not cure congenital mental defects or the mental
deterioration often observed in the epileptic. Various side
actions of different degrees of severity which have been observed
include dizziness, dry skin, dermatitis, rash, itching, tremors,
fever, nausea, vomiting, blurred vision, fatigue, apathy, difficult
breathing and swallowing, nervousness, mental confusion and
active hallucinations, and hyperplasia of the gums suggestive of
scurvy, though its use does not interfere with the utilization of
vitamin C. Dilantin sodium is strongly alkaline and it may
give rise to gastric irritation.

Dosage . — The optimum dosage of dilantin sodium must be
determined by the daily observation of its effects by the physi-
cian. The influence of the drug on seizures and the appear-
ance of any of the side actions enumerated must be a guide to
the dosage. Mild symptoms do not necessarily require that the
dosage be stopped. The beginning adult dose is 0.1 Gm. (1)4
grains) with at least half a glass of water three times daily.
If necessary this dose may be increased gradually to 0.2 Gm.
(3 grains) three times daily. Children above the age of 6 years
may be given 0.1 Gm. (1/ grains) three times daily for one

week, after which it may be increased if necessary to 0.1 Gm.
(1 y 2 grains) four times daily with at least half a glass of water
to prevent gastric irritation due to the alkalinity. Dilantin
sodium is more rapidly effective if given before meals, _ but should
it cause gastric irritation it should be given immediately after
meals. Children under 4 years of age may start with 0.03 Gm.
(one-half grain) mixed with cream (to disguise the bitter taste
and to prevent gastric irritation) twice a day. Obviously such
doses require the most careful supervision.^ If this dose is borne
without side actions the dosage may be increased to 0.03 Gm.
(one-half grain) three or four times a day._ Every slight
increase in dosage is made only after the physician is convinced
that such increase is necessary and that no harm is to be
anticipated.

The transition from phenobarbital, bromides or other hypnotic-
type drugs to dilantin sodium should be made gradually with
some overlapping in dosage. By this procedure the danger of
phenobarbital or bromide withdrawal symptoms (increased
number of seizures) is minimized, and side actions incident to
the beginning administration of Dilantin Sodium are lessened.

Manufactured by Parke, Davis & Co., Detroit. No U. S patent.

U. S. trademark applied for.

Kapseals Dilantin Sodium 0.1 Gm. (V/ 2 grains): * Each kapseal
(hermetically sealed capsule) contains 0.1 Gm. (V/z grains) of sodium

5,5-diphenyl hydantoinate.

Kapseals Dilantin Sodium 0.03 Gm. (*/ 2 grain) : Each kapseal (her*
metscally sealed capsule) contains 0.03 Gm. i}/ 2 grain) of sodium

5,5-diphenyl hydantoinate.

Dilantin sodium occurs as an odorless, white, microcrystalline
powder, possessing a slightly bitter taste. It is soluble in alcohol and
glacial acetic acid; practically insoluble in ether, petroleum ether
and benzene. Aqueous solutions of dilantin sodium yield an opalescent
crystalline precipitate of diphenyl-hydantoin, which dissolves when the
pu of the mixture is adjusted to 11.7.

Dissolve about 0.25 Gm. of dilantin sodium in S cc. of boiled
water: the mixture should not require more than 1 cc. of tenth*
normal alkali to produce a clear, colorless solution; add an excess of
diluted hydrochloric acid, shake thoroughly, collect the precipitated
diphenyl-hydantoin on a filter paper, wash with water and dry at
95 C. : it melts at 293-299 C. with decomposition.

Treat about 0.5 Gm. of dilantin sodium with 10 cc. of solution of »
sodium hypochlorite, heat to 50 C., pass in carbon dioxide; collect the/'
precipitate formed on a filter paper. Dry the precipitate in a partial!
vacuum and recrystallize from chloroform: the melting point of the X

5,5-diphcnyl-l,3-dichloro-hydantoin lies between 163 and 167 C.

Incinerate about 0.2 Gm. of dilantin sodium: the residue responds
to tests for sodium carbonate.

Dissolve about 0,5 Gm. of dilantin sodium in 100 cc. of water,
add 5 cc. of diluted nitric acid, shake and filter through paper:,
separate portions of 10 cc. each o£^ the filtrate yield no greater
opalescence on addition of 1 cc. of silver nitrate solution than that
produced by 0.25 cc. of tenth normal hydrochloric acid in 50 cc. of
water ( chlorides ) or no appreciable turbidity on the addition of 1 cc.
of barium nitrate solution (sulfates). _ Acidify about 0.2 • Gm.- of
dilantin sodium in 50 cc. of water with diluted hydrochloric acid,
using litmus paper as the indicator; filter through paper: a 10 cc.‘
portion of the filtrate yields no color or precipitate on saturating with
hydrogen sulfide ( salts of heavy metals). Dissolve 0.1 Gm. of dilantin
sodium in c cc. of sulfuric acid: the color produced should not.be
greater than that yielded by 0.1 mg. of benzilic acid in 5 cc. of
sulfuric acid.

Heat about 0.5 Gm. of dilantin sodium, accurately weighed, to
constant weight at 95 C.: the loss in weight should not exceed 2.5
per cent. Transfer about 0.25 Gm. of the dry dilantin sodium,
accurately weighed, to a separatory funnel, add 50 cc. of water and
10 cc. of diluted hydrochloric acid; extract the mixture with 100 cc.
of ether and repeat the extraction with four successive 25 cc. portions
of ether; evaporate the combined ether extracts in a tared beaker and
dry to constant weight at 95 C.: the 5, 5 -diphenyl-hydantoin should
amount to not less than 90.6 per cent, nor more .than 92,0 per cent of'
the dry sample, and should melt above 292 C.

FUNGUS EXTRACTS-ABBOTT. — Liquids obtained by
extracting dried spores with a menstruum consisting of equal
volumes of glycerin and a solution containing sodium chloride
5 Gnu and sodium bicarbonate 27 Gm. in distilled water 1,000 cc.

Actions and Uses . — See general article Allergenic Protein
Preparations, New and Nonofficial Remedies, 1939, p. 27.

Dosage . — See general article Allergenic Protein Preparations/
New and Nonofficial Remedies, 1939, p. 27.

Fungus Extracts- Abbott are marketed in 2 cc., 5 cc. and 30 cc.
vials.

Manufactured by the Abbott Laboratories, North Chicago, 111. No
U. S. patent or trademark.

Altcmaria spp. Fungus Extract-Abbott ; Aspergillus fumigatus Fungus
Extract-Abbott ; Aspergillus niger Group Fttnaus Extract-Abbott; Ccphalo -
thectum rosetwt Fungus Extract-Abbott ; Hormodcndrum spp. Fungus
Extroct-Abbott; Monilia sitophilia Fungus Extract-Abbott ; Mucor spp.
Eungus Extract-Abbott; Pcniciiluim rubrum Fungus Extract-Abbott:
UsUllogo scae (Corn Smut) Fungus Extract-Abbott; Feast Fungus
Extract-Abbott. '

uum unco »rewers yeast; the
Altcrnana spp. extract is prepared from the dried mass of spores with
Us supporting mycelium; the other extracts are prepared from the dried
spores alone. The material is extracted at room temperature with a
menstruum consisting of equal volumes of glycerin and a solution con*
taming sodium chloride 5 Gm. and sodium bicarbonate 2.7 Gm. in
distilled water 1,000 cc. for from four to five days and is clarified and
sterilized by Berkefeld filtration. The finished liquid is a 5% W/V

“ 05 Gn? of “dried taS. ^ mhh Ce ” ,in,eter presenting

1736

EDITORIALS

Jour. A. M. A.
Nov. 4, 1939

THE JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION

535 North Dearborn Street - - - Chicago, III.

Cable Address .... “Medic, Chicago”

Subscription price

Eight dollars per annum in advance

Please send in promptly notice of change of address , giving
both old and new; always state whether the change is temporary
or permanent. Stick notice should mention all journals received
from this office. Important information regarding contributions
will be found on second advertising page following reading matter .

SATURDAY, NOVEMBER 4, 1939

MEDICAL SERVICE IN A TEACHING
HOSPITAL— DR. CHRISTIAN’S
“FAREWELL REPORT”

Medicine has developed through the labor of many
and under the leadership of relatively few. During
the past half century medicine in general, and American
medicine in particular, have undergone revolutionary
changes. The mystic, religious and philosophical domi-
nation has given way to the influence of natural and
social sciences. The beneficial yield of objectivity to
human society has surpassed the most optimistic expec-
tations. Will the importance of personal leadership
wane in the light of these recent changes? A super-
ficial analysis of this problem might suggest that the
introduction of exact sciences into medicine has
decreased considerably the need for leadership. A more
detailed study of the question indicates however that,
precisely because of the rapid growth and of the
diversified interests represented in modern medicine,
guidance and correlation in medical education and prac-
tice are becoming more important than ever.

The Peter Bent Brigham Hospital under the leader-
ship of Dr. Henry A. Christian and the late Dr. Harvey
Cushing assumed a significant role in the establishment
of modern clinical medicine in America. When the
doors of this university clinic opened in 1913, it was
one of the few institutions in the country which espe-
cially cultivated scientific clinical medicine. Since then
fortunately the situation has changed. Now there are
a number of important medical centers which represent
different experiments in medical education. For this
reason Dr. Christian’s “farewell report” in the twenty-
fifth Annual Report of the Peter Bent Brigham Hos-
pital is of particular interest. 1 Here is the advice ot
a physician in chief who during a quarter of a century
observed intimately the development of American

medicine. , .

Dr. Christian describes what he believes should be
the aims and the spirit of a medical sendee in a hos-
pital. He points out that he who directs a hospital

R CPO rt of the Rhysiciati'in-CIuU , WTm^Nl^ Nnnual Report of
> e ter Bent Brigham Hosp.lal for the rear 19aS, ISO?, p. »-

service must have a plan, a method, an ideal of per-
fection. The service must represent the highest accom-
plishment of leadership. Time and conditions change
rapidly. Hence always there must be a willingness to
meet changing conditions. A spirit of friendly help-
fulness should pervade both the practical care of the
patient and the scientific study of the medical problem.
The best possible professional care should be admin-
istered to the patient in such a way that he feels that
all in the hospital are interested in him as an individual,
To the students and to the young physicians should he
given a training with a broad foundation on which they
can build themselves into the best type of clinicians.
In such a training the art of good observation, the
cultivation of memory, of logic and of technical skill,
as well as the development of personality are essential.
Diagnostic opinions should be expressed clearly and in
writing. Dr. Christian states that ". . . often cow-
ardice prevents such 'commitments.” He criticizes the
present tendency to say that the mass of literature is
so great that no one can keep up with it. "To my
mind this is but an excuse of the lazy.” Specialization
is essential but must be based on broad experience.
He quotes Osier, who spoke of Jonathan Hutchinson
as . . the only great generalized specialist which

the profession has produced.”

Dr. Christian, referring to himself, says . • the
hospital physician busied daily in the care of patients,
in contact with students, resident staff, associates and
colleagues; this seemed to me the acme of attainment
when in the day's of my youth I dreamed dreams.”

Traditions are to be cherished only if they represent
the best in the professions. It is for this reason that
Dr. Christian’s report, an expression of need for a
harmonious balance in medicine, is of importance to
the profession.

A NEW INTERPRETATION OF A PARA-
GRAPH IN THE HIPPOCRATIC OATH

The paragraph referring to lithotomy in the Hip*
pocratic Oath, ov rciiTi Si ou8e fxiJV \i8to>V7a<s,

SI ipyarytnv avSpam irpr/iios rijaSe, is one of the most
confusing in classical literature. It has been genera )’
assumed that the oath forbids the performance o
lithotomy. The two usual justifications for this injunc-
tion are (1) that the operation was often fatal and
was therefore delegated to another expert group, a
(2) that the oath indicates the beginning of speciahza-
:ion in Greek medicine as already existed in Eg) P|-
These appear to a recent student of history to be absuTd-
Savas Nittis 1 states that sufficient grammatical and
inguistic consideration has never been ghen to
paragraph. Instead a meaning was assumed arul
explanations for the injunction against lithotomy '
sought afterward. Nittis proposes a new "^rpret
jf the paragraph. His translation, for w nc i g *

aw

I*: 719 (July) 1939 .

Volume 113
Number 19

EDITORIALS

1737

matical and etymological reasons are given, would be
as follows : “I will not cut, indeed not even sufferers
from stone, and I will keep apart from men engaging
in this deed.” Since surgery could not be forbidden
in those early times, the injunction in the oath, it is
said, must refer to some abomination, such as castra-
tion, since refirur means “to castrate.”

Lithiasis was a common complaint in the early cen-
turies in the Near East and still is. It must have
required much attention by physicians; then instru-
ments were invented for locating stone in the blad-
der. Who would seriously contend, therefore, that
the ethical surgeon who performed these diagnostic
procedures was prevented from doing lithotomy by an
oral oath or a written contract? Celsus, who described
lithotomy in the first century, was copying from an
earlier Greek source. Comment by Aretaeos indicates
that lithotomy was frequently performed by the best
representatives of the Hippocratic school. Naturally
serious complications often followed such an operation.
Death frequently ensued and, if the patient survived,
a resulting fistula often made life unbearable. Since
the only relief came from cutting in the region of the
urethral orifice of the bladder, necrosis of the testicles
must have frequently followed lithotomies as a result
of occlusion of the spermatic artery. Since it would
have been easier for the surgeon to remove the inter-
fering external genitalia before the lithotomy was per-
formed, Nittis suggests, that practice was probably
followed by some surgeons. Indeed, Nittis asserts that
castration probably was the most frequently performed
operation in ancient times.

In the Odyssey there is mention of an establishment
where men were sent for castration. Herodotus speaks
of one Panionios, of Chios, who “made his living from
a most unholy trade. Whenever he came into posses-
sion of boys with good looks he castrated them and,
bringing them to Sardis and Ephesus, sold them for a
good price.” In Rome, where the vices of Greece were
imitated, castration for commercial or immoral pur-
poses was usually carried out by the magnones, a
special group of practitioners. While the regular
physician probably performed castrations occasionally
for some legitimate cause, neither Hippocrates nor
Aristotle advised castration. During the early Christian
era the number of castrates must have been impressive,
for the first Ecumenical Council of Nice provided in
its first canon to permit holy orders to a man “if he
had been castrated by a physician on account of illness.”
During the Middle Ages, castration was advocated for
the cure or prevention of many diseases, and until
recently it was sometimes performed for the cure of
epilepsy. In Europe following the renaissance, castra-
tion found widespread application for the prevention
and cure of hernia. The general opinion that the
castrated singers in the churches of Rome did not suffer
from hernia promoted the idea. During the eighteenth
century this abuse reached alarming proportions. The

physician was free to use or abuse his judgment with-
out legal restrictions in Greek society. Laws did not
exist to penalize the physician or to award damages
for malpractice to the patient or his family. In the
oath, Hippocrates attempted to formulate the essential
moral obligations of the physician and, according to
Nittis, to prevent the practice of this abominable
operation.

TRAVELING FACULTIES IN GRADUATE
MEDICAL EDUCATION

The problem of continuation study for practicing
physicians is no longer one concerned exclusively with
education; transportation is beginning to be of con-
siderable importance. A graduate program may be
quite sound educationally and yet fail if it does not
bring competent instructors to physicians desirous of
continuing their studies. This is especially true in the
more sparsely settled areas of the United States and
in those states without medical schools.

For the past five years the physicians of Idaho have
appreciated the need for continuation study. To meet
this need they have brought to the five day annual
meeting of their state association a flying medical
faculty. Each year five or six instructors from one
medical school have been invited to organize an inte-
grated, correlated course of study of general interest
to practicing physicians. Instruction in basic sciences
has initiated discussions of clinical studies, and round
table discussions have permitted attending physicians
to participate. Expenses of the traveling faculty have
been paid by the state association, since registration
fees of §5 or $10 have been adequate to finance these
programs.

In 1939 the state medical associations of Washington
and Oregon arranged their annual meetings to utilize
the same traveling faculty as was engaged in Idaho.
Thus the physicians of three states have had the oppor-
tunity to attend, at their annual meetings, a continuation
course. Attendance has been enhanced, and it lias been
possible to bring to each state systematic instruction at
less expense than is ordinarily required.

Four other western states, Colorado, Utah, New
Mexico and Wyoming, have pooled their interests in
graduate studies to bring, every two years to one of
their states, twenty out of state speakers to discuss
problems of medicine and public health which are
peculiar to the Rocky Mountain region. The medical
society in each state has been represented on the execu-
tive committee and a different state society has acted
as host every two years. The first Rocky Mountain
Conference was held in Denver in 1937, the second
in Salt Lake City in 1939, and the next meeting is
scheduled for Wyoming. A registration fee of S3 has
been sufficient to finance this effort.

1 bus seven states, five without a four year medical
school within the borders of the state, have provided

See Graduate Medical Education:
the Organization Section, this issue.

Idaho, Oregon and Washington, in

1738

CURRENT COMMENT

Jour. A. M. A.
A’or. ■), 1939

graduate opportunities for practicing physicians. Fre-
quently physicians travel from 100 to 250 miles to
attend one or two day regional meetings.

There still remain, however, physicians who are
unable to leave their practice even for a short time to
travel the distance required. For them provision is
now being made, the instructors traveling throughout
the state so that continuation study may be brought to
a greater number of communities.

Current Comment

NOBEL PRIZE TO PROFESSOR DOMAGK

The Nobel Prize for Medicine was recently awarded
to Prof. Gerhard Domagk, whose name is indelibly
associated with the drug sulfanilamide and its deriva-
tives. Domagk was born in Lagow, Germany, in 1895.
His principal early work was in the field of pathology.
After teaching at Greifswald and Muenster universities
he became director in 1927 of the Institute of Experi-
mental Pathology of the I. G. Dye Works in Elberfeld.
Late in 1932 he first demonstrated the curative effects
of prontosil (now neoprontosil) in the streptococcic
infections of mice. After many careful observations,
the details of the new discovery were finally published
by Domagk in medical and scientific journals early in
1935. He had earlier received the Emil Fischer Medal,
highest award of the German Chemical Society, in 1937
and the Cameron Prize of the University of Edinburgh
in 1939.

RABIES

The study of rabies conducted by the International
Health Division of the Rockefeller Foundation in
cooperation with the Alabama State Board of Health
already has been prosecuted to the point where the
building program has been completed. 1 The total
expenditures for public health work in this field have
come to more than $108,000 for the four years 1935
to 1938 inclusive. Particular attention is being directed
to a study of the efficacy of preventive measures in
rabies. Alabama, with an estimated dog population
of 450,000, vaccinated 220,000 dogs during 1937, the
first year the compulsory law went into effect. During
1938, 134,000 dogs were vaccinated and nearly 18,000
killed as strays. Attempts have also been made to
determine whether the rat plays a part in the spread
of rabies, but so far experiments of this nature have
been negative. All attempts to cultivate rabies street
virus have been unsuccessful. A fixed strain obtained
from the Alabama State Board of Health has been car-
ried through sixty-eight transfers without difficulty. As
vet it has been impossible to obtain growth on the chick
"embryo. A report on the effect of various diluents
acting for short periods on the rabies virus in high
dilutions has also been made. A fruitful outcome to
these investigations would be of tremendous benefit to
many portions of the country in which rabies remains
endemic.

1. Annual report of International Health Division of the Uochcfelier
Foundation, 193S. p. 62.

CHRONIC LEUKEMIA

Because of the characteristic insidious onset oi the
leukemias they are usually first recognized only after
widespread anatomic and physiologic abnormalities have
developed. Wintrobe and Hasenbush 1 reviewed all
cases of chronic leukemia in adults observed at the Johns
Hopkins Hospital between January 1926 and August
. 1938, collecting thirty-nine cases of myelogenous and
forty-seven cases of lymphogenous leukemia for study.
Five of the patients who subsequently developed typical
chronic myelogenous leukemia were found to have unex-
plained leukocytosis in the absence of typical leukemic
signs or symptoms. The discovery was made in the
course of routine examination following pregnancy in
one case, for sterility in another, because of symptoms
suggestive of disease of the gallbladder in the third, for
abdominal distress in the fourth, and because of uterine
myomas in the last. A reasonable estimate of the time
elapsing from the onset of chronic myelogenous leukemia
until symptoms of the disease commonly cause the
patient to seek medical attention is probably from two
to five years or longer. Data concerning the early phase
of chronic lymphogenous leukemia were available in
sixteen cases. The disease was first discovered in three
men aged 59, 67 and 72 when examined for symptoms
due to prostatic hypertrophy. Other patients were
examined because of sugar in the urine, a psycho-
neurotic disorder and “indigestion." Unlike myeloge-
nous leukemia, the finding of unexplained leukocytosis
was the first evidence of the disease in only about one
third of the cases of early lymphogenous leukemia. In
another third, glandular enlargement was the sign
which first attracted attention. The time interval
between the observation of signs suggesting lymphoge-
nous leukemia and the development of symptoms of the
disease was from one and one-half to two and one-half
years. The earlier recognition of lymphogenous leu-
kemia, as compared witli that of myelogenous leukemia,
is explained, these authors believe, by the greater
frequency with which glandular enlargement sufficient
to attract attention occurred in the patents with the
former. Males predominated in both groups. In 72 per
cent of the cases of myelogenous leukemia the age of
onset was between 30 and 59 years, while in 61.7 per
cent of the cases of lymphogenous leukemia symptoms
began between 50 and 69 years. In addition to the
unexplained leukocytosis so frequent in early cliroruc
myelogenous leukemia, distinct lymphocytosis was found
commonly characteristic of early lymphogenous leu-
kemia even when the leukocyte count was relatively low.
Solution of potassium arsenite was without value W
lymphogenous leukemia and of less value than irradia-
tion in myelogenous leukemia. Response to irradiation
was slightly better in myelogenous than in lymphog-
enous leukemia. Contrary to the frequently expressed
opinion, infections in the majority of cases did not pro-
duce a remission in physical signs or the blood picture.
Persistent unexplained leukocytosis must therefore be
considered a premonitory sign oi chronic myelogenous
leukemia, and persons in whom it occurs should be
carefully studied with that diseas e in mind.

I Winlrohe. XI. M.. and Hasenbush. I.. Chronic LeuVem.s.

Arch. Int. Med. C-l:?01 (Oct.) 1939.

Volume 113
Number 19

1739

ORGANIZATION SECTION

GRADUATE MEDICAL EDUCATION

A PROGRESS REPORT OF THE FIELD STUDY ON GRADUATE MEDICAL EDUCATION IN THE UNITED STATES
BEING CONDUCTED BY THE COUNCIL ON MEDICAL EDUCATION AND HOSPITALS

WASHINGTON-

WASHINGTON STATE MEDICAL ASSOCIATION

On Aug. 30, 1939, the House of Delegates of the Washing-
ton State Medical Association resolved that a program for
providing postgraduate medical education in the state of Wash-
ington be developed by' the postgraduate medical education
committee under the general supervision of the board of trus-
tees. This committee, with Dr. Homer D. Dudley as chairman,
has considered the postgraduate experiences of various state
societies. On the basis of these studies the committee has
recommended the following program :

1. Continuation of the graduate medical course for physicians
throughout the state given' annually in cooperation with the
King County Medical Society and the Extension Division of
the University of Washington with the additional assistance
of the postgraduate committee of the state medical association,
the association aiding in the arrangements and in publicity.

2. Inauguration of circuit courses by out of state lecturers
under the supervision of the committee by providing defined
lecture districts, securing competent speakers for a series of
five days’ instruction in each locality, including clinics, stress-
ing subjects chosen by the physicians of each district, and by
charging registration fees adequate to finance the regional
program.

3. Provision of speakers from the membership of the state
association to supplement the out of state lecturers. This wilt
be made from a list compiled by the association. From the
list component county medical societies may choose competent
Washington physicians, and each society will be expected to
finance their expenses.

4. Desirability of having other committees concerned with
medical education consult with the committee. The postgrad-
uate committee has emphasized this so that all postgraduate
activities within the state may be properly correlated and
coordinated.

The 1939 annual meeting of the Washington State Medical
Association, held in Spokane, was devoted to graduate instruc-
tion. Five instructors from Washington University School of
Medicine, St. Louis, were engaged in a cooperative agreement
with the state medical associations of Oregon and Idaho. At
the three day annual meeting, subjects discussed included can-
cer, chemotherapy, cholecystography, infant feeding, pneumonia,
puerperal infection and toxemias of pregnancy. Attendance
totaled 460 physicians. Of the 2,123 physicians in the state of
Washington, 1,468 are members of the state medical association.

WASHINGTON STATE DEPARTMENT OF HEALTH

(Instruction in Obstetrics and Pediatrics)

Previous to 1938 the education program of the Washington
State Department of Health for physicians practicing in the
state had been carried on through itinerant child Health con-
ferences. It was proposed in 1938 that the itinerant confer-
ences be held only as a means of introducing a clinic or of
determining the need for a clinic in a given area, the educa-
tional program to consist largely of a refresher type of course
by recognized authorities in obstetrics or pediatrics. An out
of state physician and Washington physicians were to consider
such subjects as endocrinology, internal medicine, nutrition and
dental problems.

In May 1938 an out of state obstetrician gave three days of
lectures and conferences in each of seven cities of the state.
The committee on maternal and child welfare of the state
medical association cooperated in sponsoring this program. A
?2 registration fee was charged. The course of six lectures
was attended by 217 physicians.

The chairman of the committee on maternal and child wel-
fare, Dr. H. H. Skinner, recommended in 1938 that the com-
mittee membership be made permanent and that the committee
be composed of an equal number of obstetricians and pediatri-
cians serving overlapping five year terms.

In 1938 a committee of eight was formed as a permanent
committee on medical cooperation and participation in the
maternal and child hygiene program of the state department
of health. On this committee were three representatives of
the Washington sections of the North Pacific Pediatric Society,
three of the Washington State Obstetrics Association and the
director of the state department of health and the chief of the
division of maternal and child hygiene. This committee now
acts in an advisory capacity to the health department.

During May 1939 the division of maternal and child hygiene
of the state department of health and the committee of eight
jointly sponsored a three day series of afternoon and evening
lectures in seven cities of Washington and in Vancouver, B. C.
The assistance of county medical societies was enlisted in eacli
locality and the secretaries were provided with post card
announcements. An out of state medical school instructor gave
six lectures on heart diseases, hemorrhage and toxemias of
pregnancy, obstetric analgesia and cesarean sections in each
center. Six hundred and thirteen physicians was the total
attendance recorded. No registration fees were charged, since
the state department of health provided financial support.

UNIVERSITY OF WASHINGTON

The University of Washington, Seattle, in cooperation with
King County Medical Society, has conducted a five day grad-
uate medical course during July each year since 1916. Dr.
David C. Hall is executive secretary of the course and
Dr. Raymond L. Zech was chairman of the county society
committee of fourteen in 1939. There is also a committee of
five staff members of the King County Hospital responsible
for organizing clinical instruction. Every year four or more
out of state physicians are engaged as a faculty, and in July
1939 five members of the faculty of Northwestern University
Medical School, Chicago, and a member of the United States
Public Health Service participated. Local physicians supple-
ment the guest speakers by providing clinics. Instruction is
scheduled from 9 a. m. to 10 p. m. daily. Major subjects of
medicine are included and in case discussions two or three
physicians participate, stressing the various approaches to the
problems presented. Lectures are held on the university cam-
pus and clinics and demonstrations are given at the county
hospital by members of the staff. Didactic lectures are limited
to from forty to fifty minutes and clinics to from ten to twenty
minutes. Medical and surgical clinics considered thirteen of
the various specialties of surgery and three of the special sub-
jects of medicine in 1939. Daily demonstrations were held in
pathology, roentgenology and anesthesia as well as scientific
exhibits in other subjects.

The extension division of the university aids in administer-
ing the course. A registration fee of §10 is charged which
has provided sufficient support. Every physician in the state
is sent a notice; announcements are published in Northwest
Medicine. Annual attendance has ranged from 207 to 311
physicians.

library service

The King County Medical Society, in addition to the active
participation of its members in the annual graduate programs
at the University of Washington, has provided library facilities
for physicians practicing in the vicinity of Seattle. Space has
been provided in the Cobb Building, Seattle, with adequate
stacks and reading rooms. There are 11,468 volumes, three
fifths of which are periodicals, a total of 233 being regularly

1740

ORGANIZATION SECTION

received. Ten dollars from the annual dues of every county
society member supports the library. About two thirds of the
members of the society used the library in 1938, as well as
approximately 200 other physicians. The package lending ser-
vice is available to individuals or to other libraries. Out of
town physicians must supply postage. During 1938, 6,300 items
were circulated.

Libraries with paid librarians are also maintained hy the
Spokane County Medical Society and the Pierce County Medi-
cal Society, the facilities being available to physicians prac-
ticing in the vicinity of Spokane and Tacoma.

OTHER GRADUATE ACTIVITIES

The Seattle Surgical Society provides a two day program
each year. The Spokane Surgical Society, the Puget Sound
Surgical Society and the Tacoma Surgical Society present
annual graduate days. One or more guest speakers are pro-
vided to discuss cases presented by Washington physicians.
Members of state medical associations are invited to attend.
Registration fees vary from §2 to §3.

IDAHO

IDAHO STATE MEDICAL ASSOCIATION

At the September 1933 meeting of the House of Delegates of
the Idaho State Medical Association, it was recommended by
Dr. J. N. Davis that graduate study be considered and that the
advisability and feasibility of securing members of medical school
faculties for an annual continuation course be determined.

In September 1934 the house of delegates authorized the presi-
dent of the state association, Dr. Charles R. Scott, to appoint a
committee of six members to arrange a graduate course for the
next annual meeting. Fifteen hundred dollars was the initial
allocation for financing the state association's graduate program.

In planning the course of instruction certain principles were
elaborated, since it was felt that the medical association had two
primary obligations, first, to improve medical care and, second,
to enlighten the public on personal and public health. It was
decided that five days should be devoted each year to an inte-
grated and correlated course of instruction in subjects of general
interest selected on suggestions of physicians. Five instructors
from a different medical school each year would organize as a
traveling faculty, thus providing a harmonized course. Each
day five or six fifty minute lectures would be scheduled with
additional round table discussions.

The state association has assumed responsibility for financing
its graduate program. In 1936, when the constitution and by-laws
of the association were modified, the Idaho Medical Foundation
was established with the members of the council as trustees of
the foundation. A foundation fund of §10,500 was established
by contributions from members of the state association which
constituted a percentage of fees which they had received for the
care of special groups of patients. The income from the founda-
tion’s funds is available for financing graduate activities. This
has not been necessary, however, since registration fees of $5
or §10 have been sufficient to meet each year's expenses. Each
speaker is given an honorarium and his traveling expenses.

The committee on scientific work of the state association is
a standing committee consisting of three members, one selected
each year to serve three years. The present chairman of this
committee is Dr. C. W. Pond. Ex officio members are the
president and the secretary-treasurer of the association. The
secretary acts with the committee on scientific work in arrang-
ing the annual graduate program.

Beginning in 1935 a traveling faculty from the following
medical schools lias participated each year : Northwestern Uni-
versity Medical School, University of 'California Medical School,
University of Minnesota Medical School, University of Michi-
gan Medical School and Washington University School of
Medicine. In 193? Idaho physicians presented clinical cases for
discussion in focal hospitals to supplement the faculty lectures.
Attendance has varied from 116 to 144. Of the 406 physicians
in Idaho, 2 72 are members of the state association.

IDAHO STATE DIVISION OF PUBLIC HEALTH

In November 1936 the Idaho State Division of Public Health,
in cooperation with the Idaho State Medical Association, con-
ducted an itinerant postgraduate lecture course in six cities of

Jour. A. it. A.
Nov. 4 , 1939

the state. Three out of state physicians participated in the one
and two day afternoon and evening sessions in obstetrics and
pediatrics. The chairman of the state association's committee on
scientific work arranged the program and selected the speakers
The county medical society in each locality arranged the details
for each meeting. The course was attended by 181 physicians;
no registration fees were charged. The health division financed
this effort.

During 1937 instruction in pediatrics was provided in two
cities of the state by one out of state physician. Attendance at
these lectures approximated seventy-five.

In April and May 1938 four out of state physicians conducted
a postgraduate course in pediatrics, dermatology and syphilology
and orthopedics in five cities of the state. One day sessions were
held in four places and two days were allowed in a fifth. Meet-
ings were held in hotels and in two cities ; clinical demonstra-
tions were attempted. Approximately 150 physicians attended ■
the 1938 itinerant course.

Lectures in syphilology, pediatrics, orthopedics and general
medicine were given in the spring of 1939. Three out of state
physicians participated in one day meetings held in five localities.
One hundred and seventy physicians enrolled. No registration
fees were charged.

IDAHO ANTI-TUBERCULOSIS ASSOCIATION

During the past two years the Idaho Anti-Tuberculosis Asso-
ciation has offered a consultation service to practicing physicians
of the state in the interpretation of roentgenograms. The con-
sultant also participates in the activities of the state division of
public health.

OREGON

OREGON STATE MEDICAL SOCIETY

At the 1939 annual meeting of the Oregon State Medical
Society three out of state faculty members who had participated
in the annual meetings in Idaho and Washington took part in
the scientific program. A fourth guest speaker was also included.
This enabled the committee on scientific work to provide mem-
bers of the association with an integrated general course^ of
twelve lectures in pediatrics, obstetrics, surgery and medicine.
Round table discussions were held and twenty-four contributions
were made by Oregon physicians on other subjects. The three
and one-half day session was devoted substantially to post-
graduate instruction and, by the cooperative agreement with the
medical societies of two adjoining states, it was possible to
present a comprehensive and instructive program. There are
805 members of the Oregon State Medical Society of the l,3So
physicians in the state.

At the June 1939 meeting of the council of the state medical
society the president of the society, Dr. Charles E. Sears, was
authorized to appoint a committee on postgraduate medical
education. Dr. Karl H. Martzloff was made chairman of a
committee of five members. This committee met in September
1939 to discuss the establishment of a graduate program. _

The Oregon State Medical Society, in cooperation with the
Oregon State Board of Health, provided one or two days of
lectures in obstetrics and pediatrics in nine cities of the state
this year. The committee on maternal welfare, Dr. Raymond
Watkins, chairman, with the director of the division of maternal
and child health, Dr. G. D. Carlyle Thompson, arranged the
lecture series for May 1939. Each component medical society
which participated selected topics from a list of twelve subjects
outlined by the out of state obstetrician and pediatrician engaged
to give the instruction. From six to ten afternoon and evening
lectures were held in each center, except one in which the
instruction began at 9 a. m. Two hundred and seventy -seven
physicians from twenty-one counties enrolled. No registration
fees were charged, since the program was supported by fcdcra

The Oregon Academy of Ophthalmology and Otolaryngology
and the University of Oregon Medical School have provide a
week of lectures and clinics at Portland for ophthalmologists
and otolaryngologists over the past four years. While the course
is primarily intended for physicians in special practice, suhjee
of general interest to practicing physicians arc included. M> '
gical anatomv of the head and neck is demonstrated at t
medical school and two out of state speakers present didactic

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1742

MEDICAL NEWS

Jour. A. M. A
Nov. 4 , 1M9

Medical News

(Physicians will confer a favor by sending for

THIS DEPARTMENT ITEMS OF NEWS OF MORE OR LESS
GENERAL INTEREST; SUCK AS RELATE TO SOCIETY ACTIV-
ITIES, NEW HOSPITALS, EDUCATION AND PUDL1C HEALTH.)

ARKANSAS

First Full Time Professor of Medicine. — Dr. Raymond
L. Gregory, professor of medicine at Howard University Col-
lege of Medicine, Washington, D. C., has been appointed pro-
fessor and head of the department of medicine at the University
of Arkansas School of Medicine, Little Rock, newspapers report.
This is said to be the first full time appointment to the posi-
tion. Dr. Gregory graduated at the University of Minnesota
Medical School in 1929 and has served on the faculties of the
medical schools of the University of Iowa and Louisiana Uni-
versity. He has been associated with Howard since 1937.
Dr. Silas C. Fulmer has been professor of medicine at the
University of Arkansas and acting part time head of the
department.

CALIFORNIA

Society News. — The staff of Providence Hospital presented
the following program before the Alameda County Medical
Association in Oakland October 16: Drs. Philip J. Dick,
“Rectal Polyps”; Malcolm B. Hadden, “Russell Traction and
Treatment of Fractured Femurs” ; Robert S. Peers, “Gout and
Arthritis — Differential Diagnosis,” and Lester B. Lawrence,
"Intraspinal Tumors — Comments on Diagnosis.” At a meet-

ing of the Los Angeles Surgical Society October 13 Drs.
Rupert B. Raney spoke on "Complications of Craniocerebral
Trauma Benefited by Surgery” and Mark A. Glaser, “A New

Regime for Treatment of Head Injuries.” A symposium on

sulfanilamide and sulfapyridine was presented before the San
Francisco County Medical Society October 10 by Drs. Arthur
Haim, Dwight L. Wilbur, Donald A. Dallas, Edward B. Shaw,

Thomas E. Gibson and Jesse L. Carr. The San Mateo

County Medical Society was addressed in San Mateo October
25 by Drs. Mayo H. Soley and Paul A. Gliebe, both of San
Francisco, on “Physiologic Syndromes Which Simulate Organic
Disease.”

Railway Surgeons’ Meeting. — The thirty-seventh annual
convention of the Pacific Association of Railway Surgeons
was held at the Clift Hotel, San Francisco, September 29-30
with the following speakers among others :

Dr. Lionel D. Prince, San Francisco, A Method of Treatment of Frac-
tures of the Patella.

Dr. Ralph M. L. Dodson, Portland, Ore., Fractures of the Transverse
Processes of the Lumbar Vertebrae.

Dr. Howard A. Brown, San Francisco, The Neurologic Aspects of Low
Back Pain and Sciatica.

Dr. Leo L. Stanley, San Quentin, Testicular Substance Implantation.

Dr. Charles R. L. Mathe and Robley C. Archambeault, M.A., San
Francisco, Spectrographic Analysis of Urinary Calculi: A Prelim-
inary Report.

Dr. Edward M. Butt, Los Angeles, Virus Infections.

Dr. Eugene S. Kilgore, San Francisco, The Management of Coronary
Disease in Engineers.

Dr. Grant L. Selfridge, San Francisco, Deafness.

Drs. Charles A. Thomas and Stirley C. Davis, both of Tucson, Ariz.,
Tuberculosis in the Aged.

Dr. Edmund J. Morrissey, San Francisco, A New Test for Circulatory
Disturbances in the Hand.

• Dr. Lloyd B. Crow, San Francisco, Roentgenologic Demonstration.

Dr. Richard J. Flamson Jr., Los Angeles, gave the presi-
dential address on “The Status of the Railway Surgeon.”

FLORIDA

East Coast Meeting.— The Florida East Coast Medical
Association will hold its annual meeting at Ponte Vedra
November 10-11. The speakers will include:

Dr. Clarence Larimore Perry, Miami, Differential Diagnosis and Treat-
ment of Vulvar Granuloma Inguinale.

Dr. Claude Anderson, Orlando, Intrathoracic Goiter or Adenoma of the
Thyroid. . .

Dr. Isaac M. Hay, Melbourne, Endometriosis.

Dr. Eugene L. Jewett, Orlando, Fractures of the Femur.

Dr. James C. Nowling, West Palm Beach, Acute Meningitis Caused by
Influenza Bacillus. . . _

Dr. James J. Nugent, Miami, Pyelonephritis— Recent Improvements m
Treatment.

A symposium on management of chest tumors will be pre-
sented’ bv Drs. Louie M. Limbaugh, Raymond H, King, Wil-
fred McL. Shaw and Kenneth A. Morris. All are from Jack-
sonville. Dr. Frank K. Boland, Atlanta, Ga., will be the guest
speaker at this meeting.

ILLINOIS

Free Pneumonia Serum and Sulfapyridine.— The state
department of health announces that during the current pneu-
monia season both serum and sulfapyridine will be distributed
free. To obtain them, physicians must have specimens from
patients tested in approved laboratories for the type o? pneu-
monia involved and must agree to render reports to the depart-
ment. Deaths occurred at the rate of 94 per thousand among
serum-treated patients against 150 per thousand among com-
parable nonserum-treated patients during the first half of 1939.
These two groups were all from a list of 2,100 patients from
whom specimens were taken and tested in approved laboratories.
The serum and sulfapyridine may be obtained from the centers
which have been established throughout the state.

Chicago

Personal. — Miss Alice H. Miller, Gainesville, Fla., lias
been appointed director of public health for the Tuberculosis
Institute of Chicago and Cook County, succeeding Mrs. Ade-
laide Ross, resigned.

Koessler Fellowship Awarded. — Dr. James J, Smith, St.
Louis University School of Medicine, class of 1937, has been
awarded the Jessie Horton Koessler Fellowship of the Insti-
tute _ of Medicine of Chicago. Under the fellowship, which
carries a stipend of §500, Dr. Smith will work with Dr.
Andrew C. Ivy at Northwestern University Medical School
in research on evacuation of the gallbladder in pregnancy.

Ophthalmology for General Practitioners. — The Illinois
Eye and Ear Infirmary announces that a course in refraction
and diseases of the eye will be offered during the week of
December 4 for general practitioners in towns outside of Cook
County and not nearer than 25 miles to an ophthalmologist.
The course will be limited to six men and the fee will be ?25.
Information may be obtained from the dean of instruction,
Illinois Eye and Ear Infirmary, 904 West Adams Street.

Society News.— The Chicago Society of Internal Medicine
will be addressed November 27 by Drs. Michael H. Strcicher
on “Appendicitis — Incidence of Amebiasis in a Clinical Review
of 3,407 Cases” ; Ralph B. Bettman and Gemma M. Lichten-
stein, “Acute Cholecystitis” and Laurence E. Hines, Allen H.
Hoover and Edwin C. Graf, “Effect of Sulfanilamide on the
Fibrinolytic Activity of Hemolytic Streptococci.” The Chi-

cago Laryngological and Otological Society will be addressed
November 6 by Drs. Hans Brunner on “Surgical Repair oi
Facial Paralysis”; Frank J. Novak Jr., “Giant Follicular
Hypertrophy of Nasopharynx,” and William A. Smiley, “Sub-
glottic Polyp Following Intratracheal Anesthesia.”

Symposium on Nutritional Deficiency. — The Chicago
Medical Society will sponsor a symposium on. nutritional
deficiency at Thorne Hall, Northwestern University Medical
School, November 15 with the following speakers: Dr. Tom
D. Spies, Cincinnati; Dr. Frederick T. Jung, Smith Freeman,
Ph.D., Dr. Warren H. Cole, Chester J. Farmer, A.M., Drs.
Arthur F. Abt, Don C. Sutton, John Ashworth, Nathan a.
Davis III, Edward D. Allen, Bengt L. K. Hamilton, Howard
L. Alt, Charles B. Puestow and Clifford J. Barborka and
Franklin C. Bing, Ph.D. The symposium will begin at J
o’clock in the morning, and in the evening following dinne
at the Chicago Woman’s Club Dr. Spies will discuss "Vitamin
B and Pellagra.”

INDIANA

State Medical Election. — Dr. Albert M. Mitchell, Torre
Haute, was chosen president-elect of the Indiana State Medics
Association at its annual meeting in Fort Wayne October !-■
He will take office in January 1941. Dr. Karl R. Rudde ,
Indianapolis, will be inducted into the presidency in J 3 ! 11 . 13 .-
1940. The 1940 session of the association will be hem
French Lick.

Society News. — The Fort Wayne Medical Society " 33
addressed recently by Dr. Richard W. Terrill, Fort ” '

on “Treatment of Foreign Bodies in the Eye.”— —At » *
ing of the Montgomery County Medical Society in i Crawlor -
vitle September 21 Dr. George S. Bond, Indianapolis, discus-™

coronary disease. Dr. Arthur N. Ferguson Fort ' a

spoke on heart disease at a recent meeting of the D
County Medical Society in Columbia City. .

District Meeting.— The sixty-second semiannual mcctm?
dI the Eleventh Indiana Councilor District Medical Asscua
:ion was held at Marion October IS. In the mornino •
2uitman U. Newell, professor of clinical obstetrics and g?”
-ology, Washington University School of Medicine, _ St.
:onducted a clinic and in the afternoon the following j
Drs. Cyrus J. Clark, Indianapolis, “Sulfapyridine and A»i-

Ad «»e* is 3

1744

MEDICAL NEWS

Joint. A. M. A.
Nov. 4, 19J9

the specialized knowledge of the members. The committee
consists of Drs. Robert S. Cunningham, dean, Albany Medical
College, Albany; James Ewing, director, Memorial Hospital,
New York; Thomas P. Farmer, Syracuse, chairman of the
council committee on public health and education, Medical
Society of the State of New York; John J. Morton Jr., sur-
geon in chief, Strong Memorial Hospital, Rochester, and
Francis Carter Wood, professor of cancer research, Columbia
University College of Physicians and Surgeons. Dr. Morton
L. Levin, New York, has been appointed assistant director of
the new division, which has set up headquarters in the New
York State Teachers’ Association building, Albany. Forma-
tion of the division was announced in The Journal, October
21, page 1575.

New York City

Second Harvey Lecture.— Conrad A. Elvehjem, Ph.D.,
professor of agricultural chemistry. University of Wisconsin
College of Agriculture, Madison, will deliver the second Har-
vey Society Lecture of the season at the New York Academy
of Medicine November 16. Dr. Elvehjem will speak on “The
Biological Significance of Nicotinic Acid.”

Conference on Convalescent Care. — The New York
Academy of Medicine is sponsoring a conference on convales-
cent care November 9-10. The program will include the
following subjects: physiology and psychology of convales-
cence, relation of chronic disease to convalescence, results of
recent research in nutrition with particular reference to the
convalescent state, institutional care for various types of
patients, psychosomatic factors of convalescence and the socio-
economic aspects of convalescent care. In addition to the New
York physicians who will present topics for discussion, the
following guest speakers will participate : Drs. Oliver H.
Perry Pepper and Isidor S. Ravdin, Philadelphia; William S.
McCann, Rochester; Waldo E. Nelson, Cincinnati; Lewellys
F. Barker and G. Canby Robinson, Baltimore. A general
meeting will be held Friday evening November 10 at which
the speakers will be Dr. I. Ogden Woodruff, E. H. Lewinski
Corwin, Ph.D., and Mr. Alfred H. Schoellkopf.

NORTH CAROLINA

Society Adopts Farm Security Program. — The Johnston
County Medical Society at a meeting October 10 adopted the
Farm Security Administration program for medical care for
1940. The supervisory board will be composed of the presi-
dent and secretary of the society and one other member
appointed each year by the two officers. It was also voted
to place Hygcia in all county schools at the expense .of the
society.

Special Society Meeting.— The fifth annual meeting of
the North Carolina Eye, Ear, Nose and Throat Society was
held in Statesville September 21. The guest speakers were
Drs. John J. Shea, Memphis, Tenn., on "Prevention of Com-
plications of the Surgery of Tonsils and Adenoids” and “Man-
agement of Fractures of the Facial Bones” and James W.
White, New York, “Relation of Ocular Muscles and Refrac-
tion.” Dr, Albert G. Woodard, Goldsboro, was elected presi-
dent; Dr. Milton B. Clayton, Statesville, vice president, and
Dr. Milton R. Gibson, Raleigh, secretary, reelected.

NORTH DAKOTA

Semiannual Special Society Meeting. — Dr. Lawrence M.
Randall, Rochester, Minn., was the guest speaker at the semi-
annual meeting of the North Dakota Society of Obstetrics and
Gvnecology in Grand Forks October 21. His subject was
“Some Clinical Phases of Endocrinology." Other speakers
were Drs. James F. Hanna, Fargo, on “A Fifteen Year Review
of Carcinoma of the Cervix Uteri at St. John’s Hospital,
Fargo”; John D. Graham, Devils Lake, “Medical Induction of
Labor Near Term,” and Ii. Robert Ransom, Grand Forks,
“Pyelitis of Pregnancy.”

OHIO

Annual Cardiovascular Institute. — The sixth annual car-
diovascular institute under the auspices of the Heart Council
of Greater Cincinnati, the West Virginia Heart Association
and the Academy of Medicine of Cincinnati will be held Novem-
ber 14. The morning session will be at the Cincinnati General
Hospital with Dr. William M. Sheppe, Wheeling, W. Va,
speaking on “Syphilis of the Heart and Aorta” and Dr. Marion
A. Bla'nkenhorn, Cincinnati, “Hypertensive Heart Disease,”
and discussion by Dr. Timothy Learv, emeritus professor of
pathology, bacteriology and medical jurisprudence. Tufts Col-
lege Medical School, Boston. In the afternoon session at the
University oi Cincinnati College of Medicine Drs. Oscar B.
Biem, Huntington, W, Va., and Johnson McGuire, Cincinnati,

will conduct round table discussions on cardiovascular syphilis
In the evening Dr. Leary will deliver the first Alfred Fried-
lander Lecture at the Academy of Medicine on “Pathology of
Syphilis of the Cardiovascular System.”

PENNSYLVANIA

Society News.— Dr. David M. Davis, Philadelphia, spoke
before the Lycoming County Medical Society in Williamsport

October 13 on urinary infections in females. Dr. Russell

Richardson, Philadelphia, discussed “Advances in the Treat-
ment of Diabetes” before the Cambria County Medical Society,

Johnstown, October 12. Drs. Howard J. Thomas, Grcen's-

burg, and Robert C. Johnston, New Kensington, addressed the
Westmoreland County Medical Society at the Mountain View
Hotel October 25 on “Toxemias of Pregnancj'” and “Surgical

Headaches” respectively. Dr. Stanford W. Mulholland,

Philadelphia, addressed the Delaware County Medical Society,
Chester, October 12 on “Hypertension’s Challenge to Urology.”

Philadelphia

Society News. — Drs. Michael Scott and Hershel C. Len-
non, among others, addressed the Philadelphia Neurological
Society October 27 on “De cerebrate Tonic Extensor Convul-
sions as a Sign of Occlusion of the Basilar Artery.” A

panel discussion of “Practical Orthopedics for the Pediatrist”
was presented at a meeting of the Philadelphia Pediatric
Society October 10 by Drs. DeForest P. Willard, John A.
Brooke, Jesse. T. Nicholson and John P. Scott.

The “Blockley” Dinner. — The Association of Ex-Resident
and Resident Physicians of the Philadelphia General Hospital,
lor many years known as “Blockley,” will hold its fifty-third
annual dinner at the Bellevue-Stratford Hotel December 5.
Dr. William S. Middleton, dean, University of Wisconsin
Medical School, Madison, will be the guest of honor and
Dr. Arthur C. Morgan, president of the association, will pre-
side. Members who do not receive notices are requested to
send their correct addresses to. the secretary, Dr. George
Wilson, 133 South Thirty-Sixth Street, Philadelphia.

Woman’s Hospital to Celebrate Merger. — A day of
scientific meetings in celebration of the tenth anniversary of
the merger of the Woman’s Hospital of Philadelphia and West
Philadelphia Hospital for Women will be held December 1 for
all who have served as interns and residents at either institu-
tion. In the morning Dr. Margaret C. Sturgis will conduct
an operative gynecologic clinic and Dr. Mary Hoskins Easby
a cardiac clinic, and Dr. Alberta Peltz will speak on ^ “The
Philadelphia Maternal Welfare Committee and Its Work.” At
the afternoon session the speakers will be Drs. Emily Lois
Van Loon on “Bronchoscopy and Esophagoseopy as Related
to the General Practitioner” ; Emily P. Bacon, “Disorders in
the Preschool Child,” and Drs. Berta M. Mcine and Ursula
M. E. Hobcr, “Obstetric Service of the Woman’s Hospital
for the Past Ten Years,” with demonstration. There will be
a dinner in the evening at the Penn Athletic Club at which
Dr. Mary R. H. Lewis, medical director of the hospital, will
be toastmistress.

Pittsburgh

Society News. — At a meeting of the Allegheny County
Medical Society October 17 the speakers were Drs. James »>•
Stevenson, Mount Lebanon, Pa., on “Bicornate Uterus Asso-
ciated with Pregnancj’”; Joseph W. Hampsej’, “Masking ot
Clinical Picture of Acute Mastoiditis During the Administra-
tion of Sulfanilamide”; Alfred B. Sigmann, Bridgcvillc, Clint*
cal Study of Treatment, b>’ Intra-Abdominal Lavage with
per Cent Alcohol, of Acuie Suppurative Peritonitis (Appen-
diceal),” and Kenneth D. Eskcy, “Sulfanilamide in Treatment
of Gonorrhea.”

VIRGINIA

Society News. — A symposium on pyloric stenosis was pre-
sented before the Mid-Tidewater Medical Society at baltiua
recently by Drs. Nowell D. Nelms, Mathews; Russell von '*•
Buxton and William W. Falkener, Newport News; 11 i |M "
Lowndes Peple and Charles R. Robins, Richmond.

Personal. — Dr. Leonard H. Denny has resigned as director
of the department of public welfare of Portsmouth inorww “
return to service in the U. S. Navy, it is reported. Dr. J" ’■ •

T. Miller, retired naval officer, has been appointed to succci

Dr. Denny. Dr. William D. Tiiison, director of the bureau

of industrial hj-gicne, state department of health, since J.
1936, has resigned to become medical director of the America
Viscose Company, Parkersburg, W. Va.

State Medical Election.— Dr. Walter B. Martin, Forlorn,
was named president-elect oi the Medical Society ot ' iffi,
at the annual meeting in Richmond October 4 and Pr*

Volume 113
Number 19

MEDICAL NEWS

1745

H. Trout, Roanoke, was installed as president. Vice presi-
dents elected were Drs. Karl S. Blackwell, Richmond; Frank
A. Farmer, Roanoke, and Philip W. Boyd, Winchester. Miss
Agnes V. Edwards, Richmond, was reelected executive
secretary-treasurer.

WASHINGTON

State Obstetric Meeting— Dr. William M. Wilson, Port-
land, Ore., was the guest speaker at the annual meeting of
the Washington State Obstetrical Society in Everett October 7.
Dr. Wilson summarized discussions at the morning sessions
and delivered two addresses, one at the afternoon session on
“Experience with the Newer Endocrine Products" and another
at the evening session on “Treatment of Pruritus Vulvae.”

Society News. — Dr. Arthur E. Lien, Spokane, addressed
the Spokane County Medical Society, Spokane, October 12 on

“Nutrition and Its Relation to the Public Health." The

King County Medical Society was addressed October 16 by
Drs. David Metheny on ‘‘Carcinoma of the Stomach” and Otis
F. Lamson, Seattle, ‘‘Multiple Primary Carcinoma.” Dr. Frank
J. Heck, Rochester, Minn., addressed the society October 25
on “Practical Aspects of the Treatment of Anemia.” A
motion picture was shown on “The Adequate Neurological
Examination" by Drs. Laurence Selling and Roger H. Keane,
Portland, Ore.

WISCONSIN

Personal. — Dr. Virginia Small, formerly of Nashville, Tenn.,
has been appointed staff physician of the bureau of maternal
and child health of the state board of health.

Changes in State Medical Board. — Dr. Robert E. Flynn,
La Crosse, was appointed to the State Board of Medical Exam-
iners by Governor Heil September 13. He succeeds Dr. Cor-
nelius H. Cremer, Cashton. At a recent meeting in Milwaukee
Dr. George R. Reay, La Crosse, was elected president of the
board and E. C. Murphy, D.O., Eau Claire, was elected
secretary.

Society News. — Drs. Ethel C. Dunham of the Children’s
Bureau, Washington, D. C., and Wyman C. C. Cole, Detroit,
addressed the Milwaukee Pediatric Society October 11 on
“Organization of the Pediatric and Obstetric Groups in a Cam-
paign to Reduce Neonatal Mortality” and “Cyanosis of the
Newborn” respectively.. — -Dr. Jay Arthur Myers, Minneap-
olis, addressed the Medical Society of Milwaukee County,
Milwaukee, October 13 on “Controlling Tuberculosis in a
Community.” The meeting was a memorial to the late Dr.
Hoyt E. Dearliolt, for many years secretary of the Wisconsin
Antituberculosis Association, Dr. Gilbert E. Seaman, Winne-
bago, gave an address on Dr. Dearholt's contributions to medi-
cine and tuberculosis.

PHILIPPINE ISLANDS

University News. — Dr. Antonio G. Sison, dean of the
College of Medicine, University of the Philippines, Manila,
has been appointed director of the Philippine General Hospital
also. The work of the hospital will be coordinated with that
of the various units of the medical school, according to the
Journal of the Philippine Islands Medical Association. Presi-
dent Quezon also authorized the establishment of a graduate
school in the medical college in accordance with provisions ot
a law appropriating money for the purpose.

GENERAL

Ophthalmic Board to Hold One Written Examination.
— The American Board of Ophthalmology announces that only
one written examination will be held in 1940. This will be in
various cities throughout the country March 2. All applica-
tions for this examination must be received before January 1
and all applicants must pass a satisfactory written examination
before being admitted to the oral examination. Candidates
planning to take the next oral examination, which will be in
New York June 8-10, 1940, must file their case reports before
March 1. The date of the fall examination will be announced
later. For application blanks write at once to the secretary
of the board, Dr. John Green, 6S30 Waterman Avenue, St.
Louis.

Medical Fellowships Available.— Fellowships in the medi-
cal sciences administered by the medical fellowship board of
the National Research Council will be available for the year
beginning July 1, 1940. These fellowships are open to citizens
of the United States or Canada who have a Ph.D. or an M.D.
degree and are intended for recent graduates rather than for
persons already established professionally. The fellows will

be appointed at a meeting to be held about March 1 and appli-
cations must be filed on or before January 1. For further
information address the Secretary, Medical Fellowship Board,
National Research Council, 2101 Constitution Avenue, Wash-
ington, D. C. Dr. Alfred Blalock, Nashville, Tenn., and Homer
W. Smith, D.Sc., New York, have been appointed members
of the board.

Ohio Valley Allergists’ Meeting. — The Ohio Valley
Allergy Society held a meeting in Cincinnati October 28-29.
Following a general discussion of “Potassium Chloride Therapy
in Allergic Diseases," the speakers were:

Dr. Jonathan Forman, Columbus, Histaminasc Therapy in Allergic
•Diseases.

Dr. John H. Mitchell, Columbus, Emphysema — The Importance of the
Excursions of the Diaphragm in Estimating Prognosis— Breathing
Exercises,

Dr. George E. Rockwell, Cincinnati, Present Status of Tetanus Toxoid
— Advisability of Its Use in Immunizing Horse Serum Sensitive
Individuals.

Dr. Armand E. Cohen, Louisville, K}\, The Asthma Syndrome Due to
Heart Disease.

Dr.‘ Caryle B. Bolmer, Indianapolis, Aspirin-Sensitive Asthmatics.

Special Society Elections. — Dr. Waller S. Leathers, Nash-
ville, Tenn., was chosen president-elect of the American Public
Health Association at the annual meeting in Pittsburgh Octo-
ber 16-20, and Dr. Edward S. Godfrey Jr., state health officer
of New York, Albany, was installed as president. Vice presi-
dents elected were Miss Elizabeth L. Smellie, R.N.. chief
superintendent of the Victorian Order of Nurses for Canada,
Ottawa, Ont. ; Dr. Domingo L. Ramos, Fabrica, P. I., and
Dr. Wilton L. Halverson, Pasadena, Calif. The 1940 conven-
tion will be held in Detroit. Dr. Evarts A. Graham, St.

Louis, was chosen president-elect of the American College of
Surgeons at its annual session in Philadelphia October 19.
Drs. Oliver S. Waugh, Winnipeg, Man., and Albert O. Single-
ton, Galveston, Texas, were elected vice presidents and Dr.
George P. Muller, Philadelphia, was installed as president.

European Journals and the War. — The American Docu-
mentation Institute requests that subscribers to European chem-
ical or other scientific journals who do not receive their copies
report the matter promptly. The cultural relations committee
of the institute hopes to be able to surmount such war obstacles
as interrupted transportation, embargoes and censorship, which
seriously affected the progress of research during the last war.
It is hoped that the principle will be established that materials
of research having no relation to war shall continue to pass
freely, regardless of the countries of origin or destination.
Reports with full details of where subscription was placed and
name and address of subscriber, volume, date and number of
the last issue received should be addressed to the American
Documentation Institute, Bibliofilm Service, U. S. Department
of Agriculture Library, Washington, D. C.

Southwestern Medical Association. — The twenty-fifth
anniversary postgraduate conference of the Southwestern Medi-
cal Association will be held at the Hotel Cortez, El Paso,
Texas, November 9-11. The program will consist of general
assemblies, clinical and pathologic conferences, motion pic-
ture demonstrations and round table luncheons. The speakers
will be:

Dr. Fred H. Albce, New York, orthopedic surgery.

Dr. jtlarye Y. Dabney, Birmingham, gynecology.

Dr. Deo Eloesser, San Francisco, surgery.

Dr. Samuel D. Ingham, Los Angeles, neurology.

Dr. Julius Lempert, New York, otology.

Dr, Charles F, McCuslcey, Glendale, Calif., anesthesia.
Dr. Louis H. Newburgh, Ann Arbor, Mich., dietetics.
Dr. Henry M. Wiuans, Dallas, Texas, medicine.

A special feature of the meeting will be the presentation
of a “Medical March of Time” by charter members of the
association.

Dana Medal Awarded to Dr, Ellett. — The Leslie Dana
Medal, awarded annually by the St. Louis Society for the
Blind for “outstanding achievements in the prevention of blind-
ness and the conservation of vision,” was presented to Dr.
Edward C. Ellett, Memphis, Tenn., at a dinner in St. Louis
October 14. The presentation was to be made by Dr, Edward
Jackson, Denver, first recipient of the medal in 1925, and
another speaker was Mr. Lewis H. Cam's, New York, gen-
eral director of the National Society for the Prevention of
Blindness, which cooperates in the selection of the recipient.
Dr. Ellett, _ who is 69 years old, has practiced ophthalmology
m Memphis since 1893 and was professor of diseases of the
th ?„H mve T r r s,t >'. of Tennessee College of Medicine from
1906 to 1922 He is a former president of the American
Academy of Ophthalmology and Otolaryngology and of the
American Ophthalmological Society and chairman of the Sec-
tion on Ophthalmology of the American Medical Association.

1746

FOREIGN LETTERS

Jour: A. M. A.
Nov. 4, 1939

Foreign Letters

LONDON

(From Our Regular Correspondent)

Oct. 7, 1939.

A Healthier Nation

It is interesting that the annual report of the Ministry of
Health, which of course was compiled before the outbreak of
the war, shows that as we enter a period of destruction the
health of the nation was never so good. The average weight
of school children at the age of 12 has increased by 3 pounds
and the average height by half an inch compared with ten
years ago. The same tendency was shown in the medical
examination of the conscripts, of whom nearly 83 per cent
passed as grade 1. The death rate has again fallen and is
now 8.5 per thousand of population, the lowest on record, just
half what it was in 1901. Infant mortality has a new low
record of 53 per thousand births, little more than one third
of what it was at the beginning of the century. Maternal
mortality in 1938 was less than 3 per thousand births, while
only five years ago it was 4.4. The deaths from tuberculosis
were again the lowest on record, being only half the number
in 1911. But there has been a rise in the cancer mortality,
the deaths numbering 68,605, which was 1,600 more than in
the previous year.

Great progress has been made in the control of infectious
diseases. Environmental diseases, such as cholera, typhus and
plague, have almost entirely disappeared and the cases of
typhoid have been substantially reduced. But the position is
not so satisfactory with regard to diphtheria, of which the
number of cases fluctuates from year to year without showing
any general decline. There are about 3,000 deaths from typhoid
every year. There has been no material decrease in the inci-
dence of influenza, measles and whooping cough, but the death
rate from these diseases has considerably declined. Compari-
son of the deaths per million of population for 1938 with the
average for the decade 1921-1930 shows influenza 118 against
369, measles forty against 109, whooping cough twenty-seven
against 114. In 1938 only eighteen cases of smallpox were
notified, from which there were three deaths, the first since
1934. An exceptionally large number of cases of poliomyelitis,
1,489, were notified, almost twice those of the previous year.

Women Physicians in the Army
Following representations by the British Medical Associa-
tion, a scheme has been authorized for the employment of
women physicians with the army medical services in the war.
They will be eligible for employment either as civilian medical
practitioners or medical officers attached to the army medical
corps with a military status. Civilian medical practitioners will
be engaged under the same conditions and rates of remunera-
tion as male practitioners! For the army medical corps they
will first be accepted as medical officers with the relative rank
of lieutenant but without a commission. They will receive
advancement in relative rank as for the medical corps in war.
They will wear a uniform to be decided on and will receive
the same pay and allowances as for officers of the corps, except
that their rations will be four fifths of those given to males
(the accepted principle of all women personnel in the army).

Ambulance Trains Under Construction
The British railways are engaged in the construction of a
number of ambulance trains for use both at home and oversea.
Work has already been completed on several trains and, to
enable more to be brought into service rapidly, work on
different sections has been entrusted to seven railway work-

shops throughout the country. Each train is fully equipped
with cars for traveling staffs of nurses, physicians, kitchens
and wards. Casualty evacuation trains have also been built
for use in the event of air raids, in order to assist in the
distribution of injured civilians throughout the country. The
fitting up of the trains includes electric lighting and steam
heating and many devices to ensure the comfort of patients.

The Danger of Traction on the Scalp in
Placenta Praevia

In 1925 J. A. Willett introduced a method of treating pla-
centa praevia by traction on the fetal scalp with a forceps
which he devised. This was applied to the scalp with a wide
bite and traction was made by attaching a weight not excced-
ing 2 pounds. In Great Britain Willett’s forceps has been
extensively used. At the Section of Obstetrics and Gynecology
of the Royal Society of Medicine, Prof. F. J. Browne stated
that in a series of 3,103 cases of placenta praevia which he
had collected and analyzed from the reports of eleven teach-
ing hospitals it was used in 252 with a maternal mortality of
3.5 per cent and a fetal mortality of 46.4 per cent. The
advantages claimed for the forceps are that (1) it can be
applied when the os admits only one finger and therefore is
too small to allow a foot to be brought down; (2) little
internal manipulation is necessary; (3) the fetus is spared the
dangers of breach delivery and the fetal mortality is therefore
lower than after version. The average fetal mortality under
all methods of treatment in this series was 54.2 per cent, so
that there seems some justification for the last claim. But
Browne has recently had two cases in which the use of the
forceps was followed by Bacillus welchii infection of mother
and fetus.

In the first case a secundipara aged 32 was admitted after
losing about half a cupful of blood. She was thirty-two weeks
pregnant. The position was left occipito-anterior high above
the pelvic brim. A tentative diagnosis of placenta praevia was
made and she was treated expectantly, but bleeding recurred
three and eight days later and she was examined under anes-
thesia. The cervix admitted one finger and the placenta was
felt to extend to the internal os. The membranes were rup-
tured and Willett’s forceps was applied with a weight of I /
pounds attached. Two days later labor pains had not begun,
the temperature was 102 F. and there was a foul smelling
discharge but no further bleeding. Pains began next day, when
the temperature was 103 and the pulse 150. A dead fetus
was born. It and the placenta were putrid. The mothers
condition was so bad that a transfusion was done and B. wclcnu
serum was given. Next day crepitations were felt in the
abdominal wall and she died on the following morning. The
necropsy showed gas bubbles in the rectus muscle and the blood

vessels.

The second patient was a prfmigravida aged 28, admitted
for bleeding of one week’s duration. She was eight days over-
due and the vertex was not engaged. She was treated expec-
tantly, but as slight bleeding continued she was examined under
anesthesia after nine days. The os admitted one finger with
difficulty and the edge of the placenta was felt V/s niches
above the internal os. The membranes were ruptured an
Willett’s forceps was applied. Weak pains began and after
nine hours the forceps came off spontaneously. Labor P ro "
gressed slowly and after four days a putrid fetus was born.
B. welchii serum was given intramuscularly as a prophylactic.
The mother recovered. Cultures from the cervix showed •
welchii, numerous colon bacilli and a few fecal streptococci.
Cultures from the fetal spleen grew B. welchii.

Browne pointed out that in applying Willett’s forceps a more
or less lacerated wound of the feta! scalp is necessarily mad e.
The weight enables the feta! head to compress the placenta,
but this compression arrests both the maternal and the fetal

Volume 113
Number 19

FOREIGN LETTERS

1747

circulation of the placenta, which is liable to kill the fetus and
produces ideal conditions for infection by the Welch bacillus
a ragged wound in dead tissues. If the bacillus is present in
the vagina or gains access to it, infection and gas gangrene
are likely. It has been shown by Hill, of Melbourne, that this
bacillus is widely distributed. He found it in the floor dust
of labor wards and on the hands of medical attendants after
washing and drying. Browne concluded that Willett's forceps
should have no place in the treatment of placenta praevia.

PARIS

(From Our Regular Correspondent)

Sept. 27, 1939.

Polypeptides in General Medicine and Psychiatry

Laignel-Lavastine revived the history of polypeptides before
the Academy of Medicine by investigating the comparative
value of polypeptidemia in blood urea, both in general practice
and in psychiatry. Between 1928 and 1934 polypeptides were
an object of infatuation among investigators, who now are
somewhat disappointed, perhaps because they expected too much.
According to Laignel-Lavastine and his collaborator Duguet,
loss of interest in polypeptides is hardly reasonable. The
sequence of chemical disintegrations which carries albumin to
the urea includes polypeptides, intermediate between peptones
and the amino acids. The chemical entity of these polypep-
tides is far from being precisely known. Polypeptides are
defined by their precipitations induced by means of trichloro-
acetate and phosphotungstic acid, and their quite delicate dosage
is based on these reactions. Goiffou and Spacey proposed a
simpler and precise, though indirect, method, namely measur-
ing the tyrosine content of the blood polypeptides. This is, in
fact, quite regular in polypeptides though Fischer obtained some
synthetically which did not contain any.

Pierre Duval draws from the dosage with polypeptides prog-
nostications of interest to surgeons, namely that in those with
extensive burns and in numerous cancer patients polypeptidemia
is elevated.

In general medicine, Fiessinger has shown that hypopoly-
peptidemia, or at least an increased deamination index, is
always high in hepatic insufficiency. A study of sixty cases
(forty from the general practice, twenty from psychiatry) indi-
cated to Laignel-Lavastine the same increase of the rate of
polypeptidemia in hepatic cases but accompanied with a low
azotemia rate. In mental cases, however, the polypeptidemia
and azotemia rate is higher than the normal rate. This hyper-
polypeptidemia is especially noticeable in senile dementia, con-
fusion amentia, mania and alcoholism; diseases of patients of
this class as a rule are accompanied with hepatic insufficiency.
Whenever hyperpolypeptidemia is marked (tyrosine index of
more than 100 mg.), prognosis is grave. On the other hand,
polypeptidemia can shed light on the nature of certain pro-
nounced azotemias (2 Gm. or more). If the polypeptidemia
rate is moderately high, azotemia is often transitory and indi-
cates merely renal lesions in their final stage. Claude likewise
studied the variations of the polypeptide rate in the cerebro-
spinal fluid in the course of dementia paralytica and other
mental conditions. Generally in catatonia not due to lesions
the polypeptidemia rate is variable and does not suggest paral-
lelism with the condition of the liver. In alcoholic psychosis
it varies according to the organic condition of the patients.
Normal in chronic alcoholic patients, it as well as the deami-
nation index increases in acute or subacute cases. In dementia
paralytica the polypeptides of the spinal fluid are probably
increased by a disorder of nitrogen metabolism in consequence
of brain modifications. No valid diagnostic or prognostic indi-
cations can be deduced from these investigations, at least in
the field of mental diseases.

Cancerigenic Effect of Leprous Tissue
Professor Peyron, in collaboration with Sister Marie Suzanne,
an investigator of leprosy, took from a leper of the mixed type
(N 1 L 2 ) portions of a leproma of the jaw and kept it for fifty
days in distilled water, where it underwent little change. On
the fiftieth day a large quantity of Hansen's bacilli were found
giving clear histologic proof of the leprous nature of the tumor.
These leprous portions were mixed with an emulsion and
injected into the scrotum of four adult rats and into the axil-
lary and inguinal regions of three adult female rats. The
female rats manifested no other reaction outside the common
reabsorption granuloma. Two of the male rats developed a
perceptible tumor in the third month. The first rat had an
enormous scrotal tumor encroaching on the abdomen and a
pleural metastatic swelling 2.S cm. in length. The tumor pre-
sented all the traits of malignant tumors of the interstitial cells
together with significant indications of dedifferentiation, in keep-
ing with its malignant nature manifested by general signs of
carcinomatous intoxication. In the second rat, killed before
the other, the tumor was still benign but histologically all the
more characteristic. No doubt can exist on the causal relation
between the injection of leprous tissue and the appearance of
the tumors. Spontaneous tumors in the interstitial glands of
the testicles are rare. In the large collection of the Croker
Institute and among the large number of rat tumors none have
been found. Hence Peyron’s leprous tissue products are of
great interest. They could have been caused only by the
bacillus itself or the products of the autolysis of the leproma.
Neither of these hypotheses can be considered satisfactory in
our present state of knowledge of experimental carcinoma.
Nevertheless one can invoke in favor of the former assump-
tion observations of Jensen’s sarcoma, the appearance of which
was likewise provoked by the injection of acid-resisting bacilli
derived from a pseudotuberculosis of the intestine of an ox.

Radiotherapy in Uterocervical Carcinomas
It seems that uterocervical carcinomas are slightly on the
increase. At any rate they occupy an important place in the
deaths from cancer. Last June at the meeting of the Societe
de gynecologie obstetrique de Paris Dr. Simone Lacore Laborde
set forth the results obtained by radiotherapy in cervical can-
cers at the Cancer Institute of the Faculty of Medicine of
Paris. The classification adopted by the speaker is that of
the subcommittee on cancer of the League of Nations and is
divided into four stages. In the first stage, lesions are strictly
confined to the cervix. In the second stage the parametrium
is infiltrated. This stage includes the cancers at the upper
part of the vagina. In the third stage, cancerous growth has
reached the pelvic region or, rather, the vagina as far as the
lower area. Isolated metastases may also be noted. In the
fourth stage the cancer infiltration extends more or less to
the neighboring organs, the bladder or rectum or it spreads
to a greater distance. In the ten years from 1921 to 1932,
813 cervical carcinomas in the four stages were observed at
the Institute of Cancer and S92 were treated: forty in the
first stage, ninety-two in the second, 284 in the third and 176
in the fourth. Of the 592 patients, 384 were alive and without
recidivation at the end of five years, 384 had died in the course
of the five years and six had had a recurrence. One hundred
and sixty-seven were living and without recidivation after five
years. The proportion of cures during the five years varied
according to the years between 12 and 37.9 per cent, the aver-
age being 28.2 per cent. There was the same difference
according to the stages : fifty-seven, or S per cent, in the first
stage; forty-eight, or 9 per cent, in the second; thirty-one,
or 6 per cent, in the third, and only five in the fourth. The'
therapy employed was based on the combined use of radium
and roentgen rays. Radium therapy was performed by means
of tubes containing 10 mg. of radium with a filtration equiva-

174S

FOREIGN LETTERS

Jour. A. St. A.
Nov. -1, 1939

lent to 1 mm. of platinum. For the roentgen therapy, high
voltage was used with a 300, 400 and even 500 kilovolt pres-
sure. Massive irradiation was refrained from because it induced
a general shock without yielding better results. Teleradium
therapy by means of an apparatus containing 5 Gm. of radium
and permitting irradiations at 20 cm. from the level of the
skin did not prove superior to classic methods. Technics of
irradiation seem to commend themselves in preference to exci-
sion. According to Heyman (1927), surgery’s record for cures
is only 18 per cent on the average. Besides, one must con-
sider the operative risks (from 7 to 9 per cent), whereas the
mortality due to roentgen rays does not exceed 3 per cent.

BERLIN

(From Our Regular Correspondent)

Sept. 10, 1939.

The Abuse of Hypnotics

The public health department of the reich has just pub-
lished information regarding the use of sleep inducing drugs.
It has instituted an inquiry in about 250 clinics, hospitals and
centers for mental diseases to secure exhaustive data of the
extent of the use of these drugs. It plans to propose that all
such drugs as well as pain allaying preparations containing
barbituric acid derivatives be dispensed only on medical cer-
tification. The greatest attention has officially been given to
this ever present problem and the impression may have been
created that the use of these drugs has declined. However,
the information given to the public health department by rela-
tives of sleeping drug addicts, by physicians, by druggists, by
medical district associations, by the police, by health bureaus
and by administrative authorities has been so copious that the
conclusion is inevitable that the use of these drugs is on the
increase. Observations have been made that opium addicts,
in consequence of the enforcement of antinarcotic measures,
now resort to hypnotics, which they can easily obtain since
a medical prescription is not necessary. It is also said that
the combined action of alcohol and barbituric acid is mutually
intensifying. The public health department has information
indicating that hypnotics not requiring prescriptions are increas-
ingly ordered in large quantities by individual users. The use
of hypnotics also gives rise to a diagnostic problem. Professor
Bonhoeffer, psychiatrist in Berlin, reported that within the last
decade wrong diagnoses, previously unknown, of brain tumors
had become more numerous, owing to the fact that persons
with chronic barbituric acid intoxication had concealed the use.
He mentioned among deceptive symptoms slowly increasing
stupor, speech disturbances, nystagmus and loss of abdominal
reflexes. Professor Pohlisch, psychiatrist in Bonn, reported
the case of a university professor who was dismissed because
of alleged hereditary epilepsy and for whom sterilization was
recommended. It was then discovered that the chronic use
of hypnotics was the cause of his condition.

Efforts to Use Workers Who Are Chronically 111

In view of the great demand for workers in Germany it is
especially important to examine the possibilities of economic
adjustment for those with chronic ailments. Two series of
lectures of a postgraduate nature .were recently given at the
Berlin Academy for Physicians, on the significance of primary
symptoms for timely therapy and prophylaxis, especially with
reference to workers, and on economic adaptation of workers
with chronic ailments. The lectures were intended to supply
information to factory physicians and assistant physicians in
charge of departments and practicing physicians interested in
these questions. Explanations by state secretary Syrup of the
economic needs in the four year plan formed the basis of all
the lectures. In Germany, not counting Bohemia and Moravia,
40,000,000 persons are employed in industry. In 1936 lack of
skilled laborers became noticeable. Reserves of male workers

are no longer available. Replacement of men with women
brings with it dangers to their health. It is essential for
public welfare that workers be adjusted to the jobs by which
they can maintain themselves. Responsibility for this rests
largely on physicians, especially factory physicians. The fac-
tory physician should inform himself on how workers live,
their family conditions and so on, all of which are important
factors affecting efficiency. Treatment of sick workers is not
his function; however, he may represent the patient’s physician
in supervising directions given by him. Observations of slight,
scarcely measurable pathologic changes, of scarcely noticeable
decrease in efficiency and of early recognition of harmful symp-
toms might constitute valuable information for the mainte-
nance of health of workers. By' observing health measures in
a factory and the habits of individual ‘workers the factory
physician may', like a seismograph, observe every change in
the frequency of diseases and accidents and obviate or relieve
them by determining the causative factors. He will have to
work in close cooperation with the management. Observa-
tions of large groups at work and the evaluation of extensive
observational data representing an accumulation of more than
350,000 cases may open up a new field of medical territory.
The scarcity' of qualified labor has made necessary the employ-
ment of those physically below par and involves increased obli-
gations for the cooperating and supervising factory physicians.

ECONOMIC EMPLOYMENT

The second series of lectures, on the economic employment
of persons with chronic ailments, was supplementary to the
first. The care of such persons constitutes a heavy drain on
social insurance reserves. To what extent persons with chronic
ailments are dependent on social insurance has not been deter-
mined statistically. However, the statistics furnished by indi-
vidual sick funds and state insurance companies in the provinces
offer some information. Among those chronically ill are per-
sons with tuberculosis, cancer, cardiac and vasomotor diseases,
diabetes, and those with gastric and intestinal disturbances. It
is of little value for such persons to be declared by the physi-
cian in charge as fit or unfit for work. At present fitness
for work is determined by the social insurance physicians, who
work in close cooperation with the public health office, the
labor department and the practicing physician in the detection
of public diseases. The practical operation of such cooperative
services is discernible, for example, in the clinic established
in Berlin to determine diabetes. At present, 14,300 diabetic
persons, including 118 married couples, are served there.

CARE OF EMPLOYEES

Through arrangements, workers who are not entirely unfit
physically can do satisfactory work connected with the soil
or excavation. Factory workers with circulatory disorders in
charge of machines with rotating belts can easily receive
injury, though the work is not difficult. The factory physi'
cian should be consulted in determining the speed with which
work of this kind should be done. Rational arrangement may
enable the injured and even persons with amputated limbs to
work. In the case of women, often it is not the heavy work,
but certain harmful effects like constant vibrations and injuries
caused by continued foot manipulations that arc significant.
These explanations, elaborated by detailed discussions in cc
tures, show how effort is made to utilize the working ability
of every one by exhausting all possible medical knowledge.

Water Requirements of Workers Under
Heat Pressure

Dr. Hebestreit expressed himself in the new periodical Health
Guidance of the German People on the water requirements of
workers under beat pressure. Workers who toil under cow i-
tions of great heat lose on an average more than a gallon o
water during a working day' of eight hours. This loss s i° u

Volume 113
Number 19

DEATHS

1749

be compensated by drinking during work. However, every
excess is to be avoided in order not to burden the circulation
and to prevent gastric troubles. Above all, beverages taken
should not be too hot or too cold, but lukewarm or of the
temperature of the room. Beer and mineral waters are not
suitable. Coffee should be drunk with the addition of milk.
In the stoker rooms of ships, gruel made for example of oats
and rice lias proved its worth. It slakes the thirst well and
supplies the body with salts to replace those lost in perspira-
tion. For that reason gruel is to be recommended to workers
under similar heat conditions. In place of black tea, which
has no appetizing taste at room temperature, teas of native
growth are recommended, such as teas made from blackberry
and strawberry leaves or from peppermint. To supply the
body with easily absorbable food values during great physical
exertion, sugar can be added to the tea ; “to supplement loss
of salts, from 2 to 3 Gm. of salt per quart of beverage can
be added without noticeably impairing its taste.

Marriages

Peter A. N. Pastore, Bluefield, W. Va., to Miss Julia
Anna Rourke of Prides Crossing, Mass., at Rochester, Minn.,
September 14.

Charles Weston Warren, Upperville, Va., to Miss
Geraldine Estelle Mitchell of Winston Salem, N. C., recently.

William Gregory Tiialmann Jr., Philadelphia, to Miss
Sara Carpenter Klopp of Rosemont, Pa., September 30.

Ferdinand E. Chatard IV, Baltimore, to Miss Constance
Bentley Lyon of Purcellville, Va., September 9.

Needham Bryant Bateman to Miss Florence Estele
Stevenson, both of Atlanta, Ga., September 4.

James A. Bradley to Mrs. Evelyn Neuling, both of
St. Petersburg, Fla., in Tampa, October 1.

Franklin LeRoy Wilson, Montreat, N. C., to Miss Eleanor
D. Garrett of Miami, Fla., September 7.

Robert Lee Sanders, Columbia, S. C., to Miss Helen Jessa
McDowell of Charleston, September 23.

Charles E. Conner, Wenatchee, Wash., to Miss Marthe
Irwin of Colorado Springs, July IS.

Josiah Harris Smith, Selma, Ala., to Mrs. Gladys Buck-
master Wire at Cincinnati in August.

Percy F. Guy, Seattle, to Dr. May A. Borquist of Hono-
lulu, Hawaii, in Portland, July 15.

Irving W. Salowitz, to Miss Dorcas Marie Crook, both
of Plymouth, 111., September 24.

Joe M. VanHay, New York, to Miss Helen Spangler of
Greenville, N. C., September 6.

Leon Blum, Far Rockaway, N. Y., to Miss Janette Gold-
stein of Atlanta, Ga., August 8.

J. Elliott Royer, Oakland, Calif., to Miss Helen Hay of
Pasadena, Calif., September 28.

Paul B. Wilson to Miss Esther Elizabeth Roberts, both
of Philadelphia, September 25.

Earl Stough Taylor to Miss Virginia Hanson, both of
New York, September 23.

Sidney F. Yugend, Sigourney, Iowa, to Miss Bertine Hooper
of Hartford, September 8.

Harry D. Tripp to Miss Elizabeth Kopp, both of Logans-
port, Ind., September 30.

Frederick R. Minnich to Miss Katherine Calhoun, both
of Atlanta, Ga., recently.

Walter Shriner, Elgin, III., to Miss Ruth Arline Shearer
of Aurora, August 26.

William S. Cole, Seattle, to Miss Catherine Rutledge of
Burlington, August 5.

Leon E. Pollock to Miss Jean Berry, both of Spokane,
Wash., August 13.

Francis Sauer, Canton, Ohio, to Miss Irma Dotts at Car-
rollton, August 14.

John B. Dynes to Miss Edna Bradbury, both of Boston,
September 22.

Deaths

William Bricker Chamberlin 9 Cleveland; Western
Reserve University Medical Department, Cleveland, 1900;
secretary of the Section on Laryngology, Otology and Rhinology
of the American Medical Association from 191S to 1922 and
chairman from 1922 to 1923; clinical professor of otolaryngology
at his alma mater and at various times associate clinical pro-
fessor, assistant clinical professor, associate and instructor in
otolaryngology; member, past president and vice president of
the American Laryngological Association; member, past presi-
dent and secretary-treasurer of the American Bronchoscopic
Society ; past president of the Cleveland Association for the
Hard of Hearing and of the Cleveland Academy of Medicine;
member of the American Laryngological, Rhinological and
Otological Society; fellow of the American College of Sur-
geons; on the staff of the University Hospitals of Cleveland;
aged 65 ; died, September 5, in Cleveland Heights of coronary
sclerosis and thrombosis.

Arthur Godfrey Fort ® Atlanta, Ga. ; Atlanta College of
Physicians and Surgeons, 1904; past president of the Medical
Association of Georgia; member of the American Academy of
Ophthalmology and Otolaryngology and the Southeastern Sur-
gical Congress ; fellow of the American College of Surgeons ;
instructor of ophthalmology at the Emory University School of
Medicine, 1918-1924; commissioner of health of Irwin and Tifton
counties in 1916; served at various times and in various capaci-
ties on the staffs of the Piedmont Sanitarium, Wesley Memorial
Hospital, Georgia Baptist Hospital, Crawford W. Long Memo-
rial Hospital and the Grady Hospital ; aged 61 ; died, September
15, in the Emory Hospital of myocarditis and pulmonary edema,

Albert Bernard Yudelson © Chicago; Northwestern Uni-
versity Medical School, Chicago, 1906 ; associate professor of
medical jurisprudence and nervous and mental diseases at his
alma mater; member of the Central Neuropsycbiatric Associa-
tion; past president of the Chicago Neurological Society;
served during the World War; attending neurologist to the
Cook County Hospital and the Wesley Hospital; aged 67; died,
August 27, of coronary thrombosis.

John William McIntosh, Burnaby, B. C., Canada; Univer-
sity of Toronto Faculty of Medicine, 1894; formerly medical
officer of health of Burnaby and Vancouver; served during the
World War with the Canadian Army; from 1916 to 1920, was
a member of the provincial legislature; past president of the
Canadian Public Health Association; aged 68; died, August 12.

William Garretson Carhart, Fort Lyon, Colo.; University
of Michigan Department of Medicine and Surgery, Ann Arbor,
1904; served during the World War; instructor of pathology
and bacteriology at the University of Missouri, Columbia, from
1904 to 1907; on the staff of the Veterans Administration;
aged 65; died, September 17, of coronary occlusion.

Bennett Sheldon Beach © New York; College of Physi-
cians and Surgeons, Medical Department of Columbia College,
New York, 1887; member of the American Academy of Oph-
thalmology and Otolaryngology ; fellow of the American
College of Surgeons; on the staff of the New York Eye and
Ear Infirmary; aged 77; died, September 13.

Thomas Edward Parker, Waterbury, Conn.; Yale Uni-
versity School of Medicine, New Haven, 1904 ; member of the
Connecticut State Medical Society; served during the World
War; on the staff of St. Mary’s Hospital; aged 58; died,
August 1, in the New Haven (Conn.) General Hospital of dia-
betes mcliitus and pyelitis.

William A. Zellars, Shaker Heights, Ohio; College of
Physicians and Surgeons, Baltimore, 1891 ; formerly president
of the board of education of Freeport, postmaster and member
of the county board of education ; at one time president of the
bank of Freeport; aged 73; died, August 11, in Cleveland of
uremia.

David Ernst Matzke, Punxsutawney, Pa. ; University of
Pennsylvania Department of Medicine, Philadelphia 19?5-
member of the Medical Society of the State of Pennsylvania -
served during the World War; on the staff of the Punxsutawney
Hospital; aged 40; died in August of acute dilatation of the

*°y Geo-go Pfotzer « Buffalo; Queen's University
b acuity of Medicine, Kingston, Ont., Canada, 1924; associate
m medicine, University of Buffalo School of Medicine; fellow

?r-n C i r^!f ncan T 9° llc * se , on the staff of the

Millard Fillmore Hospital ; aged 46 ; was drowned, August 9,

1750

DEATHS

Jol'r. A. M. A.
Nov, 4, 1939

Cooper Curtice, Beltsville, Md. ; Columbian University
Medical Department, Washington, D. C., 1888; formerly asso-
ciated with the Bureau of Animal Industry, U. S. Department
of Agriculture; was known for his researches on cattle tick
fever ; aged 83 ; died, August 8, of coronary occlusion.

Charles W. Bankes, Middleport, Pa.; College of Physi-
cians and Surgeons, Baltimore, 1881 ; member of the Medical
Society of the State of Pennsylvania ; bank president ; aged 82 ;
on the associate staff of the Pottsville (Pa.) Hospital, where
he died, Augus't 27, of cerebral hemorrhage.

Paul Whiting Woodruff © Chatfield, Minn.; State Uni-
versity of Iowa College of Medicine, Iowa City, 1933; formerly
resident to the Chicago Lying-in Hospital and Dispensary;
aged 34; died, August 16, in a hospital at Winona, Miss., of
injuries received in an automobile accident.

John Joseph Shea, San Diego, Calif.; Harvard Medical
School, Boston, 1897 ; member of the California Medical Asso-
ciation ; at one time member of the board of health of Beverly,
Mass,; aged 70; died, August 19, in the Mercy Hospital of
hypertrophy of the prostate and uremia.

Charles A. Duffy © Pittsburgh ; Georgetown University
School of Medicine, Washington, D. C., 1910; fellow of the
American College of Surgeons ; on the staff of the Southside
Hospital ; aged 52 ; died, August 26, in the Buffalo (N. Y.)
General Hospital of coronary occlusion.

Walter Algeno Allen © Hampstead, N. H. ; Dartmouth
Medical School, Hanover, 1893; served during the World War;
for many years member of the school board and board of
health ; formerly state senator ; aged 70 ; died, August 23, in
the Benson Hospital, Haverhill, Mass.

Leone Franklin La Pierre, Norwich, Conn. ; Yale Uni-
versity-School of Medicine, New Haven, 1901 ; member of the
Connecticut State Medical Society; for many years on the
staff of the William W. Backus Hospital ; aged 62 ; died,
August 7, of cerebral hemorrhage.

Hiram Bachelder West, Los Angeles; Dartmouth Medical
School, Hanover, N. H., 1900; member of the American Psy-
chiatric Association; on the staff of the Veterans Administra-
tion Facility, West Los Angeles; aged 59; died, August 11, of
coronary thrombosis.

Edgar Jonas Knapp, Rice Lake, Wis. ; Harvard Medical
School, Boston, 1892; member of the State Medical Society of
Wisconsin; aged 72; died, August 29, in the Veterans Admin-
istration Facility, Fort Snelling, Minn., of carcinoma of the
duodenum.

John Ludwig Loutfian, Coxsackie, N. Y. ; Medico-
Chirurgical College of Philadelphia, 1902 ; member of the
Medical Society of the State of New York; village health
officer; aged 64; died, August 5, in the Albany (N. Y.) City
Hospital.

Caroline Le Monte Rolph Bassmann, Claremore, Okla. ;
Northwestern University Woman’s Medical School, Chicago,
1897; member of the Oklahoma State Medical Association;
aged 70; died, September 30, in St. John’s Hospital, Tulsa.

Raymond Alexander Turnbull, Elmira, N. Y. ; University
of Buffalo School of Medicine, 1904; member of the Medical
Society of the State of New York; served during the World
War; aged 58; died, August 13, in St. Joseph’s Hospital.

Edwin C. Bandy, Alabama City, Ala.; Medical College
Montezuma University, Bessemer, 1898 ; member of the Medical
Association of the State of Alabama ; aged 78 ; died in September
in Gadsden of extensive burns and bronchopneumonia.

Oliver Hines Finnical, Cadiz, Ohio.; Starling Medical
College, Columbus, 1895; member of the Ohio State Medical
Association; aged 67; died, September 9, in the Ohio Valley
General Hospital, Wheeling, of cerebral thrombosis.

Franklin J. Cushman © Lansing, Mich. ; Detroit College
of Medicine and Surgery, 1921; member of the American
Urological Association; served during the World War; aged
42; died, September 11, of bilateral renal calculus.

James Merlin Fitzgerald © Chicago; Jenner Medical Col-
lege, Chicago, 190S; professor of mental physiology at Bennett
Medical College, 1903-1910; aged 69; died, August 16, in San
Francisco of carcinoma of the bladder and liver.

Harper' Leonidas Crow, Bossier, La.; University of
Louisville (Ky.) .Medical Department, 1913; served during the
World War; aged' 53; was killed, September 3, when the
truck in which lie was driving overturned.

Albert Earl Reed © Larned, Kan.; Rush Medical College,
Chicago, 1905; secretary of the Pawnee County Medical’
Society; medical director of the Larned City Hospital; aged 58;
died, August 30, of coronary occlusion.

George T. Van Cleve, Malden, Mo.; University of Louis-
ville_ (Ky.) Medical Department, 1879; member of the Mis-
souri State Medical Association; aged 86; died, August 5, in
the Baptist Hospital, Memphis, Tenn.

Fred Raines Morrow © Fayetteville, Ark.; Memphis
(Term.) Hospital Medical College, 1900; served during the
World War; on the staff of the City Hospital; aged 68; died,
August 15, of coronary embolism.

Frederick (Dgle Roman, Washington, D. C.; National
University Medical Department, Washington, 1894; member of
the Medical Society of the District of Columbia; aged 73; died,
August 12, of lymphatic leukemia.

Samuel T. Williams, Waynesburg, Pa.; Western Pennsyl-
vania Medical College, Pittsburgh, 1896; aged 70; died, August
4, in the Greene County Memorial Hospital of pulmonary edema
following fracture of the femur.

Alfred Loomis Sawyer, Fort Fairfield, Maine; Medical
School of Maine, Portland, 1907 ; member of the Maine Medical
Association ; served during the World War ; aged 57 ; died,
August 14, of acute pancreatitis.

Troy England Martin © Philadelphia; University of
Pennsylvania School of Medicine, Philadelphia, 1934; aged 29;
on the staff of the Germantown Hospital, where he died, August
21, of streptococcic pneumonia.

James Edward Rudasill © Markham, Va.; University of
Pennsylvania Department of Medicine, Philadelphia, 1893; aged
67 ; died, August 2, in the Western State Hospital, Staunton, of
hypertensive heart disease.

Elliott Benald Tobias, San Francisco; College of Physi-
cians and Surgeons of San Francisco, 1921 ; member of the
California Medical Association; aged 40; died, August 2, of
coronary occlusion.

Paul Eskeberg, Miami, Fla. ; Northwestern University
Medical School, Chicago, 1938; member of the Florida Medical
Association ; aged 28 ; died, September 3, of chronic mye-
logenous leukemia.

Benjamin Franklin Hawk, West Palm Beach, FlaJ
Columbus Medical College, 1891; aged 72; died, August U
in the Veterans Administration Facility, Bay Pines, of carcinoma
of the prostate.

Alfred Frederick Zittel, Buffalo; University of Buffalo
School of Medicine, 1S99; member of the Medical Society of
the State of New York; aged 67; died, August 28, of carcinoma
of the bladder.

Orville DeWitt Wescott, Walla Walla, Wash.; Rush
Medical College, Chicago, 1904; on the staff of the Veterans
Administration Facility; aged 68; died, August 29, of coronary
thrombosis.

Paul Luttinger, New York ; University and Bellevue Hos-
pital Medical College, New York, 1911; member of the Mcdira
Society of the State of New York; aged 54; died, August 11, 01
pneumonia.

George Lee Long, Fresno, Calif.; Hahnemann Mcdica
College, San Francisco, 1886; formerly county health officer
and county coroner ; aged 81 ; died, August 12, of coronary
occlusion.

John Henry Adams, Crockett, Calif.; College of Physician*
and Surgeons of San Francisco, 1911 ; member of the La i-
fornia Medical Association; aged 51; died, August 10, i
Oakland. _

David Martin Levine, Detroit; Wayne University College
of Medicine, Detroit, 1937; member of the Michigan bta
Medical Society; aged 28; died, August 7, of acute lympia
leukemia. ,

Newton J. Boswell, Decatur, Ga. ; Georgia College o
Eclectic Medicine and Surgery, Atlanta, 1893; aged bi , . ’

September 8, of cerebral hemorrhage, arteriosclerosis ana
tension. . . .. i

J. O. Bickham, Winchester, Ark.; Gale City Me 1 •
College, Dallas, Texas, 1903; aged 58; died, August 13,
myocarditis, acute dilatation of the heart, nephritis and VP*
tension. ' _ , „

Roy Lee Aiguier, Sulphur Springs Texas ; Sou Itcr^
Methodist University Medical Department Dallas, 1914,
luring the World. War; aged 50; died, September. 3, m
iVorth.

Volume 113
Number 19

BUREAU OF INVESTIGATION

1751

James G. Robertson, Arrington, Train. ; University of
Tennessee Medical Department, Nashville, 1899; aged 77; died,
August 21, in Cedar Hill, of carcinoma of the right side of the
jaw.

Samuel A. Benson, St. Louis; Homeopathic Medical Col-
lege of Missouri, St. Louis, 1896 ; aged 72 ; died, September 3, in
the City Hospital of burns received when his home caught fire.

Thomas Jefferson Bouldin ® St. Johns, Ariz. ; Atlanta
College of Physicians and Surgeons, 1901; past president of
the Apache County Medical Society ; aged 61 ; died in September.

James Henry O’Connor, St. Helena, Calif.; Columbia
University College of Physicians and Surgeons, New York,
1899 ; served during the World War ; aged 66 ; died, August 1.

John Henry Witbeck, Cayuga, N. Y. ; Bellevue Hospital
Medical College, New York, 1888; for many years health
officer; aged 74; died, August 2, of a ruptured gastric ulcer.

Nathaniel Massie McKitterick, Burlington, Iowa; Rush
Medical College, Chicago, 1880; formerly member of the state
board of health; aged 81 ; died, August 29, of angina pectoris.

Adelbert D. Bowen, West Lodi, Ohio; Toledo Medical
College, 1885 ; aged 79 ; died, September 2, in the Mercy Hos-
pital, Tiffin, following an operation for strangulated hernia.

Thad S. Up de Graff © Pasadena, Calif. ; Jefferson Medical
College of Philadelphia, 1883 ; aged 74 ; died, August 2, in the
Collis P. and Howard Huntington Memorial Hospital.

Norbert Vincent Mullin, Weymouth, Mass.; University
of Pennsylvania Department of Medicine, Philadelphia, 1903 ;
aged 59; died, August 18, in the Weymouth Hospital.

Edward Plotkin, Nashville, Tenn. ; College of Physicians
and Surgeons, Memphis, 1909; aged 56; died, August 24, in the
Nashville General Hospital of cerebral hemorrhage.

Frederick A. York, Navasota, Texas; University of Texas
School of Medicine, Galveston, 1898; aged 65; died, August 22,
in the Brazos Valley Sanitarium of paralytic ileus.

Robert Fred Zeiss © New York; University of Texas
School of Medicine, Galveston, 1916; member of the American
Urological Association; aged 46; died, August 8.

Randolph D. Black, Cedar Grove, W. Va. ; University of
Nashville (Tenn.) Medical Department, 1903; aged 62; died,
September 2, of carcinoma of the lumbar spine.

George William Lawler, Waukesba, Wis. ; Milwaukee
Medical College, 1908; aged 65; died, August 22, in the
Waukesha Municipal Hospital of pneumonia.

Charles H. Davies, Kansas City, Kan.; Jefferson Medical
College of Philadelphia-, 1877 ; aged 86 ; died, September 16, of
pernicious anemia and hypostatic pneumonia.

Frank J. Campbell, San Diego, Calif.; Chicago Medical
College, 1S90; aged 77; died, August 24, in the Mercy Hospital
of cerebral hemorrhage and arteriosclerosis.

John H. T. Earhart, Westminster, Md. ; University of
Maryland School of Medicine, Baltimore, 1S8S ; aged 77 ; died,
September 10, of coronary thrombosis.

Howard Leon Sumner © Asheville, N. C. ; Jefferson Medi-
cal College of Philadelphia, 1926; county health officer; aged
37 ; died, August 16, of heart disease.

William Henry Bennett, Fitchburg, Mass. ; New York
Homeopathic Medical College and Hospital, 1889 ; aged 75 ;
died, August 3, of arteriosclerosis.

Alice Grace Charlton Guequierre, Wayne, Pa. ; University
of Pennsylvania School of Medicine, Philadelphia, 1922; aged
45; died, August 6, of carcinoma.

Thomas Raymond Thorn, Los Angeles ; University of
Texas School of Medicine, Galveston, 1927; aged 35; was killed,
August 13, in an airplane accident.

George B. Hunter, Syracuse, N. Y. ; Baltimore University
School of Medicine, 1897; aged 64; died, August 25, in the
University Hospital of pneumonia.

James Frank Hufford, Elrama, Pa.; University of Pitts-
burgh School of Medicine, 1910; aged 58; died, August 26, of
uremia and arteriosclerosis.

Smith L. Bates, Adrian, Mo.; Medical College of Ohio,
Cincinnati, 1S7S ; aged 87 ; died, August 24, in a hospital at
Kansas City of pneumonia.

Frank Alonzo Dearborn, Nashua, N. H.; Missouri Medi-
cal College, St. Louis, 1S84; aged 81; died, August 3, of arterio-
sclerosis and heart disease.

James Henry Burnett © Kopperl, Texas; Atlanta (Ga.)
Medical College, 1895 ; aged 67 ; died, August 22, of hyperten-
sion, nephritis and uremia.

Bureau of Investigation

THREE POSTAL FRAUD ORDERS

Durio Cosmetic Company

A CONTINUATION OF THE C. A. WILLIAMS FRAUD IS
DEBARRED FROM THE MAILS

In this department of The Journal for Feb. 11, 1939, there
appeared a brief story about the closing of the mails to the
C. A. Williams Company, of McKamie, Ark. The title was
a trade name used by two Negroes, C. A. Williams, who was
70 years old and who founded the business in 1929, and Pies
L. Lewis, who in 1936 acquired a controlling interest (93 per
cent) from Williams.

The concern sold a line of nostrums through the mails for
the alleged cure of gonorrhea, syphilis, pellagra, paralysis,
delayed menstruation, leukorrhea, rheumatism, “lung trouble,”
and so on. The Post Office authorities showed that the two
men who conducted this swindle bought their preparations in
gallon bottles from a St. Louis drug firm and then rebottled
them into smaller bottles as needed. As the nostrums were
quite worthless as cures for conditions for which they were
sold, a fraud order was issued Aug. 23, 1938, closing the mails
to the C. A. Williams Medicine Company.

But this did not stop the fraud. Williams and Lewis changed
the name of their company and continued to do business at
the old stand. The “C. A. Williams Company” became r ‘Durio
Cosmetic Company” and the sale through the United States
mails of worthless swindles for the alleged cure of such dis-
eases as syphilis, gonorrhea and pellagra went on. As a
result the Post Office Department on March 3, 1939, issued a
supplemental fraud order closing the mails to the Durio Cos-
metic Company.

The Stroopal Fraud

A FAKE CANCER "CURE” BOBS UP AGAIN
The Stroopal case presents another example of how some
slippery individuals attempt to evade fraud orders debarring
them from the use of the United States mails. As long ago
as 1930 the Post Office Department declared the Stroopal busi-
ness of Chicago to be a fraud and closed the mails to this
concern. The principal, Alphonse P. Faupel, however, continued

Institute of Reform

STROOPAL

ft tfMrrttS to ilmd «rr UnbiW country
toe UIW

•M 4lKtKI

\ AHT5iCiAW'5 nouns

I 4

STROOPAL

i Kcfi-oM ran loo 4 1<«, *a r»»l

Sc*cid rmt&y U« urxir, Npui, tumor*
<Jc»r «nd •liver formation*, Lum
of b»w and blood.

his business in the United States by operating if from London,
England. The Post Office authorities, therefore, have found it
necessary to issue a supplementary fraud order covering the
London address.

The Stroopal cancer cure fraud originated in Germany many
years ago with a self-styled "Professor” Stroop. It consists
of three powders to be taken at monthly intervals when the
moon is new! To the city bred this in itself might appear
to arouse suspicion. But there are many otherwise intelligent
country! peo ple who are still convinced that a calf should be
weaned and the potatoes planted at certain phases of the moon
The advertising of Stroopal was declared verboten in Germany
some years ago and so the headquarters of the fraud were
transferred to London, where. a greater degree of laisscp .fairc
was permitted. A Chicago branch was opened and, for nearly
twenty years the American branch of the fraud was conducted

1752

CORRESPONDENCE

Jour. A. M. A.
Nov. 4, 1939

from that city with agencies in Centralia, Okla., and Seneca,
Kan. Most of the American business was directed to Americans
of German descent, for much of the advertising was printed in
German script.

According to Gehe’s Codex (January 1913) Stroopal was
nothing more marvelous than the powdered leaves of water
germander or wood garlic (Teucrium scordium). In August
1930 the Post Office Department issued a fraud order barring
Stroopal from the United States mails. The department
brought out at the time that in the exploitation of Stroopal
medals and “certificates of merit” were featured in the adver-
tising and the claim was made that the product had been
awarded these medals and certificates at exhibitions at Ant-
werp, Brussels and Paris. The}' were all utter fakes! It was
shown, too, that when the importation of Stroopal was barred
as dangerous to the health of the people the stuff was for a
while smuggled into this country as “metal cleaning powder.”

The scheme, and the government’s action against it, were
dealt with in an article in this department of The Journal
for Oct. 4, 1930, and the matter in a condensed form appears
in the book /‘Nostrums and Quackery and Pseudo-Medicine,”
volume III, published by the American Medical Association.
Now, in 1939, the fraud again engages the attention of the
United States Post Office Department. The Faupel quack was
still selling his stuff to such victims as he could get in the
United States from his office in London, England. As a result
the fraud order issued in 1930 was supplemented by another
issued March 6, 1939, closing the United States mails to the
Stroopal Company and to Alphonse P. Faupel, both of London.
All postmasters authorized to dispatch letter mail to England
have been notified to return all letters addressed to the Stroopal
concern to the senders with the word “Fraudulent” stamped
plainly on the envelop. Also postmasters are warned not to
issue any postal money orders payable to the Stroopal concern.

A Mate Fakery

PEREZ-MATE COMPANY OF BROOKLYN DEBARRED
FROM THE MAILS

During the past few years attempts have been made to
popularize in this country the South American beverage mate,
also known as Paraguay tea. Yerba mate, while having a
different flavor from that of the ordinary India or China teas
of commerce, has the same physiologic effect. Like common
tea it contains variable amounts of caffeine and tannin. To the
average American palate mate seems to have a medicine-like
taste and therefore it is not surprising that some of the pro-
moters, finding it a poor seller as a beverage, endowed it with
“patent medicine” qualities. As a pepper-up for weak men and
frigid women it was apparently more of an economic success.

From Brooklyn one Arthur Koppel, using the trade style
Perez-Mate Company, for about eight years put out mate under
the names “Ola Mate,” “Brazilian Mate” and "Para-Brazilian
Mate.” It was sold through the mails and the fraud order arm
of the Post Office Department finally got around to it. Accord-
ing to the memorandum that Judge Vincent M. Miles, Solicitor
for that department, sent to the Postmaster General, recom-
mending the issuance of a fraud order, Koppel bought his
Paraguay tea. in bulk at 10(4 cents a pound, repacked it and
sold it for $2 a pound. According to Koppel’s advertising,
said Solicitor Miles, all users of his brand of mate would
“enjoy real health, he-man virility, pep and strength” and
“weak men” who took it would have virile sex-power restored
“almost overnight.” Koppel also claimed that his mate would
restore all persons using it to good health but he advised a
Post Office inspector that he (Koppel) was unable to leave
bis house because of ill health!

Despite Koppel’s claim that he had discontinued advertising
his mate product, Solicitor Miles’s memorandum stated that
there was evidence that Koppel had recently sent literature on
it to persons who inquired about a perfume that Koppel adver-
tised under the name of the He-Mo Company. On March 21,
1939, the Postmaster General, acting on Judge Miles’s recom-
mendation, issued a fraud order against Koppel’s Perez-Mate
'Company of Brooklyn and its officers and agents as such.

Correspondence

“DOG BITES AND RABIES”

To the Editor :— Your remarks on “Dog Bites and Rabies"
(The Journal, October 7, p. 1434) is a fine example of how
one mistake often leads to another.

Cabot in 1899 reported that he saved 91 per cent of the
guinea pigs cauterized with nitric acid at the end of twenty-
four hours. Rosenau more recently has reported practically
100 per cent of guinea pigs saved by prompt application of
nitric acid. In my experience wounds treated with nitric acid
heal satisfactorily, and I have never seen one become infected.
I believe that the theory that the use of nitric acid causes the
spread of infection is not borne out by clinical experience.

Cases of paralysis, some of which have ended fatally follow-
ing the Pasteur treatment, have been reported in the literature.
It should be pointed out that practically all veterinarians who
treat rabies have discontinued the use of material prepared by
the Pasteur method and are now using material prepared by
the Semple method. Since they have so much more experience
in treating rabies than do physicians, I believe that their experi-
ence should be given consideration. One is forced at least to
bring out the fact that vaccine prepared by the Semple method
is evidently safer, and the dosage can be more varied according
to the clinical indications because one is using a killed rather
than an attenuated virus.

L. B. Gloyne, M.D., Kansas City, Kan.

From the Department of Preventive Medicine,

University of Kansas School of Medicine.

[Comment. — In Queries and Minor Notes (this issue, p. 1751)
appears an additional discussion of paralysis following rabies
vaccination.]

BLOOD SUGAR VERSUS URINARY SUGAR

To the Editor : — In The Journal June 17 and 24 appears a
paper entitled “Blood Sugar versus Urinary Sugar" by Dr.
Anthony Sindoni Jr. The author states that:

In view of the high incidence of disturbed carbohydrate metabolitia
frequently escaping detection by examination of the urine for sxigar an
the serious consequences resulting therefrom, blood sugar estimation?,
fasting and after meals, should be indispensable in early and » a «i
recognition of the blood sugar disturbances: .

(c) They should be the governing factor in guiding the insulin dose an
diabetic treatment. ,

(6) Control of the hyperglycemia, not the glycosuria, should he
paramount aim of diabetic treatment.

The estimation of blood sugar levels is indispensable in the
recognition of early and latent diabetes, but once the diagnosis
has been made there is a question as to the relative value o
Dlood sugar determinations. Diabetes mellitus is a metabolic dis-
:urbance not only of carbohydrates but also of proteins and fats,
tnd in evaluating blood sugar levels one must be cognizant o

1. The glycogenetic and glycogenolytic mechanism of the lner.

In diabetes mellitus the glycogenolytic mechanism in particular
plays an exaggerated role. . .

2. That hypoglycemia affects glycogenolysis in the liver. Bus
is an attempt to restore the blood sugar to its former k u -
Overstimulation of this glycogenolytic mechanism results >«-
quently in hyperglycemia and glycosuria. “Hypoglycemia beg
hyperglycemia" (Somogyi).

3. That glycogen is always removed from the liver dun s
periods of hypoglycemia (Cori).

4. That glycogen can be stored in the liver only when
blood sugar level is augmented (Cori). .

5. That ketone bodies are formed chiefly in the liver on
when glycogen stores of the liver are depleted.

Volume 113
Number 19

QUERIES AND MINOR NOTES

1753

6. That there is a relative constancy of the respiratory quotient
of well regulated diabetic patients although there is a wide
fluctuation of blood sugars during the twenty-four hour period
(Bridge and Winters).

Thus the mechanism that controls the rates of glycogenesis
and glycogenolysis must be stabilized to avoid periods of hypo-
glycemia leading to glycogen depletion in the liver and ketosis.
The latter is frequently followed by periods of hyperglycemia
and glycosuria. Blood sugar levels within the so-called normal
range may represent true hypoglycemic levels for diabetic
patients. Hj'poglycemic shock has been observed in diabetic
patients with sugar content of the blood as high as from 120
to 180 mg. per hundred cubic centimeters of blood (Grafe).
This same observation has been made by Mann and Magath in
experimental depancrcatized hepatcctomized dogs.

While the harmful effects of hypoglycemia have been repeat-
edly demonstrated, those of hyperglycemia without ketosis are
highly theoretical. In the management of diabetic patients it
is advisable to adjust their diets and dosage of insulin so that
a slight trace of glycosuria is maintained throughout the day,
thus avoiding the possibility of hypoglycemia consistently. In
this day of high carbohydrate diets it is felt that if the diabetic
patient constantly utilizes a minimum of 90 per cent of the
ingested carbohydrate he is in constant positive carbohydrate
balance and is in no danger of ketosis. The respiratory quotients
in these patients are high and approach the normal. It is felt
that if any one factor is of prime importance in the welfare
and management of the diabetic patient it is the state of liver
glycogen, and no true indication of the state of liver glycogen
can be obtained from blood sugar estimations in diabetes

melhtus. Zolton T. Wirtschafter, M.D., Cleveland.

“DENTAL CARIES AND DOMESTIC
WATER SUPPLIES”

To the Editor : — I was much pleased with and interested in
the editorial "Dental Caries and Domestic Water Supplies"
(The Journal, September 16, p. 1132). I have had occasion
to watch your part in this story of the relation of fluorine to
dental conditions.

Only recently I have been shown “An Address on Tooth
Culture” by Sir James Crichton-Browne in the Lancet of July 2,
1892. On page 7 is a paragraph discussing fluorine and dental
caries in which he advises a supply of fluorine for child-bearing
women so as to “fortify the teeth of the next generation.” An
enthusiastic follow-up on Sir James’s suggestion at that time
might have yielded some human experimental evidence of the
causes of mottled enamel, so it is perhaps fortunate that such
an application was not then made.

In your own columns may be found at least three items on
fluorine and its relation to dental caries, one in the editorial
columns Nov. 7, 1931, page 1389, and two in Queries and Minor
Notes, Jan. 27, 1934, page 315. and June 9, 1934, page 1964.

An important paper which has received little attention is that
of W. D. Armstrong and P. J. Brekhus entitled “Possible
Relationship Between the Fluorine Content of Enamel and
Resistance to Dental Caries" (J. Dent. Research 17:393 [Oct.]
1938). Their analytic data are evidence from an entirely dif-
ferent angle of the relation of fluorine to dental caries.

My associates and I have experimental evidence contained in
a paper to be published in the Journal of Dental Research that
fluorine added to the diet of pregnant rats results in increased
caries resistance in the young. This is an experimental approach
which shows that fluorine is responsible for the increased resis-
tance to caries, as it was the sole variable in our procedure.
Our work on fluorine has been mentioned in the last three
annual reports of the director of the Mellon Institute published
in the “News Edition” of Industrial and Engineering Chemistry.

It seems therefore that, with three different lines of evidence
of this beneficent dental effect of fluorine, namely the Galesburg-
Quincy survey of Dean and his associates, the analytic data of
Armstrong and Brekhus and our experimental evidence, the
case should be regarded as proved.

Gerald J. Cox, Ph.D., Pittsburgh.

Senior Fellow, Mellon Institute of Industrial
Research, University of Pittsburgh.

Queries and Minor Notes

The ANSWERS HERE rUBLISHED HAVE EEEN FRErAKED BY COMPETENT
AUTHORITIES. THEY BO NOT, HOWEVER, RETRESENT THE OPINIONS OF
ANY OFFICIAL BODIES UNLESS SPECIFICALLY STATED IN THE REPLY.

Anonymous communications and queries on postal cards will not
re noticed. Every letter must contain the writer’s name and

ADDRESS, BUT THESE WILL RE OMITTED ON REQUEST.

PLEURAL PAIN AND PNEUMOTHORAX

To the Editor : — A man aged 32 has hod artificial pneumothorax treatment
of the right lung for the past six years. Previous to collapse therapy
he had a pulmonary hemorrhage, the sputum was positive for tubercle
bacilli and x-ray studies showed evidence of a moderately advanced lesion
of the right lung with no apparent cavities. A short time after artificial
pneumothorax was established, fever and cough subsided and the sputum
became normal, as it has continued up to the present. Since a supple-
mentary year of rest, the patient has been engaged in a suitable occupa-
tion. About six months after institution of pneumothorax, approximately
a pint of pleural effusion developed, reaching to the fifth rib anteriorly.
The fluid was not removed and remained in the pleural cavity for two
years, when it suddenly absorbed, leaving x-ray evidence of "fibrin
bodies" at the base of the thorax. The lesion in the lung is apparently
healed, and at present and for several years there have been no indica-
tions of activity. However, there is this difficulty: If the patient does

not have a refill every ten days, the pleural surfaces, which are appar-

ently thickened, rub together and produce a mechanical pleuritis, which
causes the temperature to rise as high as 100 or 101 F., with nausea and
general malaise, the lung being in approximately 60 to 70 per cent

collapse according to fluoroscopic and x-ray examinations. After a refill
of from 400 to 500 cc. of air the fever subsides together with the

pleural rubbing, and in a day or two ail symptoms are gone. The patient
is anxious to discontinue pneumothorax treatments because they are no
longer needed to control the tuberculosis, but the complication mentioned
prevents this. Can any procedures be instituted to alleviate this com-
plication? Are there any studies in the literature on this phase of
pneumothorax? What would you suggest as a possible way of discontinuing
collapse without having these symptoms? Is it possible that fluid would
develop and cause subsidence of symptoms, with eventual absorption
permitting reexpansion of the lung? Would a nonirritating oil in small
amount such as is used in oleothorax lubricate the pleural surfaces and
thus prevent the pleural friction? Any suggestions or references will be
greatly appreciated. M.D., Pennsylvania.

Answer. — From the statements made it is assumed that
friction rubs can be elicited over some part of the chest while
tiie lung is still collapsed to 60 or 70 per cent of its volume.
Thus it is assumed that the visceral and the parietal pleura are
coming in contact at one or more points. Alter pleurisy with
effusion, it seems probable that the pleura contains tuberculous
lesions which cause no symptom as long as the lung is under a
fairly complete state of collapse. The lesions may be anywhere
over the surface of the pleura ; that is, they arc not necessarily
limited to the area over the pulmonary disease. The mechanical
effect of the two layers rubbing together in the region of pleural
lesions may be sufficient to cause the symptoms. Again, the
reexpansion of the lung to 60 or 70 per cent of its volume
may result in enough stretching of the visceral pleura to reac-
tivate lesions in it, even though it is not in contact with the
chest wall. In fact, too rapid stretching of the pleura in reex-
pansion may cause its rupture. The pulmonary lesion may also
be reactivated by expansion if it is not sufficiently fibrosed.

It is possible that reducing the amount of air of the ten day
refills to 100 or 200 cc. might allow the lung to expand more
gradually and thus prevent the symptoms, as this amount would
be sufficient to reduce the negative intrapleural pressure. If
this does not suffice, temporary interruption of the right phrenic
nerve so as to paralyze and elevate the diaphragm, thus reduc-
ing the size of the pleural cavity, might he given a trial. Fol-
lowing temporary interruption, the nerve fibers regenerate in
approximately three months. If this procedure aids in prevent-
ing the symptoms, it could be repeated one or more times if
necessary, while the lung is being expanded.

, T X intr ^ cl tion tfstertfe olive oil or liquid petrolatum tip
to 10° or 200 cc. might suffice while the lung is reexpanding.
Uil has a strong tendency to cause thickening of the pleura since

1754

QUERIES AND MINOR NOTES

Jour. A. J[. A.
Nov. 4,- I9J9

it is a mild irritant, and therefore it should not be left in the
pleural cavity more than a few months at a time. In some cases
it causes so much change in the visceral pleura that it becomes
impossible for the lung ever to reexpand.

There is the possibility that fluid will form again if the symp-
toms are permitted to continue, that is, if no air is introduced.
In some such cases empyema develops ; therefore it would seem
safer to employ the procedures outlined.

If from these various procedures no relief from symptoms is
experienced as the lung reexpands, it is probably safer to keep
the lung collapsed by pneumothorax to the point just below the
appearance of symptoms over a longer period, so that in case
there are still lesions in the pleura, which are easily activated,
they will be given a better opportunity to come under control.

EAGLE FLOCCULATION TEST

To the Editor : — Will you pleass send me information about the Eagle
flocculation test for syphilis: 1. What is its present standing as an
authoritative laboratory test? 2. In what respects is it superior to the
Kahn test on (a) untreated and on (i>) treated patients? 3. In what
physical conditions are false positive reactions likely to be found? 4.
Do you advise its substitution for the Kahn test or its use as a check
on the Kahn test in a laboratory which employs no pathologist?

M.D. Florida.

Answer. — 1. The Eagle flocculation test has been desig-
nated by the American Serologic Committee as a reliable lab-
oratory procedure for the detection of syphilis.

2. With regard to treated and untreated syphilis, it is impos-
sible at the present time to discuss the superiority of either
the Eagle flocculation or the Kahn precipitation test, principally
because of the small number of cases on which an authoritative
evaluation has been made from this standpoint. Studies thus
far, however, seem to give the two tests an approximately
equal rating.

3. From the evaluation studies conducted in cooperation with
the United States Public Health Service in 1935, and in the
experience of various serologists, it has become recognized that
flocculation tests in general may give appreciable numbers of
false positive results in leprosy, yaws and malaria. In occa-
sional instances false positive results may be encountered in
tuberculosis, relapsing fever, infectious mononucleosis, gono-
coccic, pneumococcic and streptococcic infections, jaundice and
malignant conditions and rarely even in a person without
recognizable disease.

4. Since the evaluation studies of the United States Public
Health Service reveal that both the Eagle and Kahn tests are
efficient procedures for the detection of syphilis from the stand-
point of sensitivity and specificity when performed in reliable
laboratories, by properly trained technicians, there should be no
valid reason for substituting either test for the other. To use
the one procedure as an intralaboratory check on the other,
however, obviously would be of merit.

PARALYSIS AFTER RABIES VACCINE

To the Editor : — Please give me symptoms, prognosis and treatment of a
condition called peripheral paralysis caused by the use of rabies vaccine.
All I can find in Meakin's Practice of Medicine is "There is no proven
explanation for such, and they are principally of an academic interest."
It happens once in 5,000 inoculations. However, it is important from
the patient's point of view. E. M. Ling, M.D., Hemlock, Mich.

Answer. — The latest figures on the occurrence of postvac-
cinal paralysis from the Bulletin of the Health Organization of
the League of Nations showed the frequency of paralysis in
patients receiving Pasteur antirabic treatment to be thirteen
among 121,000 treatments, or one in 10,729. For the entire
eight reviews the proportion of accidents has been one in 5 ,441,
or 139 out of 756,000 treatments. It is now readily apparent
that killed phenol, heated, and killed ether methods of preparing
the vaccine are alike satisfactory regarding the incidence of
accident. Nearly all patients have been adults. Two thirds had
the onset during treatment and one third soon after its termina-
tion. The time of onset has been from eleven to thirty days
after the bite for which the treatment was given. This is a
much shorter period of incubation than that for- rabies. The
incubation • period of the latter is usually from forty to sixty
days. Three clinical types may be distinguished :

Type 1, acute ascending paralysis of Landry. The onset is
sudden, with fever, headache, vomiting, severe backache, insom-
nia and restlessness. The following day the legs are weak and
in one or two more days the paralysis is apt to be complete.
The sphincters are also paralyzed. Pain, which is usually
present in the back, extends upward into the neck and chest,
and then the arms become paralyzed. This is followed by pains

in the face and paralysis of the throat (bulbar) and face. The
prognosis in this type .is grave because of. bulbar paralysis
(respiratory and circulatory arrest). The mortality is about 30
to 40 per cent.

Type 2, dorsolumbar, myelitis. The onset is gradual and the
fever at first is slight. The legs become completely paralyzed
and anesthetic. The sphincters are also involved. The tendon
reflexes are lost but occasionally there is a Babinski sign. There
are no bulbar signs. Recovery usually occurs in the course of
several weeks unless bed sores and urinary tract infection result
in lowering- the resistance and causing death by sepsis.

Type 3, neuritic form. After a brief febrile period one- or
more peripheral nerves become involved and cause paralysis.
The facial nerve is by far the most frequently concerned. The
facial paralysis may be unilateral or bilateral. Other nerves
that may become affected are the oculomotor, vagus, radial,
ulnar and sciatic. Rapid recovery is usually the rule. The
treatment is essentially that of any acute infection, with absolute
rest, forcing of liquids and aseptic care to bed sores and urinary
abnormalities. The neuritic forms may be treated with local
massage and galvanic current after the period of acute involve-
ment. This usually occurs after the second or third week when
the temperature is normal. The patient should be placed on an
air or water mattress. Foot and wrist drops should have proper
immobilization. Vitamins Bi, B 2 and C should be given.

At the present time the various ty'pes of paralysis following
administration of antirabies vaccine are supposed to be due to
the vaccine itself and not to be original rabic infection.

FORDYCE'S DISEASE OF THE VULVA

To the Editor : — A young unmarried woman complained of itching of the
labia minora. On examination I found a series of closely packed, pin-
head size, light yellow papular lesions. . The picture to a certain
degree resembles Fordyce's disease of the mouth in that it consists of
innumerable tiny faintly yellow lesions. There is a certain amount of
itch, but it - is not intolerable. There is no history in this_ case of
syphilis, diabetes. Trichomonas vaginalis, gonorrhea, masturbation, con-
traceptives or the local application of irritating ointments. It is the
first time that I have ever seen this condition and for all I know it
may be common, but I would greatly appreciate your opinion os to the
diagnosis. William J. Macdonald, M.D., Boston.

Answer.— It is probable that this young woman does, indeed,
have Fordyce’s disease of the vulvar mucous membrane.
Fordyce’s disease may occur in this situation as well as in
the mucous membrane of the lips and mouth. A noninflam-
matory dermatosis consisting of yellow, discrete puncta on the
vulvar mucous membrane and in the mouth would not ordinarily
fit in with any other entity'. A peculiar type of localized
'xanthomatosis might be considered, but its presence is not
likely. Of course, a biopsy' would settle the question. Histo-
logically, masses composed of cells resembling those found in
sebaceous glands are found in Fordyce’s disease.

Fordyce’s disease is devoid of sy'mptoms, the lesions gener-
ally being found accidentally. In consequence, the itching
present must be accounted for on some other grounds. A
moderate amount of pruritus of the vulva and anus is no
rare, the causes of which are diverse. Some of these, suet
as Trichomonas vaginalis, the inquirer has not found P rese '!;
It is assumed that no local cause for the itching can be mun ,
otherwise that should be corrected. ,

Pruritus vulvae at the menopause and later may' be due
changes in the secretions of the endocrine glands. A genera
examination should be made to rule out such possible cans
as diabetes or nephritis. ,

If no disease process can be found to account for tnc “C -
ing, local measures may' be used for symptomatic rebel o
itching. Nothing need be done for the Fordy'ces p'sea. •
Application of an antipruritic lotion, oil or ointment is i
cated. The usual antipruritics are used, such as ’

menthol and camphor-chloral. These may be employee
somewhat higher concentration than when their general aPP
cation is required. Applications of moist dressings ot 'V .
as hot as can be borne may at times tide one over an it =
crisis. Painting with a 10 per cent aqueous solution ot -
nitrate may be done once or twice a week. The most
tive nonspecific agent for vulvar pruritus is the x-ray.
care should be used not to go beyond a tolerance dos
fear of inducing a radiodermatitis. One_ fourth ot a uni
a week for several weeks is sufficient in many cases. ,

recommend local injection of such materials as aim t
quinine and urea hydrochloride. These measures are - . '

indicated and may prove dangerous. A certain expert enc
them is required. In exceptional cases surgical measure
been employed, but most observers arc not in favor ot

Volume 113
Numues 19

1755

QUERIES AND MINOR NOTES

UREA AS DIURETIC

To the Editor:— I would appreciate any information that you may be able

to give me as to the use of urea for elimination in cardiac decompen-
sation. H. 5. Rosenberg, M.D., Franklin Square, L. I., N. Y.

Answer.— The use of urea as a diuretic in cardiac insuf-
ficiency as well as in renal disease was established about twenty
rears ago in German clinics. The first careful clinical study
in the United States was reported in 1925 (Crawford, j. H.,
and McIntosh, J. F.: Arch. hit. Med. 36:530 [Oct.j 19_5).
Since then urea has achieved only moderate popularity as a
diuretic and in recent years has been largely displaced by- the
organic mercurials and acid-forming salts. The reasons for
this are the limited diuretic effect of urea and its unpleasant
taste. The mechanism of its action was recently discussed in
Queries and Minor Notes (Urea as Diuretic, The Journal,
June 4, 1938, p. 1945).

It is necessary to give from 30 to 60 Gm. of urea daily to
produce diuresis. The 40 or 50 per cent aqueous solution may
be diluted with an equal volume of some fruit syrup or taken
in carbonated water, beer, tomato juice, coffee or tea. The
daily dose is best divided into three portions, given after meals.
The salt and fluid intake should be limited in order to favor
the removal of edema fluid by the osmotic action of the extra
urea. Since urea can readily be ingested as a 20 per cent solu-
tion but concentrated by the kidney to only 4 per cent as a
maximum, diuresis will occur provided renal function is unim-
paired. That urea has no deleterious effect even when taken
daily for months or years has been fully demonstrated (Miller,
H. R., and Feldman, A.: Arch. bit. Med. 49:964 [June] 1932).
It may be advantageous to combine the administration of urea
with the use of other diuretics, such as the organic mercurials.
Urea is especially helped in preventing the recurrence of
cardiac edema after the original dropsy has been controlled by
rest, digitalization and ordinary diuretic management. For this
purpose a dose of from 15 to 30 Gm. a day may be sufficient.
In general, the use of urea will be determined by the patient's
gastrointestinal tolerance for the drug.

COCONUT MILK AND DIABETES

To the Editor : — Con you give me any information regarding the value of
coconut milk in the treatment of diabetes meiiitus or refer me to the
literature on the subject? M.D., New Jersey.

Answer. — The composition of coconuts and coconut milk is

as follows : Carbohydrate, Protein, Fat, Calories

per Cent per Cent per Cent per 100 Gm.

Coconuts 27.9 5.7 50.6 590

Coconut mnk 4.6 0.4 1.5 34

As may be seen, coconuts are rich in fat and high in calories
despite a relatively low carbohydrate content. Coconut milk
is low in carbohydrate and in calories. These facts may be
responsible for a reputed value of these foods in diabetes. No
other information on the subject has been found.

Reference :

Josliti, E. P. : Treatment of Diabetes Meiiitus, Philadelphia, Lea &
Febiger, 193", p. 6S1.

LEAD CONTENT OF CRAYON CHALK

To the Editor : — Recently there have been articles commenting on lead
poisoning resulting from the use of cholk containing lead chromate. In
this connection some of the crayon companies state that their chalk is
nontoxic. Have you any data proving whether or not chalk may have
small amounts of lead and still be nontoxic? As 1 understand lead
poisoning, lead is cumulative. Therefore a person exposed to lead,
either by inhaling dust or by nibbling chalk containing lead even though
in small amounts, would possibly be accumulating enough lead actually
to cause poisoning. The points that I would like to have answered are:
What amount of lead in chalk would be toxic, or would chalk have to
be absolutely free of lead to be considered nontoxic?

Malvin J. Nydahl, M.D., Minneapolis.

Answer. — In 1937, C. M. Jepbcott (Lead in Certain Coloured
Chalks and the Danger to Children, Caimd. Pub. Health J.
28:391 [Aug.] 1937) reported finding high concentrations of
lead chromate in yellow, orange and green crayons but no lead
in other colored chalks. Chalks recently analyzed by the
Massachusetts State Division of Occupational Hygiene, under
the direction of Manfred Bowditch, were found to contain
between 2.2 and 1S.7 per cent of lead. These high percentage
chalks would seem to be definitely undesirable for children
to use, particularly because of the dust which they produce.
Crayon manufacturers are now cognizant of this risk, and it
is believed that this high lead content already has been elimi-
nated from some colored chalks. One cannot say exactly how
much lead would be permissible in that chalk. The factor of
importance is the amount of lead present in the air which is

breathed. A larger percentage of lead in chalk would be safe
if blackboards were cleaned with water rather than with the
dust-producing eraser. The usual safe limit of daily lead
absorption is stated to be about 2 mg. a day in breathed air.
Somewhat larger amounts could be taken by mouth without
deleterious effects. Therefore chalk would not have to be
absolutely free of lead to be considered nontoxic, but it ought
not contain a large percentage of lead. Certainly the high per-
centage now found in some chalk should be reduced, no matter
what chemical compound of lead is employed.

EFFECT OF SULFANILAMIDE ON GONOCOCCI

To the Editor : — It hos repeatedly been stated that the use of sulfanilamide
in the treatment of gonococcic infections may alter the morphologic appear-
ance of the gonococcus. A detailed report of the changed appearance of
the sulfanitamidized gonococcus os observed microscopically would be appre-
c 'dt e d. Heinrich lamm, M.D., La Feria, Texas.

Answer. — Under sulfanilamide therapy the slide characteris-
tics of both gonococci and secondary organisms become unusu-
ally irregular. Size, shape, relationship to pus and epithelial
cells and to a lesser extent staining characteristics change. The
organisms may become unrecognizable and confused with one
another. There are more extracellular organisms and the pus
cells confusingly contain what may be a single organism or
pair of organisms, a fragment of nuclear material or merely
debris. The gram-negative short coliform bacilli' in the early
division stage can easily pass for gonococci. They may be
intracellular.

The most reliable diagnostic criteria are cultural. Atypical
gonococci always revert to type when implanted on suitable
soil, whether it is a laboratory medium or the uriuogenital
epithelium.

POSSIBLE SCIATIC OR PERINEAL HERNIA

To the Editor : — Please suggest possible diagnoses or diagnostic procedure
in the following case: A white woman aged 36, 5 feet 6 inches {168
cm.) tall, weighing 235 pounds (106.6 Kg.), complains of a large "fump"
present on the upper outer quadrant of the left buttock. This “lump" is
transient, appearing within a space of a few hours, persisting for several
hours or days and finally disappearing as rapidly as it came. It has
been present intermittently for the past six months. The time of appear-
ance does not seem to be influenced by activity. There is some pain
associated with this mass — at times referred medially to the region of
the sacroiliac joint and at other times anteriorly to the groin. There
is moderate discomfort on walking because of its size. The past history
reveals three normal pregnancies, no miscarriages and no previous infec-
tious diseases. She has complained of some pain in the left thigh of
an indefinite nature for years. About six months before this swelling
made its appearance she had a large carbuncle on the left knee. This is
entirely healed at present. Physical examination reveals nothing of
interest other than marked generalized obesity. On the upper outer
quadrant of the left buttock is a swelling the size of a large grapefruit.
There is no discoloration or fluctuation. It is apparently a muscular
swelling and is only slightly tender. The upper edge reaches the crest
of the ilium posteriorly. The temperature, pulse, blood pressure, urine
and blood count are normal and the Wassermann reaction is negative.
X-ray examination of the hip joint and adjacent structures revealed no
pathologic condition. The patient was seen a day later. She stated
that the mass had disappeared during her sleep the night before. Exami-
nation then showed no deviation in the normal contour of the buttock.
About two days later, however, the patient returned with the mass
present again; it had appeared that morning while she was baking and
looked essentially the same as before. M.D., Pennsylvania.

Answer, — This is an unusual case and certainly warrants
careful study. The transient nature of the swelling excludes
neoplasms of the soft part. Moreover, x-ray examination
excludes neoplasms originating from the bone. It would seem
that this swelling must be either some type of hernia or a fluid
collection .which has an hour-glass shape permitting the fluid
to go back and forth from one to the other of two compart-
ments. Hernia seems the more likely explanation, although the
situation high on the buttock is hard to explain.

About thirty cases of' sciatic hernia have been reported. In
this condition the hernia emerges from the pelvis through the
sacrosciatic notch and protrudes into the folds between the
buttock and the leg (Andrews Edmund, in Textbook of Surgery
Frederick Christopher, editor, Philadelphia, W. B. Saunders
Company, 1936). This type of hernia is best repaired by laparo-
tomy, and great care should be exercised to avoid injury to the
sacral plexus.

In_ perineal hernia the herniation is through the pelvic floor
but m the posterior type of this hernia it emerges behind the
transverse perineal muscle. It is possible that one of these two
rare types of hernia may explain the condition. Help to sub-
stantiate the diagnosis of hernia might be obtained by the x-ray
film showing gas bubbles in the soft part as of loops of small
intestine. Or, if an x-ray film of the gastrointestinal tract could

1756

QUERIES AND MINOR NOTES

be taken when the swelling is present it might show barium-
filled loops outside the pelvis. Aspiration would seem to be
somewhat risky.

A rupture of the insertion of the gluteus muscle with bunch-
ing up of this muscle toward the crest of the ilium might be
considered, but this would be constantly present with every
effort to contract the gluteus.

After all other efforts at diagnosis have been exercised, this
case would warrant surgical exploration from the outside.

DIGITALIS AND EPHEDRINE

To the Editor : — In The Journal, May 16, 1931, Johnson ond Gilbert advised
that "when digitalis is being used for the heart, ephedrine should not be
used or with extreme caution." Has this been substantiated by other
observers? Lutcn in his book The Clinical Use of Digitalis (Springfield,
ilk, Charles C. Thomas, 1936) mentions Johnson and Gilbert's statement,
p ° 9 ° 127 ‘ H. B. Aitkens, M.D., Le Center, Minn.

Answer. — The work of Johnson and Gilbert has neither been
confirmed nor denied. It would only rarely be of importance
clinically. Clinical doses of digitalis seldom reach SO per cent
of the minimal lethal dose. The lethal dose of ephedrine in the
anesthetized dog is 70 mg. per kilogram, but in the unanes-
thetized dog it is about 40 mg. per kilogram. It is improbable
that any clinical dose of ephedrine could possibly approach half
this figure. On the other hand, if enough digitalis had been
given to increase the irritability of the cardiac muscle up to
a certain point, a moderate dose of ephedrine might further
increase irritability and result in ventricular fibrillation and
death. Digitalis, of course, should never be given to such a
point.

The experimental work indicated a definite synergistic action
between the two drugs. While fatal results clinically would
be unlikely, except with a dosage of either drug which would
never be necessary and which should never be used, it is just
as 'well to bear in mind that experimental work does show a
definite synergism, and they should be used with a moderate
degree of caution.

EFFECT OF HIGH INTRACRANIAL PRESSURE ON
PULSE AND BLOOD PRESSURE
To the Editor : — What influence docs a rise in intracranial pressure of from
400 to 800 mm. of water have on the pulse rate and blood pressure?

The literature is contradictory. Do you know any references fo reports

of cases, traumatic or otherwise, characterized by (1) a high cerebrospinal
fluid pressure (but not high enough to approach the level of the systolic
blood pressure), a lowered pulse rate and a rising blood pressure and
(2) a return of pulse rate and blood pressure to normal when the intra-
cranial pressure has been sufficiently reduced? M.D., New York.

Answer. — In the presence of increased intracranial pressure
the pulse is usually, but not always, slow until the breaking
point of compensation, when it becomes increasingly rapid. In
many instances, however, the pulse rate is not affected. The

blood pressure is usually not altered but at times is increased

slightly when the rise in pressure is sudden or rapid. The
bradycardia will return to normal within a week or two after
relief of intracranial pressure. There seem to be no precise
records on this point, but the facts as given are well recognized
in all clinics where intracranial pressure is commonly seen in
the presence of tumors or cranial trauma.

DERMATITIS FROM ROCK WOOL

To f/io Editor : — Do you have any information concerning a dermatitis
occurring among insulators who handle rock wool? What type of der-
matitis is most common and is there definite evidence that the rock wool
is the etiologic factor? What have been the most successful means
of preventing this dermetitis? In other words, if there have been any
reports of such a dermatitis 1 would appreciate learning as much about
it as possible. Ralph E. Jones, M.D., Chicago.

Answer. — Rock wool, slag wool, slagbcstos or mineral wool
is made by blowing air and steam through iron blast-furnace
molten slag or through natural siliceous limestone or calcareous
shale rocks when in a molten state. This converts the slag or
rock into fine threads like cotton wool which are insect and
fire proof. The product is used as an insulating material, a
filtering medium, a covering for steam pipes and for packing.

Occupational dermatitis attributed to rock wool and confirmed
by positive patch tests has previously been reported to the Office
of Dermatoses Investigations of the U. S. Public Health Ser-
vice. The irritating properties of this substance arc said by
R. Prosser White (The Dcrmatergoses or Occupational Affcc-

Jour. A. SI. A.
Nov. 4, 1939

t'° n , s . of Skin, ed. 4, London, H. IC. Lewis Company, Ltd,
iyd4) to be due to its content of quicklime, 10 per cent and
calcium sulfide, 5 per cent, as well as to spicules which it
contains. Its dust is said to be irritating also to the mucous
membranes of the nose and eyes.

Since its alkaline content and the spicules it contains are said
to be the causes of dermatitis from this material, it would seem
that the wearing of rubber gloves and dust-proof clothing, with
frequent changes of work clothes and cleansing shower baths
after work, would offer the best protection against this occupa-
tional hazard to the skin. The use of protective ointments,
especially those which are said to give protection against alkalis,
may also be of benefit.

MIGRATION OF TESTES

To the Editor : — A boy now 10 years of age was seen shortly after birth, at
which time he had an undescended right testis with the left testis in
the scrotum. A few months later there was torsion of the right testis
with gangrene, requiring its removal. I saw the boy recently and the
left testis was still in the scrotum and was about the size of a pea.
The mother showed me his brother, aged 7 years, whom I also saw ot
birth, and I know that both testes were normal at that time and were
in the scrotum. When I saw the boy yesterday neither testis could be
palpated and there was no evidence of any hernia. The youngest son,
aged 4 years, has a small left testis with no evidence of a right testis.

I know likewise that at birth he had both testes in the scrotum. I
should like advice as to the prognosis and treatment.

M.D, Massachusetts.

Answer. — With regard to the boy aged 10 years who had
one testis removed for gangrene because of torsion, as long as
the left testis is in the scrotum one should do nothing and
merely keep the boy under observation. It would be desirable
to have the boy see bis physician once a year.

With regard to the boy aged 7 years, in whom the testes
were normal and in the scrotum at birth, it is stated that the
physician saw the boy recently and neither testis could be pal-
pated. It is well known that in some patients the testes do
retract and move up and down — a phenomenon that has been
recognized for a long time. It is failure to recognize this which
leads to erroneous diagnoses. Some of these patients are pre-
pared for operation for undescended testes, and just before
the operation is started the testes are found in the scrotum. In
several observed instances in which the testes moved up and
down they ultimately found their way into the scrotum and
stayed there.

The same explanation will suffice for the boy aged 4 years.
He should be kept under close observation. Some patients who
belong to this group and in whom this condition is not recognized
are given long courses of endocrine treatment and the descent
of the testes is erroneously ascribed to the use of the endocrine
substance. _ t

To sum up, these boys should report to the physician’s office
once a year. Nothing should be done in a surgical way and
certainly they should not be given endocrine therapy.

TABES WITH NEGATIVE SEROLOGIC REACTIONS OF
THE BLOOD AND SPINAL FLUID

To the Editor : — Is it possible fo hove syphilis of the control nervous
with repeatedly negative Wassermann and Kahn reactions of the bloo
since childhood and a spinal fluid in which the cell count is 1 and ■ c
colloidal gold curve and the Wassermann reaction arc negative and giobuu
normal? The patient has a fixed, dilated right pupil, the knee jerks ore
absent, the Romberg sign is absent, there are questionable saber sfn »
there is a backache with questionable root-pain type of radiation and s -
is married to a man who has tabes but who was treated moderately beto
marriage. M.D., New Jersey.

Answer. — It is possible, in fact it is noted quite frequently
in a syphilologist’s practice, that patients with clinical signs ot
tabes dorsalis will have negative reactions of the blood and
spinal fluid. These are known as “burnt out tabetics” and the
negative serologic reactions may have developed in one or t\vo
ways, either as the result of treatment or spontaneously. I ‘j c
latter group are less numerous and, although these serologic
negative reactions developed without treatment, the use ot
arsphenaminc' and bismuth compounds does not control the
persistent symptoms such, for example, as the neuritis of tabes.
The evidence presented in the inquiry is not enough on wine
to base a conclusive diagnosis of tabes, since some neurologist
believe that such suggestive clinical manifestations might t>
the residue of a nonsyphilitic inflammatory lesion of the centra
nervous system. The fact that the husband has tabes increase
the possibility that the patient under discussion may have liau
syphilis. Even so there is little that can be d one for her, since
antisvphilitic therapy in such cases offers but slight relict.

JfptWAfE U?
XVitDER ' -

19

Medici] Ex ^in AT io n

^notions ^ Licen

c °m,ng T^r ** lce nsure

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'■ (1938)
■(1937)
0938)
(1937)

Illinois

ft*nsas

fffinois

i^'no/s

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Dr , 'V. p*J»«o 0P n ’ ■ Dr ‘ J°hn Green""' °

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1758

BOOK NOTICES

Jour. A. M. A.
Nov. 4, 1939

Universitat Basel Medizinische Fakultat (1936) 80.4, 80.4

Universite de Lausanne Faculte de Medecine (1936) 82

Vpir Per

School " ILED Grad. Cent

Medizinische Fakultat der Universitat Wien (1924) 74.1

Universite de Montpellier Faculte de Medecine (1933) 73.3

Albertits-Universitat Medizinische Fakultat, Konigsberg. . (1922) 73.9

Christian-Albrechts-Universitat Medizinische Fakultat,

Kiel (1900) 72.9

Friedrich-Wilhelms Universitat Medizinische Fakultat,

Berlin ....(1911) 73.5, (1929) 74.5

Ludwig-Maximilfans-Universitat Medizinische Fakultat,

Munchen (1912) 72.4

Vcreinigten Friedrichs-Universitat Medizinische Fakultat,

Halle-Wittenberg (1921) 73.2

Regia Universita degli Studi di Genova Facolta di

Medicina e Chirurgia (1924) 72.6

Regia Universita degli Studi di Modena Faculta di

Medicina e Chirurgia (1934) 70.9

Regia Universita degli Studi di Roma Facolta di Medi-
cina e Chirurgia (1936) 68.8

Universite de Lausanne Faculte de Medecine (1938) 72

* These applicants have completed the medical course and will receive
the M.D. degree on completion of internship. Licenses have not been
issued.

t These applicants have received the M.B. degree and will receive the
M.D. degree on completion of internship.

Virginia June Examination

Dr. J. W. Preston, secretary, Virginia State Board of Medi-
cal Examiners, reports the written examination held at Rich-
mond, June 21-23, 1939. The examination covered eight subjects
and included eighty questions. An average of 75 per cent was
required to pass. One hundred and three candidates were
examined, 102 of whom passed and one failed. The following
schools were represented:

School PASSED

George Washington University School of Medicine

Howard University College of Medicine

Tulane University of Louisiana School of Medicine...

Harvard Medical School

Hahnemann Med. College and Hospital of Philadelphia

Jefferson Medical College of Philadelphia

Temple University School of Medicine

Medical College of Virginia (1936) 88, (1939) 75, 78,
80, 81, 82, 82, 82, 82, 82, 82, 83, 83, 83, 84, 84, 85

85, 85, 85, 85, 86, 86, 86, 86, 86, 87, 87, S7, 87, 87

88, 88, 88, 89, 90, 91

University of Virginia Department of Medicine (1938)
77, 78, 78, 79, 80, 80, 80, 81, SI, 81, 81, 82, 82, 82

82, 82, 82, 83, 83, 83, 83, S3, 83, 83, 83, 83, 83, 83

S3, 83, 84, 84, 84, 84, 84, 84, 84, 84, 84, 84, 85, 85

85, 85, 85, S5, 85, 86, 86, 87, 90

Queens University Faculty of Medicine

School PAILED

Howard University College of Medicine

Year

Per

Grad.

Cent

(1938)

82

(1938)

SO

(1917)

76

(1939)

80

(1939)

79

(1939)

84

(1939)

84

78, 79, 80,

80,

79, (1939)

76,

(1928)

77

Year

Per

Grad.

Cent

(1938)

73.5

Thirty-four physicians were licensed by reciprocity and seven
physicians were licensed by endorsement on February 10 and
June 23. The following schools were represented:

School LICENSED BY RECIPROCITY £rad.

University of. Arkansas School of Medicine. (1937)

George Washington University School of Medicine. ... (1926)

(1934) Maryland

Georgetown University School of Medicine. ... (1916), (1937)Dist. Colura.

Northwestern University Medical School (1932) Wisconsin

University of Louisville School of Medicine. . (1926), (1935) Kentucky
University of Maryland School of Medicine and College

of Physicians and Surgeons (1917), (1937, 2)

Johns Hopkins University School of Medicine. . (1930), (1935)

Harvard Medical School (1933)

Washington University School of Medicine (1934)

Columbia Univ. College of Physicians and Surgeons. . (1935)

Long Island College of Medicine (1931)

University and Bellevue Hospital Medical College. ... (1904)

(1931) District of Columbia . . .

Duke University School of Medicine. (1932) W. Virginia

University of Cincinnati College of Medicine.. (1938) Ohio

Western Reserve University School of Medicine. (1937) Ohio

Hahnemann Medical College and Hospital of Philadel-

phia (1918) Dist. Colum., (1936) W. Virginia

Temple University School of Medicine (1910)

University of Pennsylvania School of Medicine (1917)

Medical College of the State of South Carolina (1912)

Meharry Medical College (1926)

(1938) Tennessee

University of Tennessee College of Medicine. . (1922), (1935)

Medical College of Virginia * (1938) N. Carolina

University of Wisconsin Medical School (1936) Wisconsin

McGill University Faculty of Medicine.. (1922)

Reciprocity

with

Arkansas
New York,

Maryland
Maryland
New York
Illinois
New York
S. Dakota
New York,

Penna.
Penna.
S. Carolina
Missouri,

Tennessee

Penna.

„ , . LICENSED BY ENDORSEMENT

School

Georgetown University School of Medicine

Harvard Medical School _.»•

Temple University School of Medicine....

University of Tennessee College of Medicine

Medical College of Virginia *•

McGill University Faculty of Medicine

University of Oxford School of Medicine

Year Endorsement
Grad. of
. (1935)N. B.M. Ex.
. (1935)N. B. M. Ex.
(1936)N. B. M. Ex.
.(1929) U. S. Navy
(1917) U. S. Navy
. (1936)N. B. M. Ex.
(1920) Australia

Book Notices

Treatment in General Medicine. Edited by Hobart A, Relmann, M.D.,
Magee Professor of Practice of Medicine and Clinical Medicine, Jef-
ferson Medical College, Philadelphia. In Three Volumes and Desk
Index. Cloth. Price, $30 per set. Pp. 895 ; 1001-1896; 2001-2S34,
with illustrations; 107. Philadelphia: P. A. Davis Company, 1939.

Recognizing that advancement of modern medicine has made
medical problems so highly specialized that it is no longer pos-
sible for one individual to cover completely any single medical
field, Dr. Reimann has developed a system of therapeutics in
which distinguished specialists consider various phases of the
treatment of individual diseases. Since treatment must depend
on knowledge of cause and on symptoms, space is given to these
subjects and also to considerations of other factors in disease
intimately associated with treatment. It is recognized that
psychotherapy is an intimate part of all the treatment of disease,
and special attention is also given to this aspect of medical
care. Finally, the volume includes discussions of minor surgical,
gynecologic and obstetric treatment, as well as a chapter of the
conditions associated with old age. The volumes are important
also because they emphasize standardized and controlled treat-
ment. Thus the remedies concerned are those available through
the United States Pharmacopeia, the National Formulary and
New and Nonofficial Remedies. In line with the recommenda-
tions of standard therapy, the work begins with a foreword hi
the editor of The Journal discussing the basis of scientifii
therapy. Thereafter the volume takes up, in the usual order, thi
treatment of infectious conditions, parasitic diseases, the heart
the blood vessels, the gastrointestinal tract and the genito
urinary tract. There are excellent discussions of prophylaxis
Selected bibliographies indicate to the reader the places for
further detailed study. The list of contributors includes man)
of the best known names in modern medicine. In the final
volume there are chapters on technical therapeutic procedures,
irradiation, all of the various forms of physical and occupational
therapy, and finally chapters on rest and the use of spas. This
is a modern, direct, useful system of treatment.

The Surgical Treatment of Hypertension. By George Crllc. Edited
by Amy Rowland. Cloth. Price, $4. Pp. 239, with 52 Illustrations.
Philadelphia & London: W. B. Saunders Company, 1938.

This work is a conglomeration of theories, facts, fallacies,
scientific and pseudoscientific observations and unwarranted
assumptions, welded together loosely in an unconvincing manner
and in a style in which repetition and reiteration are apparently
used to bolster the faltering argument. The constant assump-
tion of unproved facts and the wide digressions into far Hung
fields of investigation, fields which are evidently unfamiliar to
the author, confuse rather than clarify the subject. Many o
the basic principles on which the flimsy superstructure is bui
are false or are erroneously interpreted. Controversial points
are assumed to be definitely established. One is impressed wit
the apparent superficial knowledge of the author regarding muci
of present day physiologic concepts and especially of the n' nc
tions and modus operandi of the sympathetic nervous system.

Considerable space is devoted to a comparison of the brains,
thyroids, adrenals and celiac ganglions of fish, python, alligator,
lion, tiger and man in the hope of promulgating a general :l ' v
that the size of these organs determines the oxygen requiremen s
and speed of oxygen utilization. “The size of the brain an
the thyroid gland, the adrenal glands, the sympathetic system,
the celiac ganglia, the aortic plexus, the heart, the volume o
blood, the richness of the capillaries — all of these would
governed by a general law of energy release.” It takes c° 1 ’
siderable imagination after reading the entire hook to see J u -'
what this lias to do with hypertension in man. However, exccp
in small mammals and birds, Crile finds, “man is mechanize
for the highest energy requirements of any animal on Ian 0

in the sea.” . . , ,

The next chapter indicates that it is a pathologic physiology
of this mechanism governing the rate of oxidation and t K
culation which produces hypertension. Later he suggests ^ ^
only individuals who have abnormally large celiac gang
and plexuses can have hypertension.

Volume 113
Number 19

BOOK NOTICES

1759

Numerous errors in his concept of the anatomic physiology
of the sympathetic system are evident. Perhaps the most strik-
ing one is his evident belief that the sympathetic impulses to
the entire arterial system are made directly to the aorta from
the overlying celiac ganglion. "This principle of synaptic func-
tions is found in the sympathetic control of the vascular system
by the centralization of all the synaptic functions into one major
end-plate, which is strapped down on the aorta with such a
strength of cordage that in the midst of every kind of fighting,
running, etc., the function would be secure, to the end that
power could be discharged into the great vascular tree with the
sdddenness of a bullet.”

The theories of the surgical treatment of essential hyperten-
sion are discussed at considerable length but apparently without
a firm grasp of the basic principles involved. Other diseases
of the sympathetic nervous system are considered and he states
that “each of these diseases— hyperthyroidism, neurocirculatory
asthenia, Raynaud's disease — are abated or cured by adrenal
denervation or celiac ganglionectomy.”

The technic of celiac ganglionectomy is fully described and
illustrative cases are given in detail. There is also a some-
what inaccurate historical summary of the various surgical pro-
cedures used in the treatment of hypertension.

Three chapters by other members of the clinic are included:
types of arterial hypertension and their recognition by Ernstein,
the ocular examination of the patient with hypertension by
Ruedemann, and the renal lesions in essential hypertension by
McDonald. Ruedemann’s chapter is well worth reading. In
summary he states that adrenalectomy exerts only a temporary
effect on blood pressure, that denervation of the adrenals is
little better, that division of the splanchnic nerves with denerva-
tion of the adrenals produces a more lasting effect, and that the
best result in his hands is secured by bilateral celiac ganglionec-
tomy and adrenal denervation.

Medical Opinions on War. Published on behalf of the Netherlands
Medical Association (Committee for War-Prophylaxis). Paper. Pp. 72,
Neiv York, Amsterdam & London : Elsevier Publishing Company, tn. d.I

This pamphlet, published on behalf of the Netherlands Medical
Association, is a compilation of brief statements by fifteen
physicians representing England, Germany, the United States,
the Netherlands and Sweden, together with a letter to the states-
men signed by 340 leading psychiatrists from twenty nations,
representing Europe, Asia and North and South America. It
sets forth the conviction of the psychiatrists that war is a
psychologic problem and that the solution must be along psycho-
logic and psychiatric lines. The titles include such significant
ones as war and human nature ; the war problem — a psychologic
approach; psychology and peace; imagination and war prophy-
laxis; biologic considerations in the prevention of war; women
and war (by a woman physician) ; war and mass psychology ;
war and nervous diseases; personalities and war; convulsions
of mankind, and back to the land. A common thesis runs through
all these statements, to wit : war is not a necessary expression of
human nature and the world can and must be organized for
peace. Such specific suggestions for the avoidance of war are
included as (1) adequate food and shelter, (2) sufficient air and
light per person, (3) a universal means of exchange, (4) room
for expansion, (S) work programs suited to the capacity and
aptitude of the individual, (6) the constructive use of leisure
time and (7) educational programs developed to fit the needs
of individual mental capacity for learning so that the best which
is in the human being may be brought forth for the service of
humanity. A Scotch phj'sician gives advice about going back to
’the land:

Only a return to its natural base in the land will now save
civilization from destruction.

In the old classical legend, Hercules, god of Force when
engaged in a wrestling match with the young giant Antaeus,
was surprised to find he could not overthrow him. Finally he
learned the secret — that his young opponent was gegenes,
earth born, and that, so long as he kept one of his feet on the
earth, strength was imparted to him against which no external
power could prevail. So the Olympian lifted Antaeus clear of
his Mother Earth and, there and then, crushed him to death in
his arms.

Antaeus is civilization, and Hercules is the Machine, which is
on the point of crushing it. Can we yet learn from this fable,
or have things gone too far?

The importance of this pamphlet is in the fact that it is issued
by a medical association. Its significance is enhanced by the
appearance at about the same time of such books as William
Alanson White : The Autobiography of a Purpose, and Karl A.
Menninger’s Man Against Himself, both of which propound the
principle that the solution of human problems, including war,
lies along a better realization and a wider application of the
totality concepts in medicine, of which the psychosomatic move-
ment in medicine is a further manifestation. Futile as one small
group may seem in a world gone mad, it should be a source
of pride and hope that the medical profession has set its face
officially against war as it has in times past against other major
threats to the safety and integrity of man.

investigations on the Sterilization Efficacy of Gaseous Formaldehyde.
By Gunner Nordgren, Med. Lie. Acta patiiologlca et microbiologica
Seandinavica, Supplementum XL. Paper. Pp. 1G5, with 11 Illustrations.
Copenhagen: Einar Munksgaard, 1939.

This monograph presents not only a thorough critical review
of the subject but also the author’s investigations in which
improved and original methods were used, leading to conclusions
of practical and theoretical value, based on thorough bacteriologic
studies in which physical-chemical factors were well controlled
and analyzed. The aim of the investigation is stated by the
author to have been of “a practical nature : to be able to stipulate
under what conditions formaldehyde sterilization is reliable."
As test organisms many strains of non-spore forming and spore
forming aerobic and anaerobic bacteria were used. These were
placed on “test objects” of various materials and forms.

“According to generally accepted opinion the bactericidal
effect of formaldehyde depends upon simple molecules while
polymerized molecules, as such, are considered to be biologically
inactive.” The author questions the opinion that “dry” formal-
dehyde gas consists almost entirely of polymerized molecules at
ordinary temperatures. As a result of his experiments be con-
cludes : “Paraformaldehyde vaporizes at room temperature
mainly in the form of simple formaldehyde. . . . Judging from
experimental results it would seem that at least 90 per cent of
the molecules are simple formaldehyde molecules. . . . Thus one
should doubtless be able to abolish the prevailing theory that
the oft indicated, inadequate effect of ‘dry’ formaldehyde steriliza-
tion is due to the polymerized state of the gas. To the extent
that a reliable differentiation in bactericidal effect between ‘dry’
and ‘moist’ formaldehyde gas can be attained, other factors must
be involved. , . . Paraformaldehyde evaporates even in vacuum
very slowly. The tardy increase of the formaldehyde vapor pres-
sure in a closed vessel containing paraformaldehyde would at
least partly explain why ‘dry’ formaldehyde sterilization in
practice often gives unsatisfactory results.” Another source of
failure may be the presence of water. It is stated that only
0.016 cc. of water is required to dissolve half the quantity of
formaldehyde in 1 liter of air saturated with formaldehyde at
about 18 C. “Slight moisture on, for instance, a more complicated
instrument might probably therefore serve as an obstruction to
the diffusion of the formaldehyde toward the inner infected parts
of the instrument. For this reason it is imperative that one
adopt a . critical attitude toward the general method, in both
disinfection and sterilization praxis, of seeking to saturate the
moisture of the air by the evaporation of water in order to bring
about condensation.”

Briefly, the reviewer understands that the sterilization efficacy
of formaldehyde is greatest in an atmosphere of water vapor
saturated with formaldehyde gas but that instruments should not
be wet when placed in the sterilizer and the condensation of
water during the process of sterilization should be avoided. In
the author’s experiments gas pressure, vapor pressure, time of
exposure and temperature were carefully controlled. Heat was
found to enhance the bactericidal action of formaldehyde
Recovery of organisms after exposure to formaldehyde was more
frequent after the use of a sulfite solution ; ammonia was of
liUlc or no value as a neutralizing agent. “The bactericidal
efficacy depends upon the relative moisture of the gas in all
probability through the effect it has on the dried condition of
the bacteria (spores) themselves. Dry formaldehyde gas is

1760

BOOK NOTICES

Jous.' A. Sr. A
Nov. 4, 1939

nevertheless able to kill even spores which are in a very dry
condition. . . . The gas has at least as strong sporocidal effect
on spores which are not dried up as would have a formalin
solution with which the gas is in equilibrium. . . . Sixteen
experiments comprise simple sterilization tests carried out with
seventy strains” of spore forming and non-spore forming bac-
teria and molds. For these tests the "test objects” were pieces
of glass on which the organisms had been smeared and allowed
to dry at 37 C. for from fifteen to twenty minutes. “In all
cases the test objects were found to be sterile within a shorter
space than an hour under the effect of air which, at room tem-
perature (20-22 C.) , was from half to three quarters saturated
with formaldehyde and approximately saturated with water
vapor.” Greater difficulties are encountered in the sterilization
of coarse particles of soil, porous materials and instruments with
canals such as catheters. “For a safe sterilization of ureteral
catheters not even the ‘formalin-vacuum principle’ at 60° and an
operation time of one hour is adequate. . . . Improvement is
possible through previous evacuation followed by a relatively
quick rise of pressure (by letting in air having a relative per-
centage of formaldehyde and water vapor as high as possible).

. . . It must be pointed out that it is the rise of pressure as such,
not the vacuum itself or the absence of air, which causes the
penetration of the formaldehyde gas.”

“The present prevailing opinion on formaldehyde sterilization
must be completely changed. It should be unmistakably borne in
mind that, although gaseous formaldehyde, as such, has a rather
strong bactericidal efficacy, it has a very limited capacity to
sterilize without the aid of specific technical expedients. Under
such simple technical conditions as afforded by' the Janet and
Albarran principles, formaldehyde sterilizations can only be
employed for very special purposes and with great precautionary
measures. For more general purposes — for most of the objects
which, in present day praxis, are treated in the Janet and Marion
apparatuses — formaldehyde sterilization can only be made use
of with the help of more complicated technical devices.” The
author describes the principles and uses of two such devices: (1)
“a specific apparatus having no vacuum device, for the steriliza-
tion of one single instrument”, _ such as an object “of simple
shape, lacking canals or crevices, for instance, a simple endo-
scope” ; (2) "an apparatus with a vacuum device for general
purposes” in which alternate evacuation and admission of air
saturated with formaldehyde may be employed.

A College Course in Hygiene. By Ii. Frnuees Scoft, Pli.B., M.D.,
Associate Professor of Hygiene, Smith College, Northampton, Massa-
chusetts. Boards. Trice, $2.50. Pp. 202, with 48 illustrations by Dr.
William Dunlop Sargent and Margaret J. Sanders. New York: Macmil-
lan Company, 1939.

This is an excellent college manual evidently intended for use
primarily in Smith College for Women. The approach is bio-
logic. The first chapter deals with the biologic nature of the body.
Subsequent chapters in part 1, which is devoted to hygiene as it
concerns the individual, deal with the body’s equipment for motion,
equipment for energy production, the secretory function or chemi-
cal laboratory, the transportation systems (circulatory), metabo-
lism and excretion, breathing, temperature control, equipment
for acquiring information and equipment for coordination. The
material is clearly, logically and briefly presented with numerous
simple diagrams, charts, schematic drawings and silhouettes.
The selection of material for practical usefulness has evidently
been made with great care and excellent judgment. Elimina-
tion of extraneous material has contributed to the brevity of
the work and yet is sufficiently complete to give the student an
excellent orientation with relation to personal health. The
second section is devoted to hygiene as it concerns the group,
dealing with the human being’s equipment for group living, his
position as part of the race, and subsequent chapters taking up
physical environment, control of the sources of supply, com-
municable diseases, special health needs and group agencies
(public and private) for protecting health. Particularly com-
plete, restrained and sensible are the sections relating to vita-
mins, stimulants, depressants, mental hygiene, sex and the
venereal diseases. The venereal diseases are dealt with in con-
nection with communicable diseases as is appropriate, and the
sexual function is discussed in the chapters on the human being
as part of the race immediately following the chapter on the
human being’s equipment for group living. The workbook

section is commendably brief, consisting of knowledge tests and
personal inventory on general health, nutrition, food habits,
colds, sleep, periodic function and civic health knowledge, plus
ventilation surveys and lighting surveys. There is a brief bat
adequate index. Brief reading suggestions follow each chapter.
The most frequent reference given in these reading lists is to
Hygcla, the Health Magazine. The book can be recommended
without reservation for use in institutions where women are
taught or as a study manual for adult groups of women any-
where.

Grundriss der Geschlcchtskrankheiten. Von K. Zieler. Third edition
by Dr. Georg Birnbaum, o. Professor und Direktor der Unlversttatskltnlk
mid Poliklintk flir Haut- und Geschlechtskrankheiten In Konlgsberg/Pr.
Boards. Price, 4.90 marks. Pp. 213, with 19 Illustrations, Ldpzl::
Georg Tliteme, 1938.

This is the first revision of “Zielers Grundriss” in more than
fifteen years. It is a brief discussion of the field of venereal
diseases including gonorrhea, syphilis, soft chancre, venereal
warts and nongonorrheal infections. This edition is by Birn-
baum, a pupil of Zieler’s. During the intervening years since
the second edition political changes in Germany have definitely
established the combating of venereal diseases as a public health
problem. Therefore a brief discussion of the legal aspects ol
these diseases has been included. In the introduction, the point
that prevention is more important than treatment is stressed. It
is stated that there is little excuse for the continuance of venereal
disease, it is so readily recognizable and treated. A third of the book
is devoted to gonorrhea, including a brief discussion of the
anatomy of the urethra, bacteriology, identification of the
organism by staining and culture, the complications arising with
treatment of each, explicit directions for examining both the
male and the female, criteria for cure and a short discussion of
the disease in children. Recent chemotherapeutic advances arc
not discussed, probably because the preparation of the book
antedated them. Endocrine therapy in juvenile gonorrheal vagi-
nitis is not discussed, nor is beat treatment. Complement fixation
is regarded as merely a diagnostic adjunct. Vaccines are dis-
cussed at length. Soft chancre and venereal lymphogranuloma
receive just a few pages ; treatment of the latter with antimony
and gold is briefly discussed. By far the greater part of the
book is given to syphilis, including technic of preparation of the
lesion for dark field examination, which the author believes is
the most certain diagnostic point in recognizing syphilis. Die
lesions are thoroughly described and each drug is well discussed.
Intramuscular mercury is favored by the author and the toxic
effects are exhaustively shown. Malarial therapy is briefly dts
cussed but no other iorms of fever therapy are considered, h’
most respects the book fulfils the aim of the author. Many new
trends in the field of venereal diseases are not included, proba J
because of the time element and the fact that the author inten >
to present briefly only facts that are certain.

Alcohol: Its Action on the Human Organism. By a •'OmmitWc
inally Appointed by the Central Control Board (Liquor 2™'"^ .
Later Reconstituted by the Medical Research Council. Third e
Boards. Price, 30 cents : Is. Tp. 170, with one Illustration.
York : British Library of Information ; London : Hfs Majesty
ttonery Office, 193S.

In 1916 a distinguished British committee including
lames as those of Cushny, Dale, Mott and Sherrington, a
upplemented by Mellanby and Myers, prepared a statemen
he effects of alcohol on the human body. In 1920 there "j*
areful revision, and a second edition appeared in 19- •
iresent edition has been prepared by a new committee, si
ome of the former members have died, and the book is n
lublislied on the authority of the Medical Research Co unci ^
meat Britain. It is an authoritative work as to the cnee
lcohol on digestion and respiration and also considers
ioisonous effects, its uses as a medicine, and the effect o a c ^
n longevity. Here, it is the conclusion that mortality ™ . .

ersons especially' exposed to the temptations of njeoh 0 (
re unfavorable, but the statistical data now available ®
uggest that a strictly moderate use of alcohol unfavo > ■ -
fleets the mortality rates of the users. The final con _
re: “The temperate consumption of alcoholic liquors w _

nee with these rules of practice may be considered to x P ,
igically harmless in the case of the large majority ot n
dults; this conclusion, it may be added, is fully borne o

Volume 113
Number 19

BOOK NOTICES

1761

the massive experience of mankind in wine-drinking and beer-
drinking countries. On the other hand, it is certainly true that
alcoholic beverages are in no way necessary for healthy life;
that they are harmful or dangerous if the above mentioned pre-
cautions are not observed; further, that they may be definitely
injurious for children and for most persons of unstable nervous
system, notably for those who have had severe injuries of the
head or who have suffered from attacks of mental disorder or
from nervous shock.”

Practical Dermatology and Syphilis. By Harry M. Itobtnson, M.D.,
Professor of Dermatology and Director of the Syphilis Clinic, University
of Maryland School of Medicine, Baltimore. Cloth. Price, $4.50. F|>.
307, with 439 illustrations. Philadelphia: P. Blaklston’s Son & Co.,
Inc., 1939.

Robinson presents a small textbook on dermatology which he
states is “intended as an aid to the beginner in the study of
dermatology (1) by helping him acquire a knowledge of the
fundamentals of skin diseases, and (2) by showing how one
may learn to recognize and diagnose the commoner diseases of
this field.” In his introduction he gives in a succinct manner
a review of the “high spots” in dermatology with pertinent
excerpts from some of the classic articles of the last decade.
Since the work is intended as a small textbook on dermatology,
the accounts are brief and there is no bibliography. There are
forty-four pages on syphilis, and the subject on the whole is
excellently treated. The illustrations are reproduced with a
fair degree of accuracy. Figure 298, labeled Pemphigus foli-
aceus, shows a lesion in the left temporal area which impresses
one as being more likely a patch of secondary vegetative derma-
titis or epithelioma. The author deserves credit for knitting
the details of his own diagnostic, clinical and therapeutic experi-
ences into the text. While the book is an admirable small one
and occupies a favorable position between the usual compend
and the standard textbook on dermatology, it does not impress
one as comparing with our better standard American textbooks.

Priests of Lucina: The Story of Obstetrics. By Palmer Findley,
M.D., F.A.C.S. Cloth. Price, $5. Pp. 421, with 38 Illustrations. Bos-
ton: Little, Brown & Company, 1939.

This book will be a welcome addition to the library of those
members of the profession who are interested in medical history,
whether or not they are obstetricians. It portrays the person-
alities of obstetricians, from the beginning of recorded literature
to the present era, in a particularly interesting biographic style.
The contents of the text are divided into two parts. Part one,
comprising twenty-one chapters, presents in an especially readable
way facts of obstetric history and biography. Part two deals
with the history of special phases of obstetrics. Seldom does a
book of this character present such a complete bibliography or
one so well arranged for reference. To one interested in the
history of medicine this is a treasure house of data. This alone
should cause one to add the volume to one’s library. The author
states in the preface that he "has endeavored to select only the
creative masters of the art, those who have contributed most
largely to the making of an obstetric science, but it has not
been possible to include all who have collaborated in the great
work — it would be an endless task.” He has selected well and
made a decidedly valuable and interesting book.

Personality Changes After Operations on the Frontal Lobes: A Clinical
Study ot 32 Cases. By Gusta Bylander. Acta Psychiatric! et Neuro-
logies, Supplementum XX. Paper. Price, 15s. Fp. 327, with Illustra-
tions. Copenhagen: Einar Munksgaardj London: Oxford University
Press, 1939.

Any contribution on the functions of the frontal lobes of man
is assured a large body of hopeful but apprehensive readers,
for they have been disappointed often. Within this volume
Gosta Rylander has gathered from the literature the salient
opinions of other writers and has added a superb contribution
of his own, The historical survey of twenty-seven pages covers
the early epoch and the lessons learned from the study of
brain injuries, tumors, Pick’s disease, animal experimentation
and partial excisions of the frontal lobes of man. The author’s
own contribution consists of follow-up examinations of thirty-
two patients whose frontal lobes had been operated on from 1931
to 193S in the Neurosurgical Clinic of the Serafimer Hospital.
A critical selection of suitable cases, based on a study' of the

excellent hospital records, was made. The author not only
examined the patients by appropriate psychologic tests, of which
he gives an informative description, but also visited them in
their homes. He laid particular emphasis on appraising their
adaptation to their work and to society in general. The case
reports, which cover 169 pages, are followed by a survey of the
results of the investigation, a discussion and summary, an appen-
dix of tables and a helpful bibliography of fifteen pages. The
felicitous selection of Mrs. Helen Frey as translator has given
to the members of the profession an English rendition of a
decidedly meritorious work on the personality changes after
operation on the frontal lobes of man.

The British Encyclopaedia of Medical Practice Including Medicine,
Surgery, Obstetrics, Gynaecology and Other Special Subjects. Under
the General Editorship of Sir Humphry liollcston, Bt., G.C.V.O., K.C.B.,
M.D. Volume XI: Scarlet Fever to Testis, Undescended. Clotli. Price,
$12. Pp. C7C, with 94 Illustrations. Toronto & London: Butterworth
& Co., Ltd., 1939.

This volume is well up to the standard of the previous books
in this system. The subjects discussed go from scarlet fever
through such other main topics as sciatica, scurvy, sex hormones,
sexual behavior and abnormalities, skin diseases, spinal cord
diseases, spleen diseases, statistics, sterility, syphilis, and the
testis. The authors are all British physicians of considerable
note as investigators and practitioners in the fields of which they
write. The volume is handsomely printed, profusely illustrated
and well indexed.

A Textbook of Bacteriology: The Application of Bacteriology and
Immunology to the Etiology, Diagnosis, Specific Therapy and Prevention
of Infectious Diseases tor Students and Practitioners of Medicine and
Public Health. By Hans Zinsser, M.D., Consulting Bacteriologist to the
Peter Bent Brigham Hospital and the Children's Hospital, Boston, and
Stanhope Bayne-Jones, M.D., Professor of Bacteriology, and Dean, Yale
University Medical School, New Haven, Connecticut. Eighth edition.
Cloth. Price, $8. Pp. 990, with 116 illustrations. New York & London:
D. Appleton-Century Company, Incorporated, 1939.

Although there have been rapid advances in bacteriology and
immunology in the last few years which have necessitated the
addition of a good deal of material, this edition is somewhat
smaller than the preceding one. The section on pathogenic pro-
tozoa has been omitted, and redundant and obsolete material in
other sections has been deleted. Together with minor changes,
this has provided space for the addition of material based on
recent systematic studies of genera and species, bacterial vari-
ability, bacterial metabolism, chemical progress in refining of
antigens, viruses and bacterial chemotherapy. Parts of the book
make heavy reading and in some respects it is more suitable as
a reference book than as a textbook for beginning students of
bacteriology. The book will be used doubtless for both purposes
quite successfully.

Travaux pratiques et demonstrations de pharmacodynamic. Par L.
Dautrebande, professeur de pharmacodynamic et de pharmacologic,
Faculte dc medecine, Unlversitd de Ltdge, E. Phllippot, chef des travaux,
F. Nogaride et R. Charller. Paper. Price, 35 francs. Pp. 134, with 56
illustrations. Paris : Masson & Cie, 1938.

This laboratory manual on pharmacology is well organized
and abundantly illustrated with kymographic tracings. In addi-
tion to the conventional pharmacologic experiments there is
included material on such subjects as the carotid sinus and the
technic of inducing gas anesthesia. The book goes briefly into
the simpler chemical and biologic tests for poisons, and ten pages
is devoted to methods for identifying war gases. On the whole,
however, the book contains little that cannot be found in similar
manuals published in this country. There is no index.

The Common Diseases ot the Skin: A Handbook for Students and
Medical Practitioners. By R. Cranston Lon-, JI.D., P.R.C.P.E , F.R S E
Consulting Physician to the Skin Department, Royal Infirmary,' Edin-
burgh. Third edition. Cloth. Price, 10s. Od. Pp. 319, with 148 Illus-
trations. Edinburgh & London: Oliver & Boyd, 1939.

This concise summary of present day dermatology gives the
student and the practitioner an excellent introduction to 'the
subject. The author’s style is simple and easy to read, with
emphasis on diagnosis and therapy of the commoner cutaneous
disorders. In the chapters on eczema and urticaria the role
of sensitization and focal infection is stressed. In the therapeutic
sections most recent advances have been incorporated, although
mention is not made of sulfanilamide and its possible uses in

1762

BUREAU OF LEGAL MEDICINE AND LEGISLATION

Jour. A. M. A.
Nov. 4, 1939

dermatologic therapy or of the cutaneous reactions produced
by it. In the chapter on drug eruptions mention should also
have been made of phenolphthalein, phenobarbital and related
compounds. The illustrations are well selected, including
colored reproductions of moulages, black and white photographs,
diagrams and characteristic histologic sections. Treatment in
general is modern and not unnecessarily complicated. As an
introduction to more complete volumes on dermatology, this
book deserves unqualified approval.

A Classified List of Diagnoses for Hospital Morbidity Deporting. A
Preliminary Report Based on a Study of 570,023 Hospital Discharges
from 113 Hospitals In New York City In 1033. (WPA Project Number
G05-97-3-54.) Welfare Council Publications 1939-IX. Paper. Price,
50 cents. Pp. 27. New York: Research Bureau, Welfare Council of
New York City, 1939.

Tin's is the first publication by the Welfare Council of New
York City based on the results of the study of hospital dis-
charges in New York City in 1933. The classified list of diag-
noses of hospital morbidity reporting represents a study of
nearly 600,000 discharges of patients from 113 hospitals in New
York City. The diagnoses are based on the Standard Classified
Nomenclature of Disease but for simplicity the diseases are listed
under only 629 titles under such large divisions as “infectious
diseases,” “neoplasms,” “neurology and psychiatric conditions”
and “cardiovascular diseases.” It will be most useful to some of
the larger institutions and to those cities which desire to combine
their morbidity figures from all different hospitals for extensive
morbidity reports.

The Morphology of tho Brachial Plexus with a Note on the Pectoral
Muscle and Its Tendon Twist. By Wilfred Harris, M.D., P.R.C.P., Con-
sulting Physician, St. Mary’s Hospital, London. Cloth. Price, $8. Pp.
117, with 87 Illustrations. New York & London : Oxford University
Press, 1939.

This excellent monograph describes the investigation of the
different forms of the brachial plexus found in 158 varieties
of animals from the amphibia to man. It followed the author’s
desire in 1902 to trace the different components of the fifth
cervical nerve in a monkey with a view to a possible nerve
anastomosis operation on a young child with a localized polio-
myelitic paralysis of the deltoid and spinatus muscles. There
are included sections of amphibia, reptilia, aves and mammalia,
the latter including thirty human plexuses. The illustrations
show various brachial plexuses and attachments of shoulder
muscles (especially the pectoralis major). Harris explains the
cutaneous supply of the median and ulnar nerves on the back
of the hand and the motor supply of the ulnar nerve to the
dorsal interossei in man by finding the dorsal fibers joining
the ventral branches of the inner cord and distributed with the
median and ulnar nerves. This monograph is highly recom-
mended to all neurosurgeons and neuro-anatomists.

Health Problems In Negro Colleges. Proceedings of the First Regional
Conference for Health Workers In Negro Colleges, Atlanta, Georgia, April
7 and 8, 1939. Paper. Pp. 03, New Yuri; : National Tuberculosis
Association, 1939.

This pamphlet represents the proceedings of the first Regional
Conference for Health Workers in Negro Colleges. This con-
ference was called in Atlanta, Ga., by the National Tuberculosis
Association, the American Social Hygiene Association and the
Atlanta School of Social Work. It deals with general admini-
strative problems related to the health of Negro college students
under four principal headings : the tuberculosis problem, venereal
diseases, health examinations and the improvement of hygienic
teaching in Negro colleges. It should be of interest to ail per-
sons concerned with the higher education and social welfare of
the Negro.

The Evolution and Organization of the University Clinic. By Simon
Flcxner, JI.D. Paper, rrice, $1.25. Pp. 41. New York & London:
Oxford Unirersity Press, 1939.

This little pamphlet combines two lectures given by Dr. Flex-
ner at the Nuffield Institute in Oxford, England, in January
1938. The author traces briefly the development of the modern
clinic and especially of the scientific laboratory, emphasizing the
important features of organization of such modern institutions
as the Rockefeller Institute.

Bureau of Legal Medicine
and Legislation

MEDICOLEGAL ABSTRACTS

Malpractice: Suspected Pregnancy or Ovarian Cyst;
Failure to Use Friedman Test Negligence.— One of the
plaintiffs, a married woman, consulted the physician defendant
in either September or November 1934 relative to a possible
pregnancy. The physician made a digital examination of the
uterus. According to her testimony, he told her that she was
pregnant. He testified, however, that he told her that she had
an ovarian cyst, but she denied that he did so. Apparently she
visited the physician’s office from time to time thereafter and
was examined, the physician defendant, according to the record,
telling her repeatedly that she was pregnant. When she visited
the physician in April 1935 her abdomen was distended and she
complained that she had suffered severe pains during the pre-
vious month and had become very nervous. At that visit her
husband asked her physician if there was not some way of
determining whether his wife was or was not pregnant and her
physician then suggested “the rabbit test,” meaning thereby,
presumably, the Friedman test or some similar test. The test
was made and showed that the plaintiff was not pregnant.
Thereafter an ovarian cyst about 6 inches (15.2 cm.) in diameter
and weighing about 2 pounds (907 Gm.) was removed. The
patient and her husband then sued the physician for malpractice.
From a judgment in favor of the physician, the patient and her
husband appealed to the Supreme Court of Washington.

In the course of the trial the plaintiffs offered to prove the
number of "rabbit tests” that a chemist, the proprietor of a large
local pathological and chemical laboratory, had made since 193 1,
the total number he made in 1934 and the number that he made
for the defendant during that year. The trial court rejected
the proffered evidence. The propriety of this rejection P rc ‘
sented, according to the Supreme Court, the question to be deter-
mined on appeal.

It is well settled, said the court, that a physician must exercise
that degree of care and skill which is ordinarily exercised by
the members of his profession in the community in which e
practices and in similar communities, having due regard for t <■
state of medical and surgical science at the time. Ordinari y,
whether a physician has exercised the degree of care and ski
that the law requires is established by professional opinion, **
this is not an invariable rule. There are instances in w ic
facts alone prove negligence and it is unnecessary to have
the opinion of persons skilled in a particular science to prove
unskilled and negligent treatment. There is a difference, too,
in malpractice cases, between mere errors of judgment an
negligence in collecting beforehand data that arc essentia .
the forming of a judgment. If a physician fails to inform him-
self as to facts and circumstances essential to the forming 0
judgment and injury to the patient results from, such fai of,
the physician is liable. Bearing these principles in mind, co
tinued the court, we come to the question whether the c emi
whose testimony was proffered should, have been permittc
testify concerning the number of “rabbit tests” he. had ma e -
The evidence showed that the “rabbit test” yielded cor U
results in 96 per cent of all cases. It was employed by P ’)
cians generally in the locality in which the defendant was pr
ticing, in obscure cases. The physician defendant testinc
the test was not in general use but was an aid and that tie
from time to time employed it. Professional opinion was a
in stating that where there was an ovarian cyst and the pa
was not pregnant, it was correct practice to remove it, bu
if the patient was pregnant it was correct practice to delay
operation, if it could be safely delayed, until after the bir
the child. An operation for the removal of the cyst wi n»
patient was pregnant would in all probability result in the
of the child. In this case, the physician defendant testitieu
he suspected pregnancy and that he suspected also the pre
of the cyst when he made the first examination of the p a
and that it was a matter of first importance when an o\

Volume J 13
Number 19

BUREAU OF LEGAL MEDICINE AND LEGISLATION

1763

cyst was discovered to find out whether the patient was preg-
nant. The question then, continued the court, was whether the
physician, in failing to employ the “rabbit test" earlier than he
did and relying on the digital examination, neglected to collect
data essential to a proper conclusion in the case. If he had
discovered sooner that the patient was not pregnant, the cyst
could have been removed earlier and the patient would have
been saved from a long period of inconvenience and severe pain,
resulting in a nervous condition.

The extent to which the "rabbit test” was applied in the
locality in which the physician defendant practiced had a material
bearing on the question of whether he was or was not negligent
in not applying the test earlier. Courts have repeatedly held
that the failure on the part of a physician to make a roentgeno-
gram or to have a roentgenogram made as an aid to correct
diagnosis, when x-ray machines are available and are commonly
used by physicians in similar cases, may constitute actionable
negligence. Applying the same principle to the utilization of
the “rabbit test,” it follows that the extent to which that test
was utilized by physicians in the locality in which the physi-
cian defendant practiced was a material subject of inquiry in
determining whether the physician was or was not guilty of
negligence in failing to make use of the test at an earlier date.
The testimony of the chemist which was proffered and rejected,
said the court, was material and competent and its rejection was
prejudicial error.

Judgment in favor of the physician defendant was reversed
and a new trial ordered . — Peterson v. Hunt (Wash.), 84 P.

(2d) m.

Workmen’s Compensation Acts: Back Injury; Objec-
tive Evidence of Injury — Determinative Effect of Lay
Testimony. — The claimant, in the course of his employment,
attempted to lift a bucket of nuts and bolts weighing about
60 pounds. He felt a sharp pain in the lower part of his back
and in his hips and could not lift the bucket nor straighten up.
An osteopath, whom the claimant’s foreman advised him to
consult, found, so he testified later, “a severe .injury to the
ligaments and muscles in the area of the back, in the location
of the first lumbar vertebra.” He believed that “a fracture or
injury of the vertebra had occurred.” A company physician
ordered the disabled workman to a sanatorium, where he
remained nine days. After he returned home he Remained in
bed for about three weeks more. Thereafter he instituted pro-
ceedings under the Louisiana workmen's compensation act for
compensation for total and permanent disability. The trial court
rejected his claim and he appealed to the court of appeal of
Louisiana, second circuit.

The employer contended that there was no evidence of objec-
tive symptoms of the alleged injury and that the Louisiana
workmen’s compensation act made such symptoms a condition
precedent to an award of compensation. The court believed,
however, that the evidence adduced met the requirements of
the statute. The court pointed out that there was evidence that
the claimant complained of his injury immediately after the
accident; that his foreman and his fellow employees saw that
he was injured and assisted him to the osteopath’s office; that
the osteopath recognized the injury; that the employer’s physi-
cian sent him to a sanatorium, and that certain patients in that
sanatorium observed the claimant’s distress and suffering during
his stay there.

To substantiate the defendant’s contention that at the time
of the trial the claimant was not suffering from any disability,
it relied principally on the testimony of six physicians. Some
of them had made clinical examinations of the claimant and
others testified solely on the basis of roentgenograms. Their
testimony was in irreconcilable conflict with the testimony of
four physicians called on behalf of the claimant. In any case,
said the court, in which the medical testimony is as conflicting
as here, the court is forced to look to the lay testimony for a
solution.

It is immaterial, continued the court of appeal, whether or not
a claimant can prove the exact injury he suffered. It is suf-
ficient in this case for the claimant to show that his back was
injured and the location of the injury and the fact that the
injury renders him unable to perform ordinary manual labor.

Were a workman required to prove the exact part of his back
that was injured “he would be left to the mercy of the medical
profession, which never fails to disagree as to the injury of a
back.” The lay testimony, however, in this case was over-
whelmingly in the claimant’s favor. It was shown beyond
question that he had performed no manual labor since the acci-
dent and that on stated occasions he suffered pain and discomfort
when be attempted to exert himself. The claimant, said the
court, is either totally disabled to perform manual labor or he
is an "A No. 1 malingerer.” The record does not justify this
court in finding him to be a malingerer. The court is, therefore,
forced to find that he was totally disabled to perform work of
a reasonable character at the time of the trial.

There is evidence in the record, said the court, that the
claimant’s back shows an arthritic condition. Practically all the
medical witnesses testified that an injury to the back when in
that condition will often cause a dormant arthritis to flare up
and give trouble. Even if that is what happened, however, the
injury is compensable.

The court accordingly entered a judgment in favor of the
claimant . — Phillips v. Yazoo & M. V. R. Co. (La.), 183 So. 43.

Hospitals: Nonprofit Hospital Corporation Not Liable
for Negligence. — The plaintiff was born in a hospital Oct. 6,
1926. He was placed in a crib in the nursery with several
other infants, among them a premature baby. To afford warmth
for the premature baby an incubator was improvised, using as
a source of heat an electric light globe. Either because of the
defective condition of the electric wiring by which the globe
was put into service or because of the close proximity of the
globe to the cotton bedding, the crib in which the premature
baby was lying caught fire. That baby was burned to death
and the fire passed from the crib in which it was lying to the
crib in which the plaintiff was sleeping, and the plaintiff was
injured. On behalf of the injured child, his mother sued the
hospital for damages. The jury returned a verdict in favor of
the plaintiff, but on motion of the defendant a judgment was
rendered in its favor notwithstanding the verdict. From that
judgment, the plaintiff appealed to the appellate court of Illinois,
first district, third division.

There is no controversy, said the court, as to the happening
or as to the cause or result of the injury sustained by the
plaintiff. It was conceded, too, that if the defendant in the case
was a charitable organization as defined by the laws of the
state of Illinois it was not liable for the negligence of its servants
and employees. The provisions of the charter, said the court,
determine the character of the organization and the purposes -
for which it was organized. Where a corporation, as shown by
the terms of its charter, is operated not for profit and has no
provision for the issuance of stock or the payment of dividends
to incorporators or stockholders and where it appears that its
purpose is to conduct a hospital, the law recognizes it as a
charitable institution. The evidence, the court thought, was
sufficient to prove the charitable character of the hospital defen-
dant in this case. The injuries were grievous and would enlist
sympathy if that were one of the elements to be considered in
arriving at a decision, but under the law the court was obliged
to hold that no liability attached to the defendant hospital.

The judgment of the trial court was affirmed . — Marctick v.
South Chicago Community Hospital (III.), 17 N. E. (2d) 1012.

Autopsies: Liability for Performance of Autopsy on
Illegal Order of Justice of the Peace.— A workman, Love,
instituted proceedings under the Texas workmen’s compensation
act for compensation for an injury allegedly due to his employ-
ment. Love died and a claim adjuster for the insurer of Love’s
employer procured from a justice of the peace an order for an
autopsy. The autopsy was performed by the county health
officer and another physician, each of whom was paid §50 by the
insurance company. Information obtained through the autopsy
was used by the insurance company to defeat the claim for
compensation. Loves brothers and sisters sued the insurance
company for having unlawfully procured the performance of
the autopsy without their consent. The trial court directed a
verdict in favor of the insurance company, but the court of civil
appeals of Texas, Beaumont, reversed that judgment and
remanded the case for a trial on its merits. Love v. Aetna

1764

SOCIETY

PROCEEDINGS

Jour. A. M. A.
Nov. 4, 1939

Casualty and Surety Company (Texas), 99 S. W. (2d) 646;
abstr. J. A. M. A. 109:387 (July 31) 1937. The insurance
company then appealed to the Supreme Court of Texas.

In Texas, the Supreme Court pointed out, the authority of a
justice of the peace to order an autopsy is derived exclusively
from statute and may be lawfully exercised only for the detec-
tion of crime. It is to be presumed that a justice of the peace
who orders an autopsy acts in the exercise of sound discretion
and in good faith for the purpose of detecting crime, but this pre-
sumption is rebuttable. In the judgment of the Supreme Court,
the testimony of the claim adjuster justified a finding that he
had submitted the facts of Love’s injury and death to the justice
of the peace to induce that officer to order an autopsy for the
purpose of determining whether or not Love had sustained a
compensable injury and that the justice of the peace ordered
the autopsy for that purpose. Such a finding by the jury would
have destroyed the presumption of regularity of the justice of
the peace’s order for the autopsy and would have established
that the justice of the peace ordered the autopsy for a purpose
not authorized by law.

The Supreme Court of Texas therefore affirmed the judgment
of the court of civil appeals, remanding the cause for a trial on
its merits. — Aetna Casualty & Surety Co. ct al. v. Love ct al.
(Texas), 121 S. W: (2d) 986.

Medical Practice Act (Utah) : Revocation of License
for Violating Narcotic Drug Act; Both Convicting
Court and Licensing Agency Authorized to Revoke. —
The medical practice act of Utah authorizes the Department
of Registration to revoke or suspend the license of a physician
guilty of unprofessional conduct, which the act defines to
include, among other things, the prescribing of narcotic drugs

in violation of law. The narcotic drug act of Utah, enacted

subsequent to the enactment of the medical practice act, author-
izes the court before which a physician has been convicted
of violating its provisions not only to fine or imprison him

but also, in its discretion, to revoke or suspend his license to

practice. 1 Light, a licensed physician, was convicted of pre-
scribing narcotic drugs in violation of the act, but the court
did not revoke or suspend his license. The Department of
Registration later instituted proceedings to effect that end.
Light then petitioned the district court of Salt Lake County
for a writ of prohibition to prevent further proceedings by
the department. On demurrer, the trial court refused to issue
such a writ and Light appealed to the Supreme Court of Utah.

The petitioner contended that the department had no juris-
diction to revoke or suspend the license of a physician con-
victed of violating the state narcotic drug act, since authority
to revoke or suspend a license for such an offense was vested
by the narcotic drug act itself exclusively in the court before
which the physician was convicted. It is apparent, however,
answered the court, that the state narcotic drug act intended
to give the convicting court a power additional to that of
fining and imprisoning a physician convicted of violating the
act when it authorized it also to revoke or suspend his license
to practice. If the court does not revoke or suspend the
license, the Department of Registration, said the Supreme
Court, still has the power to do so. This is shown by the
fact that the clerk of the court, on conviction, is required by
the act to send a copy of the judgment and sentence, together
with the opinion of the court, if any, to the Department of
Registration. If this sentence shows that the court has revoked
or suspended a license, the department needs to go no further
in that regard but has only the duty of seeing that the physi-
cian does not practice while his license is not in force. If the
sentence does not include revocation or suspension, however,
the department can proceed administratively to revoke. or sus-
pend the license of the convicted physician. Even indepen-
dently of any criminal charge, too, the department may institute
revocation proceedings. There is nothing inconsistent or incom-
patible in giving the court the power to revoke or suspend a

1. In this respect the provisions of the Utah act correspond with those
of the Uniform Narcotic Drue Act as formulated by the National Con-
ference of Commissioners on Uniform I-aws and enacted by many states.

license and at the same time leaving in the administrative
board or department authority to proceed to the same end.

Accordingly, the Supreme Court affirmed the judgment of
the court below, in effect permitting the Department of Regis-
tration to institute and maintain proceedings for the revocation
or suspension of the license of the petitioner notwithstanding
the fact that the court did not do so— Light v. Golding,
Director o} Department of Registration (Utah), 85 P. (2d) 111

Cosmetology: Electrolysis as “Beautifying the Human
Face. In New York City no person may conduct a beauty
parlor without a permit from the board of health. The Sanitary
Code defines a “beauty parlor” as a place “wherein the business
of . ... beautifying the human . . . face, ... or
hands, is conducted for fee, charge, or hire.” The defendant
practiced electrolysis in a one story house located in a residential
zone. She had applied for a permit to operate a beauty parlor
but her application was denied because the building department
would not certify to the propriety of a business use in a resi-
dence zone or district. She was convicted of operating a beauty
parlor without a permit and appealed to the supreme court of
New York, appellate division, second department.

The defendant did no manicuring or massaging but confined
her activities to the removal of hairs, by electrolysis, from all
parts of the bodies of patrons. There is no doubt, the court
said, that the removal of unwanted hair from the human face is
commonly deemed "beautifying the human . . . face,” within
the meaning of the Sanitary Code. The fact that the defendant
removed hair from the body, not mentioned in the Sanitary
Code, as well as from the face and hands, did not exclude her
activity from the purview of the code. To interpret the pro-
visions of the code so as to enable a person who does certain
types of work, not mentioned therein, also, without a permit,
to do work specifically within its terms, when the latter work
is general and not casual or sporadic, would, the court said, he
to nullify the statutory provisions and countenance clear evasion
thereof. The removal of hair from the face was characterized,
the court continued, as a “type of beauty culture” in a case
holding that using electrolysis was not the unlawful practice
of medicine. Likewise, it has been held that the use of elec-
trolysis to prevent growth of hair is similar to the work of a
barber in Removing hairs on a man’s face. People v. Lchnntm,
251 App. Div. 451, 296 N. Y. S. 580, affirmed 276 N. Y. 479,
12 N. E. (2d) 166; abstr. J. A. M. A. 110:839 (March 12)
1938.

In the opinion of the supreme court, the defendant conducted
a beauty parlor without a permit in violation of the statute.
The judgment of conviction was therefore affirmed. — People t\
Cohen (N. Y.), 8 N. Y. S. (2d) 70.

Society Proceedings

COMING MEETINGS

American Academy of Pediatrics, Cincinnati, November 16-18. h r *
Clifford G. Grulee, 636 Church Street, Evanston, III., Secretary. ^
American Society of Anesthetists, Los Angeles, Dec. 14. Dr. Paul
Wood, 745 Fifth Ave., New York, Secretary. _

American Society of Tropical Medicine, Memphis, Tenn., Nov. 21-24.

E. Harold Hinman, Wilson Dam, Ala., Secretary.

Pacific Coast Society of Obstetrics and Gynecology, Portland, f -’
Nov. 8-11. Dr. T. Floyd Bell, 400 29th St., Oakland, Calif., Sect*
Radiological Society of North America, Atlanta, Ga., Dec. * ^ . irV
Donald S. Childs, 607 Medical Arts Bldg., Syracuse, N. Y., ? eCT y *S'
Society for the Study of Asthma and Allied Conditions, Phila e P
Dec. 9. Dr. W. C. Spain, 116 East 53d St., New York, ScCr V p r>
Society of American Bacteriologists, New Haven, Conn., Dec. 28-3 -
I. L. Baldwin, Agricultural Hall, University of Wisconsin, - M3a ”
Wis., Secretary*. . ✓* p^

Southern Medical Association, _ Memphis, Tenn., Nov. 21-24. Mr.

Loranz, Empire Bldg., Birmingham, Ala., Secretary'* AUc n

Southern Surgical Association, Augusta, Ga., Dec. 5-7. Dr. 1
Ochsner, 1430 Tulane Ave., New Orleans, Secretary'* p #

Southwestern Medical Association, El Paso, Texas, Nov. 9* 1L 1

Spearman, 1001 First National Bank Bldg., El Paso, Mar«ha^*

\ CSiem surgical .•\-vsociuiion, - - —

Montgomery*, 122 South Michigan Blvd., Chicago, Secretary.

Volume 113 .
Number 19

CURRENT MEDICAL LITERATURE

1765

Current Medical Literature

AMERICAN

The Association library lends periodicals to members of the Association
and to individual subscribers in continental United States and Canada
for a period of three days. Three journals may be borrowed at a time.
Periodicals are available from 1929 to date. Requests for issues of
earlier date cannot be filled. Requests should he accompanied by
stamps to cover postage (6 cents if one and 18 cents if three periodicals
are requested). Periodicals published by the American Medical Asso-
ciation are not available for lending but may be supplied on purchase
order. Reprints as a rule are the property of authors and can be
obtained for permanent possession only from them.

Titles marked with an asterisk (*) are abstracted below.

American Journal of Clinical Pathology, Baltimore

9 : 545-580 (Sept.) 1939

Preparation of Universally Compatible Ascitic Fluid for Transfusion.
K. M. Choisser and Elizabeth M. Ramsey, Washington, D, C. — p.
545.

Silent, So-Called Primary Tuberculosis of Spleen. H. Fox, Phila-
delphia.— p. 549.

Effect of Ingested Sodium Chloride on Concentration of Hemoglobin.

A. G. Sheftci, Los Angeles. — p. 554.

Lciomyofibromatosis: Multiple Tumors of Abdomen and Pelvis. . \V.
M. German, Cincinnati. — p. 558.

Spindle Cell Sarcoma of Prostate. M. J. Fein, New York. — p. 564.

American J. Digestive Diseases, Huntington, Ind.

6: 429-504 (Sept.) 1939

Etiology, Diagnosis and Medical Management of Pancreatic Disease.
E. H. Gaither, Baltimore. — p. 429.

Activity of Lower Part of Ileum of Dog in Relation to Ingestion
of Food. D. M. Douglas and F. C. Mann, Rochester, Minn. —
p. 434.

Over Two Thousand Estimations of Hydrogen Ion Concentration.

M. A. Bridges and Marjorie R, Mattice, New York.— -p. 440.
Phenolphthalein as Test for Gastrointestinal Ulceration in Experi-
mental Animal. B. Slutzky and C. M. Wilhelmj, Omaha. — p. 449.
Anal Cryptitis. C. J. Drueck, Chicago. — p. 450.

Adenocarcinomatous Pedunculated Polyp of Esophagus: Report of
Case. M. Feldman, Baltimore. — p. 453.

Abnormalities in Rectal Tone and Contraction in Paraplegia and Hemi-
plegia. S. J. Rosenberg and O. R. Langworthy, Baltimore. — p. 455.
•Nutritional Availability of Iron in Molasses, R. S. Harris, L. M.
Mosher and J. W. M. Bunker, Cambridge, Mass.— p. 459.

New Approach to Prevention of Hemorrhages from Esophageal Varices
as Occur in Cirrhosis and Banti’s Disease. C. H. Drenckhalm,
Utbana, 111.— p. 462.

•Significance of Presence of Calcium Bilirubin Pigment and Choles-
terol Crystals in Feces. F. Boerner, T. A. Johnson and M. Gian-
niny, Philadelphia.— p. 466.

Physiologic Control of Normal Human Gastric Secretory Curve. C.
M. Wilhelmj and A. Sachs, Omaha. — p. 467.

Available Nutritional Iron in Molasses. — Harris and bis
co-workcrs estimated the availability of iron in molasses by tiie
chemical (dipyridyl) procedure and by the biologic assay pro-
cedure. The molasses used in theiv tests was prepared from
Louisiana sugar cane. Juice is extracted by pressure from
crushed cane, heated, treated with sulfur and lime to precipitate
some of the impurities, clarified and concentrated to 40 degrees
Baume by heating at 63 F. Tin's sugar cane syrup is boiled

down still further to crystallize the sugar, and the resulting

liquor was called sample A. A portion of this “first” molasses
is diluted with cane juice and reworked to obtain another extrac-
tion of sugar. The resulting liquor was called sample B. The
"second” molasses is diluted with water, reboiled to obtain

another extraction of sugar and the resulting liquor was called

sample C. The "available” iron by the chemical method in the
three kinds of molasses was found to be 97, S5 and 54 per cent,
respectively. By the biologic (rat) method the availability was
slightly more than 90, 80 and 50 per cent, respectively. The
dipyridyl procedure is acceptable for the determination of the
availability of iron in molasses. Molasses is a rich and inex-
pensive source of available iron. The authors point out that,
although the iron in high grade molasses is more available than
that in a lower grade of molasses, the higher grade is not as
rich in total available iron. For example, 100 Gm. of molasses A
furnished slightly more than 3.1 mg. of “available” iron, whereas
the same quantity of molasses B contained approximately 5.1 mg.
of “available” iron. The results obtained with molasses C do
not agree with those of Shackleton and McCancc, who reported
that the iron in black treacle is 100 per cent available. In
the authors’ experience only 54 per cent was available. It is
not correct to base one’s judgment of a food on its total iron

content, since iron availability varies with the kind of food.
Molasses B is the type commonly used in the home ; 85 per cent
of its iron is available. Of the foods reputed to be excellent
sources of iron, only liver compares favorably with molasses.
Whipple and Robscheit-Robbins have listed chicken and beef
liver, chicken gizzard, beef kidney, eggs, apricots and raisins as
especially valuable in the treatment of anemia. From the
authors’ studies on these foods it appears that molasses is
superior to all these foods in this respect and is, moreover, the
most inexpensive food source of iron.

Significance of Bilirubin and Cholesterol in Feces. —
The occasional presence of calcium bilirubinate, cholesterol or
both in routine feces examinations led Boerner and his colleagues
to examine 2,003 stools, in sixty-seven of which calcium bili-
rubinate, cholesterol crystals or both were found. In many
instances the stools came from patients who wefre in the hos-
pital for study of some condition unrelated to the biliary tract.
Calcium bilirubinate alone was found in the feces in twenty-five
cases and cholelithiasis was confirmed in eighteen. Of the
remaining seven cases the diagnosis of cholelithiasis was not
substantiated. Apart from cholelithiasis, two mechanisms may
account for the presence of calcium bilirubin pigment in the bile
and consequently in the feces: sudden release of noncalculous
mechanical block of the main bile ducts or an increase in the
serum bilirubin secondary to increased hemolysis may give rise
to calcium bilirubinate in the bile in the absence of biliary dis-
ease. In a number of instances the first intimation of possible
gallstone disease was the finding of calcium bilirubin pigment
in the feces of a patient in whom that diagnosis was not sus-
pected. Of fourteen cases in which cholesterol crystals alone
were reported in the feces, there was only one in which the
diagnosis of cholelithiasis was confirmed. Seven of the cases,
however, were not studied for cholelithiasis.

American Journal of Medical Sciences, Philadelphia

198 : 301-444 (Sept.) 1939

•Streptococcus Viridans Endocarditis Lenta: Clinicopathologic Analysis
o( Experience in Wisconsin General Hospital. W. S. Middleton and
M. Burke, Madison, Wis. — p. 301.

Occurrence of Coronary Artery Thrombosis in Polycythemia Vera. H. R.
Miller, New York. — p. 323.

Voluntary Hypercirculation. E. Ogden and X. W. Shock, Berkeley,
Calif.— p. 329.

. Brucellosis with Endocarditis: Report of Case with Failure of Sulfanil-
amide Therapy. K. M. Smith and A. C. Curtis, Ann Arbor, Mich.—
P. 342.

‘Effect of Sulfanilamide on Spermatogenesis in Man. N. J. Heckel and
C. G. Hori, Chicago. — p. 347.

•Treatment of Pneumonia with Type Specific Immune Rabbit Serum.
V. B. CnIJomon, Pittsburgh. — p. 349.

Respiratory Defense Mechanism: Its Relationship to Pulmonary Dis-
eases. I. L. Applchaum, Newark, A', J. — p, 356.

•Studies on Oxyuriasis: XVIII. Symptomatology of Oxyuriasis as
Based on Physical Examinations and Case Histories on 200 Patients.
F. J. Brady and W, H. Wriglit, Washington, D. C. — p. 367.

Platelets in Pernicious Anemia, with Review of Literature. F. K.

Paddock and Katharine Edsall Smith, New York. — p. 372.
Erythroblastic Anemia: Report of Two Cases in Adult Siblings, with
Review of Theories as to Its Transmission. Dorothy W. Atkinson, San
Francisco. — p. 376.

Mitotic Leukoblasts in Peripheral Blood in Infectious Mononucleosis.
H. Bowcock, Atlanta, Ga. — p. 3S4.

Prognostic Significance of Eosinophils in Blood in Pneumonia. M. M.
Bracken, Pittsburgh. — p. 3SG.

Evaluation of Phenolphthalein Test of Woldman. R. Lc. Vine and J. B.
Kirsner, Chicago. — p. 3S9.

“Numeral Test" in Transverse Lesions of Spinal Cord. R. Wartenherg,
San Francisco.— p. 393.

Effect of Alterations in Metabolic Rate on Action of Insulin. G. W.

Hayward and G. G. Duncan, Philadelphia. — p. 396.

Cevitamic Acid Deficiency: Frequency in Group of 100 Unsclectcd
Patients. J. D. Croft and L. D. Snorf, Evanston, 111. — p. 403.

Streptococcus Viridans Endocarditis Lenta. — Middleton
and Burke present the clinical and pathologic features of eighty-
eight cases of Streptococcus viridans endocarditis lenta which
were observed at the Wisconsin General Hospital. They think
that some of the details of the clinicopathologic analysis merit
special emphasis. They adduce further evidence in support of
a close relationship between congenital and rheumatic lesions
of the heart and endocarditis lenta. Acute upper respiratory
infections, rheumatic fever, infected abortion, dental extraction
and massage for nonspecific prostatitis apparently served as
precipitating factors in the development of certain cases of this
condition. Contrary to the accepted opinion, congestive heart
failure may attend or mask this condition. The clinical mani-
festations and course arc varied and inconstant. After the

1766

CURRENT MEDICAL LITERATURE

Jove. A. SI. A
Nov. 4, i;r,

cardiac changes, particular attention was directed to its toxic
and its embolic features. Splenic and renal changes, including
embolism, were frequent. Mycotic aneurysms offered serious
diagnostic problems. Cerebral accidents were not infrequent.
Occasionally a mycotic aneurysm of a cerebral vessel may
explain certain neurologic phenomena of this condition. Again
the clinical picture may suggest thyrotoxicosis, and the unex-
plained elevation of the basal metabolic rate may add to the
diagnostic confusion. This study offers material support to the
importance of the diagnostic triad petechiae, splenomegaly and
a positive blood culture for the Streptococcus viridans. Given
the background of a congenital or a rheumatic heart lesion and
a remittent fever, this triad offers the logical direction of attack.
The prognosis of Streptococcus viridans endocarditis lenta is
grave. Only inferential evidence of the pace of the decline is
offered by the circulatory, renal, embolic, toxic, constitutional
and hematologic reactions. Although remissions of varying
durations and degrees are the rule, certain of these patients
undergo a rapidly progressive decline. Attention is directed to
the ominous significance of the euphoria that attends late remis-
sions. This group included one instance of healed endocarditis
lenta. The clinical activity apparently occurred at a period
previous to the hospitalization. In the remaining eighty-seven
cases all treatment was unavailing.

Effect of Sulfanilamide on Spermatogenesis. — Heckel
and Hori say that the administration of sulfanilamide derivatives
to man has been thought to influence spermatogenesis. To study
this problem the authors analyzed the semen of eleven patients
before and after sulfanilamide was given. They describe their
method of examination and in a table they show the number of
specimens examined, the total number of spermatozoa and the
percentage alive before, during and after treatment; the time
specimens were obtained in relation to the treatment and the
duration of the treatment. The sulfanilamide was given by
mouth up to a total of 40 grains (2.6 Gm.) daily, except when
the drug was not tolerated, and then the dose was reduced or
the patient was put on a rest period for two or three days. In
contrast to other reports, these data indicate that in eleven cases
there were no noteworthy effects on the total number or' per-
centage of live spermatozoa from the use of sulfanilamide. Such
variations as occurred in the spermatozoa counts during and
after treatment were no greater than the variations which
occurred before the drug was given.

Type Specific Immune Rabbit Serum in Pneumonia. —
Callomon reports experiences with type specific antipneumono-
coccus rabbit serum in forty-five cases. Included in this series
are cases of pneumonia of types I, II, IV, V, VII and VIII.
The only factor entering into their selection was the availability
of a homologous immune serum at the time of their admission.
In the majority of cases the product employed was uncon-
centrated. In a few of the more recent cases a concentrated
preparation was administered. All cases reported showed roent-
genographic evidence of consolidation and a positive blood culture
or sputum in which the pneumococcus was the predominating
organism. A history, physical examination, urine analysis, blood
count, blood culture, sputum examination and roentgenogram of
the chest were obtained on admission. Blood cultures were
taken at two day intervals or more frequently when indicated.
Identification of the type of pneumococcus present in the sputum
was made by the Neufeld method and in many cases confirmed
by passage through the mouse. Before treatment was instituted,
all patients were given ophthalmic and intracutaneous tests for
sensitivity to the specific serum which was to be used. The usual
precautions, advisable in all serotherapy, were observed. When
a positive intracutaneous test was associated with a negative
ophthalmic test, the administration of serum was undertaken,
but with more than the usual caution. AH serum was given
intravenously. At first, doses of 20,000 units were given at
two hour intervals. Later this plan of treatment was altered,
as the administration of larger doses seemed preferable in order
to introduce the total dose in as short a time as possible. Fol-
lowing an initial dose of 20,000 ''units, one or more doses of
100,000 units were given until it was apparent that the disease
was being brought under control. Subsequently, smaller doses
were given as seemed indicated until recovery was complete.

In several cases one injection of 100,000 units following the

initial dose of 20,000 units was sufficient to secure the desire!
result. Supplementary treatment consisted only of dietary’ regu-
lation and symptomatic treatment, including oxygen administra-
tion, when indicated. Regarding the results obtained with this
treatment, the author says that two deaths occurred in this
series. . Premature recovery by crisis or rapid lysis ensued u
thirty-six cases. No serious serum reactions were observed.

Symptomatology of Oxyuriasis.— Brady and Wright made
studies in 200 cases of oxyuriasis. This material included per-
sons seeking treatment for known pinworm infestation, persons
referred to them because of symptoms suggestive of oxyuriasis,
and persons in whom pinworms were detected by anal swab
examinations made in the course of studies on the incidence ci
oxyuriasis. Comparative studies were made on two control
groups. One group of seventy-two persons was negative for
pinworms on examination by' the swab method, but they lived in
households together with infested subjects. A second group ci
twenty-one persons was negative for pinworm and lived in homes
in which no member of the family was found infested. In each
of the 200 cases of oxyuriasis the history was taken, a physical
examination was made, a stool sample was examined for hel-
minth ova, anal swabs were made, and in girls a vulvar suab
was made. The opinion is expressed that symptoms may k
caused by mechanical stimulation and irritation by the parasite,
by allergic reactions, and by the transportation of organisms to
places where they may become pathogenic. Many infested chil-
dren showed gains in weight, improvement in color, and dis-
appearance of dark circles under the eyes after treatment. There
was an average eosinophil percentage of 5.1 in 144 pimvona
cases compared to 3.7 in twenty-one children coming from
households in which all persons were free from pimvor®-
There is too much deviation from the mean for these figure 5
to assume statistical significance, but it is likely that there is >
slight increase in eosinophil percentage in oxyuriasis. One nse
presented symptoms of nausea and vomiting that could not
attributed to causes other than the pinworm infestation. T i®
symptoms disappeared when the pinworm infestation was era
catecl. The authors found no proof that abdominal pain a"
oxyuriasis were directly related. Only one patient of 1 IC " ,
had had an appendectomy. The appetite in many cases was mne
improved after treatment. It is believed that pinworms cau-^
conscious sensation when moving on the rectal and anal me -
but that no sensation is felt in the majority of cases a ter -
pinworm has migrated onto the skin. Allergic reactions
pinworm products are probably associated with the nlar
sensation experienced by some few persons from skin miS ra J
Enuresis was not found to be more common in infested pa ■
than in noninfested controls. Evidence is presented tna a
worm vaginitis may' be much more frequent than it as
considered to be in the past. Restlessness and insomnia ^
symptoms occurring in pinworm cases. Restlessness
may lead to scholastic difficulties. The feeling of sna ^
an impressionable child may have from the consciousn ^
having pinworms may have repercussions in the e a ', . [a .
the child. Evidence to show that pinworms cause nervous
bility was inconclusive. i

American. Journal of Ophthalmology , St. o

88 : 953-1070 (Sept.) 1939

So-Called Ogucbi's Disease in the U. S. A.: Case. Berths

VaS^e'ofHomatropine-nenzedrine Cyclop, cgia: Further
L. S. Powell, Lawrence, Kan.— p. 956. 956 .

Icular Papilloma. R. E. Windham, San Angelo, *'**’■
tetinal Hemorrhages After Transfusion. R. J. Cray,

so, at!d ? Rheumatic Nodule of Upper Eyelid: Report of Tuo &
J. S. Guyton and J. M. McLean, Baltimore.— p. 98a. .

'he Need for Social Service Work m Glaucoma. • ‘

Grand Forks, N. D., and H. S. Cradle. Chicago. P- ura j
Iphthalmomyiasis Interna Anterior: Report of HVpJ r City-
Anterior Chamber. C. S. O'Brien and J. H. Allen,

lypermetropia. A. Cowan, Philadelphia.— p. 998. Tb 3 C l r :

tudy of Ocular Defects Among University Students. -
Urbana, III— P- 1003. .. jr c Cl 0 «

lligoseptic Treatment of Ocular Infection. L. 1. y,

rophylactic Foreign Protein Therapy in Cataract Extraction. c -
Noe, Cedar Rapids, Iowa. — p. 1019.

Volume 113
Number 19

CURRENT MEDICAL LITERATURE

1767

American Journal of Surgery, New York

45:417-6)4 (Sept.) 1939. Partial Index
Tumefactions of Abdominal Wall. W. H. Meade and W. R. Brew-
ster, New Orleans.— p. 419. . , _ . „

Preoperative 3nd Postoperative Care of Patients with Gastric Cancer.

G. T. Pack and Isabel M. Scliarnagel, New York.— p. 435.

Rational Postoperative Treatment Following Abdominal Operation. L.

E. Mahcney, Santa Monica, Calif. — p. 452.

Surgical Considerations of Temperature in Ligated Limbs. F. M.
Allen, New York. — p. 459.

Treatment of Intractable Sciatic Pain Due to Protruded Interverte-
bral Disks. W. M. Craig, Rochester, Minn. — p. 499.

Pigmented Nevi, with Special Reference to Their Surgical Treat-
ment. J. \V. Maliniac, New York. — p. 507.

‘Impurities in Ether. H. H. Bradshaw, Philadelphia. — p. 511.
•Appendicitis Complicated by General Peritonitis: Method of Treat-
ment That Lowers Mortality Rate. E. G. Williamson, and L. M.
Rankin, Philadelphia. — p. 528.

Treatment and Management of Burn Cases. H. J. Lavender, Cin-
cinnati. — p. 534.

Treatment of Burns. H, D. Cogswell, Tucson, Ariz., and C. Shirley,
Tyler, Texas. — p. 539.

Traumatic Torsion of Ovarian Pedicle: Medicolegal Study with Pres-
entation of Cases and Review of Literature. H. Sneierson, Bing-
hamton, N. Y.; J. Schlesiuger, College Point, N. Y., and A. E.
Gold, Binghamton, N. Y. — p. 546.

Impurities in Ether. — Bradshaw reports a case in which
death in convulsions occurred during the administration of
nitrous oxide-oxygen-ether. Some blood was obtained for
examination before death. The blood showed an oxygen content
of 6.9, oxygen capacity of 14.6, saturation of 47.3 and a carbon
dioxide content of 61 volumes per cent. The concentration of
sugar was 400 mg. per hundred cubic centimeters of blood
(intravenous dextrose was being administered). The ether was
analyzed and showed aldehyde present, 1 : 50,000 in two samples.
No other impurities were found. Although 100 per cent oxygen
was given for a period of ten minutes the cyanosis became
greater and the convulsions continued. The oxygen content and
capacity of the venous blood were low, with a low saturation.
The carbon dioxide content was within normal limits. Excess
carbon dioxide, hypoglycemia and lack of preoperative medica-
tion have been mentioned as causes of these convulsions. How-
ever, none of these conditions could have been active in this
case. The only positive observation was a low oxygen content
of the venous blood despite the administration of 100 per cent
oxygen.

Appendicitis Complicated by General Peritonitis. —
Williamson and Rankin treated thirty-two cases of appendicitis
complicated by general peritonitis without a fatality. They
attribute this result to the immediate removal of the appendix,
after a reasonably brief period of preoperative preparation,
Rapid evacuation of the septic material was secured by placing
the patient in the ventral position. This rapid elimination of
irritating material also tends to prevent postoperative adhesions
and related postoperative complications. They prevented sepsis
in the abdominal wound by leaving the wound open. Anaerobic
bacteria cannot grow in air. If this factor were taken into
consideration in the treatment of general peritonitis complicating
appendicitis, it is doubtful that there would be need for bacterins,
serobacterins, vaccines and the like against anaerobic bacteria.
Thus the open wound prevents sepsis in abdominal wounds.
Paralytic ileus is treated mainly by prevention. The ventral
position aids considerably. The efficacy of prostigmine for this
purpose has been demonstrated. This drug maintains the mus-
cular tone of the intestine by preventing parasympathetic paral-
ysis. In large doses it is a parasympathetic stimulant. In short,
the peritoneum was closed down to the drains, the fascia and
skin were left open and the wound was packed with gauze
saturated with tincture of merthiolate, azochloramide or similar
antiseptic. Deep through and through retention sutures were put
in but left loose in order to pull the edges of the wound together
gradually as the infection disappeared. When the patient was
returned from the operating room he was immediately put on
his abdomen and the head of the bed was elevated from 8 to
12 inches. Routine treatment consisted in liypodermoclysis of
saline and dextrose solution and saline solution intravenously.
An ampule of prostigmine was given every four hours and
morphine was used for pain. Contrary to expectations- the
patients complained of little discomfort because of the position.
The dressings were quickly saturated with the drainage from

the abdomen, necessitating frequent changing during the first
twenty-four hours. The amount of discharge by far exceeded
that of patients placed in the Fowler or other positions. This,
because of rapid elimination of toxic material, undoubtedly
accounted for the rapid drop in the temperature and pulse rate.
As soon as they were tolerated, water and then liquids were
given by mouth ; after thirty-six to forty-eight hours the patient
was put on his back. All patients were discharged from the
hospital well after an average stay of 20.9 days and the wounds
were healed, with the exception in a few cases of a small area
at the site of the drains.

Am. J. Syphilis, Gonorrhea and Ven. Dis., St. Louis

23 : 549-684 (Sept.) 1939

Some Problems in Control of Syphilis as a Disease. J. H. Stokes,
Philadelphia. — p. 549.

•Treatment of Postarsphenamine Jaundice. L. J. Softer, New York.
— p. 577.

Malarial Treatment of General Paresis: Relation of Height, Duration
and Frequency of Fever to Clinical and Serologic Results. I.
Kopp and H. C. Solomon, Boston. — p. 585.

Sulfanilamide versus Suifanilyl Sulfanilamide in Gonococcic Infections.
B. J. Waizak, Cleveland. — p. 5 97.

•Sulfanilamide in Chancroid Disease. R. B. Greenhlatt and E, S.
Sanderson, Augusta, Ga. — p. 605.

Death Following Mapharsen Therapy: Report of Case. S. D. Simon
and A. Iglauer, Cincinnati. — p. 612,

Clinical Application of Twenty-Minute Staining Method for Spiro-
chaeta Pallida in Tissue Sections. A. A. Krajian, Los Angeles. —
p. 617.

Simplified Technic for Administering Old Arsphenamine: Report
on 16,943 Injections Given at Vanderbilt Clinic. A. B. Cannon,
New York. — p. 621.

Postarsphenamine Jaundice, — Since hepatitis is difficult to
reproduce experimentally, its clinical treatment is based on
empirical experience and therefore Soffer points out that the
prevention and treatment of postarsphenamine jaundice assume
increasing importance. When it is considered that from 5 to
10 per cent of the general adult population has syphilis, that a
considerable number of this group is receiving antisyphilitic
treatment and that in 1 per cent of this treated group jaundice
will develop with a mortality rate varying from I to 6 per cent,
there is reason for concern as to the proper methods of treat-
ment. From a review of the clinical and experimental data
presented in the literature concerning the treatment of arsphen-
amine jaundice it is seen that a high carbohydrate diet is well
accepted as an important therapeutic measure. Such diets should
consist of from 400 to 600 Gm. of carbohydrates daily. This
should be divided into five or six feedings. As the sugars fruc-
tose and dextrose are most readily converted into glycogen by
the liver, foods made up of these carbohydrates should be used.
Thus the most desirable are cane sugar, which is hydrolyzed
into dextrose; honey, which is mostly dextrose and fructose;
and fruit juices. When the amount of carbohydrate taken orally
is inadequate, diets should be supplemented by a constant intra-
venous drip of a 5 per cent solution of dextrose. Insulin is
indicated only when glycosuria is present. The use of chola-
gogues and choleretics in the treatment of arsphenamine jaundice
is unsound.

Sulfanilamide for Chancroid,— Greenhlatt and Sanderson
have used sulfanilamide in the treatment of thirty-three cases of
chancroid disease. The doses varied in individual cases, the
average being from 400 to 500 grains (26 to 32.5 Gm.) of sulf-
anilamide. The by-effects were nausea, anorexia, dizziness and
cyanosis. The twenty-seven ambulatory patients were usually
given from twenty-five to forty tablets of sulfanilamide at a
time with instructions for medication and to return every few
days. Treatment was discontinued in one case because a rash
developed, in two because of excessive vomiting and in one
because of cyanosis. With cessation of treatment the untoward
effects abated. Dizziness was the most frequent complaint, but
treatment was never discontinued because of it. Surgical "pro-
cedures other than aspiration of buboes were not performed.
The therapeutic results, for the greater part, were so consis-
tently good that the drug is regarded as a specific. The
previously reported results of the British and American investi-
gators are substantiated. Sulfanilamide proved more efficient
than any of the standard methods in vogue. It succeeded in
some cases in which vaccine therapy had failed.

1768

CURRENT MEDICAL LITERATURE

Joint. A, 51. A.
Nov. 4, 1933

Archives of Dermatology and Syphilology, Chicago

40 : 521-686 (Oct.) 1939

•Immunotherapy for Coccidioidal Granuloma: Report of Cases. H. P.
Jacobson, Los Angeles. — p. 521*

Pyoderma Gangraenosum, Onychogryphosis and Onycholysis with
Ulcerative Colitis. Ida J. Mintzer, Jamaica, N. Y.— p. 541.

Diseases of Skin in Oklahoma Indians. H. Fox, New York. — p. 544,

Differential Diagnosis of Keratosis Blennorrhagica and Psoriasis
Arthropathica, E, Epstein, Oakland, Calif.— p. 547.

Dermatitis Nodularis Necrotica: Report of Case in Which Changes
Characteristic of Lymphosarcoma Were Observed at Necropsy. H.
A. Nieman, Dayton, Ohio, and F. Wise, New York. — p. 560.

Active Spectral Range for Phytogenic Photodermatosis Produced by
Pastinaca Sativa (Dermatitis Bullosa Striata Pratensis, Oppenlieim).
T. Jensen and K. G. Hansen, Copenhagen, Denmark. — p, 566.

Dermatofibrosarcoma Protuberans: Report of Six Cases. G. W.
Binkley, Cleveland. — p. 578.

•Abscesses of Sweat Glands in Adults. P. Tachau, Chicago. — p. 595.

Coccidioidal Granuloma.— Theoretically, the ideal treat-
ment of infectious diseases seems to be tiie administration of
immunogenic antigens capable of activating the tissues and fluids
to production of immune bodies. With this thought in mind,
Jacobson decided to give vaccine treatment a trial in tiie man-
agement of coccidioidal disease. Since 1936 he has treated
twenty-four cases of coccidioidal infection in its various clinical
manifestations by this method. The character, extent of involve-
ment and clinical course of the infection varied considerably.
For the most part the clinical picture at the commencement of
treatment was of the subacute variety. Evidence of past or
present pulmonary involvement was present in the majority of
cases. Next in frequency was involvement of the cutaneous-
subcutaneous system, either as a primary manifestation or secon-
dary to pulmonary or other systemic or structural coccidioidal
disease. Involvement of bone was present in about 30 per cent
of the cases. The aim of all therapeutic efforts was the raising
of the patients’ level of resistance to the existing infection.
Accordingly, all febrile patients were kept in bed at complete
rest. Nutritious and adequate diet, sunshine and fresh air played
a definite part in the therapeutic regimen. Halibut liver oil
with viosterol was given to all patients, and those seriously ill
received injections of ascorbic acid daily or on alternate days.
Anemic, dehydrated and undernourished patients also received
blood transfusions, infusions of dextrose and parenteral injec-
tions of liver extract, according to clinical indications. Injec-
tions of vaccine constituted the specific part of the treatment.
The vaccine was at first given subcutaneously, but later it was
administered by the intravenous route. The standard initial
dose has been 0.05 cc., and each succeeding injection has been
increased by 0.05 cc. at intervals of from eight to fourteen days.
In instances of unduly severe constitutional reaction, the dose
of the succeeding injection was not increased and the interval
was lengthened. A course consisted of from twelve to fifteen
injections. Most patients received two or more courses of
injections, punctuated by intervals of rest of from six to eight
weeks. Five of the patients are still under treatment. Three
are ambulatory and engaged productively but come to the office
for injections of vaccine at regular intervals. All others have
been discharged as fully recovered or are reporting regularly for
observation. Two patients, one with widespread meningeal
involvement and another suffering from the acute fulminating
type of the disease, died. Specific immunogenic therapy is a
rational procedure theoretically and has proved its worth
clinically.

Abscesses of Sweat Glands. — Tachau reports 107 cases of
sweat gland abscesses of the axilla. In 26 per cent a symmetri-
cal involvement of both axillas was noted. In the others only
the right or the left axilla was infected. In ten cases the
abscess formation must be considered as a complication of local
or generalized inflammatory dermatoses (contact dermatitis,
eczema, epidermophytosis, erythrasma or arsphenamine derma-
titis). Two patients were observed with abscesses of the sweat
glands secondary to scabies and furunculosis, and another with
Bockhart's folliculitis. One patient had retrograde lymphangitis
extending down the arm. In other regions the author never
observed a coincidental or successive involvement of many
apocrine glands. Thus, only single abscesses running an acute
course were occasionally observed around the nipple, on the
pubic area, on the labia majora and around the anus. The infec-
tion of the apocrine glands starts from the outside. Local

inflammatory processes, irritation by depilatories or sharing or
the friction of tight clothing often 'favors the infection. The;
should never be considered as the actual causes. According to
present knowledge, abscesses of the sweat glands are due to
infection with Staphylococcus pyogenes aureus (and periapt
albus or citreus). The cultivation of streptococci or other germs
from the abscesses does not prove their etiologic significance.
The prognosis of abscesses of the apocrine glands is alwap
favorable. The treatment of a single abscess consists in to!
application of dressings with a mild ointment (3 per cent of
boric acid in petrolatum) or topovaccines, such as Sherman’s
mixed antivirus cream. Wet applications are not advisable,
since they favor maceration and may give rise to the formation
of new abscesses. As soon as softening occurs, a small incision
is made for evacuating the pus. This is followed instantly bv
a quick and complete cure. Even in the axilla this simple treat-
ment succeeds in uncomplicated cases. When the abscesses
multiply and the patient is disabled, treatment with roentgen
rays is the method of choice. In many cases a small dose
suffices to give relief (from 100 to 120 roentgens, 70 to 80 kilo-
volts, filtered by 3 mm. aluminum; focal skin distance, fa
25 to 30 cm. ; diameter, from 10 to 15 cm.). Two or three days
later the pain is usually gone. For more resistant lesions this
dose must be repeated once or twice at intervals of ten days. 0!
thirty-seven patients treated since 1931 according to this technic,
eight were cured after only one dose of from 100 to 120 roent-
gens ; ten were cured after two exposures, or from 200 to 210
roentgens, while seventeen needed three exposures, or front
300 to 360 roentgens. In only two cases did considerable residual
infiltrations or sinuses make it necessary to repeat the x-ray
cycle after an interval of six or more weeks. Recurrences were
never seen in this series.

Arkansas Medical Society Journal, Fort Smith

SC: 87-102 (Sept.) 1939

Relationship Between Heart Disease and Chronic Pulmonary AiR<* wn<i *
C. T. Chamberlain, Fort Smith, — p. 87. ... n .

Present Status of Antipneumococcus Serum and Sulfapyridine in *» 3 '
agement of Pneumonias.” F. E, Schmidt, Chicago. — p. 91.
Electrocardiography. S. A. Thompson, Camden. — p. 93.

Connecticut State Medical Society Journal, Hartford

3: 479-540 (Sept.) 1939

Treatment of Burns. R. D. McClure, Detroit. — p. 479.

Treatment of Wounds. A. H. Bissell, Stamford.— p. 484. # -

Factor of Delay in Recognition of Common Surgical Conditions.

Ottenheimer, Willimantic. — p. 487. m

Problem of Cleit Lip and Cleft Palate. C. C. Kelly, Hartford.— *P*
Urogenital Deformities. C. H. Neuswanger, IVaterbury. p- 49—,
Congenital Orthopedic Deformities. A. S. Griswold, Bridgeport.—
Management of Congenital Defects of Nervous System. W, J. c
New Haven. — p. 498. „

Medical Air Raid Preparations in England. C. W. Goff, « 3r
p. 504.

Johns Hopkins Hospital Bulletin, Baltimore

65 : 223-290 (Sept.) 1939

Actions of Procaine on Neuromuscular Transmission. A. N. s
London, England. — p, 223. . ... p ros ( 3 {k

"Squamous Metaplasia, Simulating Carcinoma, Associated wi
Infarction. O. S. Culp, Baltimore.— p. 239.

Chemical Reactions of Nicotinic Acid Amide in Vivo. L. u. *
more. — p. 253. , r w nn j e Haiti*

Relation of Psychiatry to Internal Medicine. I. A. v. « '

more. — p. 265. , r „ .. _ r x tr3ct‘-

Use of Low Temperature Ball Mil! for Preparation of Men
H. Eagle, C. Arbesman and W. L. Wirikemverder, Baltimore- P-

Squamous Metaplasia and Prostatic Infarction.-- OP
nous cell metaplasia and infarcts of the prostate hat ■
iescribed independently by several authors but Cu P s
hat the frequent coexistence of these two pathologic P ‘ (e
las been overlooked. In a recent routine study or a P
■emoved by operation, islands of squamous epit c ' u . - n;) |
ibserved along the margins of three infarcts, iuc P <(u( jy
liagnosis was early squamous cell carcinoma. ' . “‘j „j an dufar

if the remainder of the prostate showed only typical g ;n
lyperplasia. Eight additional prostatic infarcts, occ ^

even different cases, were studied and in each instance s ^
ristologic changes were seen, limited to the perip k
nfarcted areas. The uniformity of these observations i
hat benign metaplasia frequently is associated w P
lfarction and may be misinterpreted as carcinoma.

i

volusie 113 CURRENT MEDICAL LITERATURE

Number 19

1769

Journal of the Mount Sinai Hospital, Hew York

6:113-168 (Sept .-Oct.) 1939

Function of Thymonucleic Acid in Living Cells. E, Hnmmarsten*
Stockholm, Sweden.— p. 115.

Psychic Factors in Recurrent Graves’ Disease. S. S. Bernstem, New
York. — p. 126.

Roentgenkymography in Diagnosis of Myocardial Infarct, with Normal
Electrocardiograms. M. L. Sussman, New York.— p. 130.

•Angina Pectoris of Psychogenic Origin. A. M. Master, S. Dack
and H. L. Jaffe, New York. — p. 134.

Deficiency Syndrome and Diffuse Inflammation of Central and Peri-
pheral Nervous System. J. Marmor, New York. — p. 138.

A Chemist Looks at Surfaces. H. Sobotka, New York. — p. 141.

Experimental Auticancerous Immunity. L. Gross, Paris, .France.-"
p. 146.

Angina Pectoris of Psychogenic Origin. — Master and
his associates point out that generally the anginal syndrome is
caused by coronary artery disease and can be differentiated from
a functional syndrome by the type of pain. In the organic type
the pain is nearly always substernal and occurs as a rule after
exertion, meals or excitement, whereas in the functional type the
pain is usually over the precordium or nipple, often lasts longer
and is not related to effort. In the main, this differentiation
holds true but that angina of psychogenic origin may also be
substernal and come on with exertion is illustrated by the case
that they report. Although the anginal syndrome for which the
patient (29 years of age) presented himself was characteristic
of coronary artery disease and at one time was actually diag-
nosed coronary occlusion by a cardiologist, after four years it
became obvious that it was merely the first symptom in what
later became a well established neurotic complex. There cer-
tainly was no organic heart disease, for, after four years, the
physical examination and all laboratory tests are normal. The
authors are cognizant of the claim of some authors that angina
pectoris due to coronary artery disease may be present in the
absence of confirmatory evidence of any kind. However, they
believe that this is rare if all tests are considered, particularly
after a period of several years of observation. While the physi-
cal examination of the heart, fluoroscopy, electrocardiogram,
exercise tolerance, and vital capacity may individually remain
normal, it is improbable that all of these will do so. In the
mechanism of pain in coronary artery disease a nervous mecha-
nism is important, as even when organic coronary artery disease
is present the frequency and severity of the anginal syndrome
are greatly influenced by mental and emotional factors or, in
the words of Heberden, “by passionate affections of the mind.”
Two patients with similar degrees of coronary artery disease
may suffer pain of different severity, depending on the psychic
makeup of each patient. Psychiatrists have emphasized the
importance of the heart as the “specific sense organ of anxiety”
and the close interrelation of the brain with the innervation of
the heart. And, indeed, precordial pain is often the major
symptom of a neurosis without organic basis. While the pain
of organic heart disease is usually related to effort, not infre-
quently such an association is lacking. And pain of psychogenic
origin may come on with effort occasionally. Exertion produces
changes in pulse rate and contraction of the heart which in
susceptible persons may cause sensations of pain, as was true
of the patient presented. It is thus sometimes impossible to
differentiate an anginal syndrome of organic origin from a func-
tional one by the type of pain and its relation to effort.

Journal of Nervous and Mental Disease, New York

90 : 297-42S (Sept.) 1939

Form of Congenital Myotonia in Goats. S. L. Ciark, F. H. Luton and
Jessie T. Cutler, Nashville, Tenn. — p. 297.

Reactions and Behavior of Schizophrenic Patients Treated with Metrazol
and Camphor. B. Glueck and N. W. Acherman, Ossining, N. Y. —
p. 310.

Induction of Seizures hy Closing of Eyes, or by Ocular Pressure, in a
Patient uith Epilepsy: Case Report. L. J. Robinson, Palmer, Mass. —
p. 333.

-Preliminary Observations on Course of Traumatic Psychoses. P. Hoch,
New York, and E. Davidoff, Syracuse, N. Y.~— p. 337.

Unilateral Torsion-Dvstonia: Clinicohistologic Study: Case. R. Gordin,
Helsingfors, Finland.-— p. 344.

Death Associated with Metrazol Therapy: Report of Case. R. M.
Fellows and F. Koenig, Osawatomie, Kan, — p. 358.

Course of Traumatic Psychoses. — In order to ascertain
the prognosis and ultimate fate with regard to patients who
became psychotic following head injury, Hoch and Davidoff
investigated the records of 251 consecutive cases of traumatic

psychoses. The preponderance of cases in males (205) is due
to the more frequent exposure of men to trauma and in part to
occupational causes. Many of the traumatic psychoses were
not psychoses due purely to the trauma alone but were asso-
ciated with other conditions. Of the total number of cases 117
were complicated, in order of their frequency, hy alcohol,
cerebral arteriosclerosis, senility, neurosyphilis and other mis-
cellaneous conditions such as mental deficiency and epilepsy'.
These complicating factors are of prognostic importance, as the
prognosis is graver in these cases than in those in which no
complicating factor exists. Senility and cerebral arteriosclerosis
offer the gravest prognosis. The outlook is possibly rendered
less hopeful in those cases in which there is an antecedent dis-
turbance to the cerebral circulation. Besides the foregoing
complicating concomitants there is another factor which has
not been stressed sufficiently in relation to the traumatic psycho-
sis group. An important prognostic determinant is the previous
personality organization of the patient who has sustained an
injury to the head. Of the schizoid personalities, 75 per cent
were definitely unimproved. For patients more of the syntoid
type, the prognosis was far better and the percentage of recovery
and improvement greater. The ratio of unimprovement in the
introvert type as compared to the extrovert type was approxi-
mately 2 : 1. Hallucinations and delusions were present in many
cases but were not accompanied by neurologic phenomena char-
acteristic of cortical or subcortical lesions. In the absence of
these signs, it would be very difficult to attempt any localization
of these psychic manifestations. While it is commonly known
that hallucinations and delusions may occur in transitory form
in any organic psychosis during the delirious state, they tend to
disappear in concomitance with the improvement or recovery
of a patient from the confusion or clouded state. In the trau-
matic psychoses, however, an important feature has been that
a patient witli a schizoid or introvert makeup regains his mnestic
functions and the approximate lucidity of his prepsychotic intel-
lectual state but unharmoniously retains the hallucinations and
delusions. Other factors no doubt enter into the clinical pic-
ture of the more protracted cases. In addition to the stresses
and strains to which the patient is exposed and his reaction to
change and thwartings, to financial and family situations, to
occupation and to the important questions of compensation and
litigation, attention should be focused on the previous personality
makeup and what bearing this has on how the individual reacts
to the situation. Also it is likely that study of the personality
would greatly aid in the understanding of traumatic neuroses.

Journal of Pharmacology & Exper. Therap., Baltimore

67 : 1-126 (Sept.) 1939. Partial Index

Action of Sympathomimetic Amines in Cyclopropane, Ether and Chloro-
form Anesthesia. O. S. Orth, M. D. Leigh, C. H. Mellish and J.
\V. Stutzman, Madison, Wis. — p, 1,

Pharmacology of Trimethyl Bismuth. T. Soilmann and J. Seiftcr
Cleveland. — p. 17.

Analeptic Potency of Sympathomimetic Amines. M. L. Tainter, L. J.
Whitsell and J. M. Dille, San Francisco. — p.‘ 56.

Action of Sulfapyridine (2-SulfaniIy! Aminopyridine). H. M. Powell
and K. K. Chen, Indianapolis. — p. 79.

Toxicity, Fats and Excretion of Propylene Glycol and Some Other
Glycols. P. J. Hanztik, H. \V. Newman, \V. Van Winkle Jr., A.
J. Lehman and N. K. Kennedy, San Francisco. — p. 101.

General Metabolic 3nd Glycogenic Actions of Propylene Glycol and
Some Other Glycols. P. J. Hanztik. A. J. Lehman, W. Van Winkle
Jr., and N. K. Kennedy, San Francisco. — p. 114.

Kentucky Medical Journal, Bowling Green

37 : 377-422 (Sept.) 1939

Responsibility of the Physician in Lunacy Inquests. J. G. Wilson
Frankfort. — p. 377. *

Clinical Diagnosis in General Practice. T. A. Griffith, Mount Vernon —
p. 381.

Exhibits of the A. M. A. at St. Louis, May 1939. M. Casper, Louis-
vule.— p. 385.

Endocrine Therapy in Gynecology and Obstetrics. S. S. Gordon Louis-
ville. — p. 392.

Annular Skin Lesions of Body Mistaken for Ringworm Infections.
\V. u. Rutledge, Louisville. — p. 390.

Treatment of Infected Wounds. J. E. Hamilton, Louisville. — p. 398

Treatment of Carbuncles. A. D. WiHmoth, Louisville.— p. 402

Some of Newer Drugs and Their Uses. D. T. Roberts, West Point —

p. 4uo.

Armamentarium of Cardiac Therapy. M. If. Weiss, Louisville.— p 409

Hydronephrosis. L. Atherton, Louisville.— p. 412.

1770

CURRENT MEDICAL LITERATURE

Jobs. A. M. A
No'". 4, uj:

Maine Medical Association Journal, Portland

30:213-246 (Sept.) 1939
Hip Nailing. G. M. Morrison, Boston. — p. 213.

Traumatic Shock. F. G. Balch Jr., Boston. — p. 216.

Anesthesia for Traumatic Surgery. S. C. Wiggin, Boston. — p. 219.
Tracheotomy: Bronchoscope as Aid in Emergency Cases. E. L. Pratt,
Lewiston. — p. 222.

Michigan State Medical Society Journal, Lansing

38: 741-836 (Sept.) 1939

Opportunities for Continuous Medical Education in Wayne County.
R. B. Allen, Detroit. — p. 759.

Congenital Dislocation of Hip. F. C. Kidner, Detroit. — p. 762.
Pyometritis Associated with Metrojnenorrhagia. C. B. Loranger, Detroit.
— p. 768.

Limitations of Transurethral Prostatectomy. R. M. Nesbit, Ann Arbor.
— p. 770.

Nontuberculous Pneumothorax Proved by Autopsy: Case. R. L. Fisher,
Detroit. — p. 774.

Military Surgeon, Washington, D. C.

S5: 197-276 (Sept.) 1939

Syphilis and Mobilization. W. F. Lorenz and W. J. Bleckwenn. — p. 197.
Activities of Military Surgeons in International Congresses of Military
Medicine and Pharmacy. W. S. Bainbridge. — p. 211.

Oral Pain as Factor in Diagnosis. H. B. DierdorfF. — p. 216.

Treatment of Lobar Pneumonia with Serum and Sulfanilamide. H. P.

Marvin and E. P. Campbell. — p. 224.

Army Medicodental Relationship. W, I. French. — p. 232.

Anxiety Neurosis. M. E. Segal. — p. 239.

Cold and Heat Therapy in Dentistry. C. C. Ellison. — p. 241.

Minnesota Medicine, St. Paul

22: 595-666 (Sept.) 1939

Tuberculosis Problem Viewed in the Light of Recent Pathologic Studies.
H. C. Sweany, Chicago. — p. 595.

Treatment of Vaginal Discharges. E. D. Plass, Iowa City. — p. 610.
Placenta Accreta. J. C. Feuling, Bovey. — p. 615.

Cerebral Calcification (Parkes Weber-Dimitri Type). G. R. Kamman,
St. Paul. — p. 618.

Parenteral Administration of Fluids: Principles and Indications in Sur-
gical Treatment. M. A. Falconer, Rochester. — p. 621.

*Carbon Monoxide: A Public Health Hazard. L. B. Franklin, Minne-
apolis. — p. 628.

The Medical Library: A Laboratory for the Literary Physician. T. E.
Keys, Rochester. — p. 633.

Traumatic Inguinal Hernia. S. R. Maxeiner and H. E. Hoffert, Minne-
apolis. — p. 636.

Pseudodiaphragmatic Shadow Due to Pleural Fluid. O. Lipschultz,
Minneapolis. — p. 638.

Public Health Hazard of Carbon Monoxide. — The haz-
ards of carbon monoxide to public health are discussed by
Franklin, who states that ordinarily it does not appear in nature
but results almost entirely from incomplete oxidation of car-
boniferous material. It has been reported to have been formed
in large amounts during severe electrical storms and to have
been produced by growing kelp. It is present when buildings
burn, is produced in lime, brick and charcoal kilns, is present
following explosions and fires in mines and it is also produced
on detonation of high explosives. In the laboratory it is pro-
duced by heating formic or oxalic acid with sulfuric acid. It
is found in smoke and in compartments which have been painted
with oil paints and sealed. It has even been reported formed
from burning cigarets. About 16 per cent of coal gas is carbon
monoxide, 28 per cent of blast furnace stack gas, from 1 to
8 per cent of mine air after dust explosions is carbon monoxide
and about 7 per cent of the exhaust from automobile motors.
The author points out that 5 per cent of the cars tested on the
highways by Van Deventer showed a dangerous concentration
(0.03 per cent or more) of carbon monoxide in the air that
the driver breathed. The public should be educated on all phases
of the hazard, and especially those likely to come in contact
with a high concentration of carbon monoxide, such as firemen
and policemen. It should be able to recognize symptoms, know
the incidence and be able to give first aid. Statistics should
be compiled and made available to the public. Methods of
accurately detecting injurious amounts of the gas in air should
be developed and the public educated in detecting the gas in
homes, garages, motor cars and other places. A possible solu-
tion of this point could be that the gas companies when installing
gas in a home or apartment be required to supply each patron
with a piece of apparatus for detecting leaking gas. There
should be more experimentation to determine better methods of
treatment. Legislation should be enacted for the elimination of
the hazard in factories, public garages, mines and wherever there
are employees. Such legislation should be supplemented by
regular inspection under public health jurisdiction.

Missouri State Medical Assn. Journal, St. Louis

36: 353-382 (Sept.) 1939

Late Advances in Diseases of Pancreas. W. H. Cole, Chicago.-p. Jjl
The Female Sex Hormones: A Digest. F. H. Scharles and A. Sopth:
Kansas City. — p. 359.

Ophthalmia Neonatorum. L. C. Drews, St. Louis.— p. 366.

Loss of Eyesight in Children Due to Refractive Errors and Crossed Eics.
W. L. Post, Joplin. — p. 368.

Congenital Syphilis and Its Effect on Eyesight. P. S. Lueddc, St. Lois
— p. 371.

"Causes and Prevention of Blindness in Adults: Role of the Gened
Practitioner. J. McLeod, Kansas City. — p. 372.

Industrial Eye Injuries and Hazards: Their Prevention and Treatment
R. E. Mason, St. Louis. — p. 373.

Conservation of Eyesight. C. P. Dyer, St. Louis.— p. 374.

Blindness in Adults. — In discussing the prevention of blind-
ness in adults, McLeod examines a typical set of statistics, the
tabulation of 11,852 cases of blindness in Pennsylvania. When
all congenital anomalies, for which treatment is of little avail
in any case, traumatism, all external infections (except gonor-
rheal conjunctivitis but excluding ophthalmia neonatorum) r J
all predominantly juvenile diseases are excluded a total of 8,/
cases remains. If ulcerative keratitis (194) is also eliminat
on the assumption that all cases were due to external infect!
and ail cases of senile cataract (2,666) there remain 5,919 cas
of blindness due to general disease. It is questionable if sea
cataract should be omitted, since under this diagnosis we
classified all cases of diabetes in which the cataracts develop
after the age of 50 and since complete blindness with catara
depends on some retrolenticular disturbance. Breaking dov
this figure of 5,919 cases due to general disease gives the folio'
ing incidence : uveitis (all causes) 25.3 per cent, choroidil
8.2 per cent, chronic glaucoma 24.8 per cent, acute glaucon
1.9 per cent, vascular diseases (including diabetic and nephnl
retinitis) 10.6 per cent, optic atrophy 20.3 per cent and neur
retinitis 5 per cent. This group makes up a total of 96.1 p
cent of the 5,919 cases. If from this group glaucoma is excludi
there is still 69.4 per cent of these cases (approximately 35 P 1
cent of the total number) the origin of which lies in son
systemic condition with focal infection, vascular disease, syphil
and tuberculosis predominating. The importance of watchir
for early optic nerve changes in syphilis cannot be too strong!
emphasized. Here, as in glaucoma, the disease may pres rC:
to a dangerous point before visual acuity is noticeably diminish 0
particularly if the patient is not too intelligent. Recognita
of the possible causal agents of certain eye conditions, notab
iritis and uveitis, is of great help in searching for the prow ■
factor (usually focal infection or syphilis) responsible for then
Knowledge of the ophthalmologic pictures in chronic disease
involving the vascular systems is of help in formulating ^
diagnosis and prognosis of these conditions. Nothing can
done about them by local measures and their treatment reso vt
itself into treatment of the underlying disease.

New England Journal of Medicine, Boston

221: 367-402 (Sept. 7) 1939

Carcinoma of Fallopian Tube. L. Parsons, Boston.— p. 367. gy!:
Evolution of Treatment of Pulmonary Tuberculosis at tbe Rutin
Sanatorium. P. Dufault, Rutland, Mass. — p. 374. „ c:

Calculus Formation in Urethral Diverticulum in a Woman: 1 ^

Case. E. A. Gaston and J. Ferrucci, Framingham, Mass. P-
"Meningitis Due to Micrococcus Tetragenus:_ Report of
Recovery Following Treatment with Sulfanilamide. Al.

Jr., Pittsfield, Mass. — p. 383. .

Radiation Therapy. R. Dresser, Boston. — p. 386. _ ,

Meningitis Due to Micrococcus Tetragenus.—Cjff
tiello reports a case of meningitis due to Micrococcus te 01
with recovery. A lumbar puncture was done, and 1 1 °
phology, the staining reaction and the cultural c “ a . r . ac C occui
of the organisms were consistent with those of Micr ^
tetragenus. Ordinarily this organism is found in the
throat, where it is not considered to be pathogenic. 0 ;

this patient gave no history of infection of the upper P ^
the respiratory tract, it is likely that the organism 0 :,j
entrance to the central nervous system from the rign
sinus. Therefore, one should carefully examine the upp {
of the respiratory tract for possible foci of infection 1 '
cases. A blood culture was not done on the day ot a
Although one taken seven days later was negative, c ^ t]0 ,
had already been taking sulfanilamide for .five days. _♦ deal-
is of the opinion that in this type of meningitis one is n

Volume 113
Number 19

CURRENT MEDICAL LITERATURE

1771

ing with a virulent type of organism and that if the patient can
be kept alive until he has manufactured enough immune bodies
he will recover. Were the author again faced with the same
situation, he states that he should look for possible foci of infec-
tion in the upper part of the respiratory tract, give supportive
treatment, do a lumbar puncture as often as indicated by the
patient’s condition and give sulfanilamide in adequate doses.

Hew Orleans Medical and Surgical Journal

92:113-170 (Sept.) 1939

The Medical Profession; A Businessman’s Point of View. E. D.
Rapier, New Orleans. — p. 113.

Toxic Effects of Sulfanilamide and Sulfapyridine. C. Brooks, New
Orleans, — p. 115.

Emotional Factors in Disease. T. A. Watters, New Orleans. — p. IIS.
Diagnostic Survey of the Allergic Patient. N. K. Edrington, New
Orleans. — p. 125.

The Eye and Its Care. L. F. Gray, Shreveport, La. — p. 131.

Use of Anatomicophysiologic Incision in Appendicitis. H. S. Coon,
Monroe, La. — p. 135.

Diagnosis and Treatment of Diabetes. M. Gardberg, New Orleans. —

p. 137.

Management of Diabetic Acidosis and Diabetic Coma in a General Hospi-
tal. H. J. Frachtman, New Orleans. — p. 143.

Bacillus Pyocyaneus Meningitis: Report of Six Cases. R. A. Wise and
J, H. Musser, New Orleans. — p. 145.

New York State Journal of Medicine, New York

39: 3707-1816 (Sept. 15) 1939

-Treatment of Types V, VII and VIII Pneumococcus Pneumonia with
Rabbit Antipneumococcus Serum. E. H. Loughlin, R. H. Bennett
and S. H. Spitz, Brooklyn. — p. 1713.

Treatment of Type III Pneumococcus Pneumonia with Sulfanilamide.

R. H. Bennett, S. H. Spitz and E. H. Loughlin, Brooklyn. — p. 1722.
Industrial Low Back from Orthopedic Standpoint. S. Kleinberg, New
York— p. 1725.

Neurologic Aspects of Backache. E. D. Friedman, New York.-— p. 1734.
Herniation of Nucleus Pulposus and Hypertrophied Ligamenta Flava.

D. M. Bosworth and C. C. Hare, New York. — p. 1739.

Uniden'' r ' ~ " ' " ■ Bacillus Lignieri and Pasteur-

ella . r Man. J. I. Schleifstein and

Mari

Evaluation of Laughlen Test in Diagnosis of Syphilis: Report Based on
2,005 Tests. J. Churg and N. Sobel, New York. — p. 1754.

Indications for Estrogen Therapy: Including a Preliminary Report on
Use of Two New Estrogen Preparations (Estradiol Dipropionate and
Diethyl Stilboestcrol) and Subcutaneous implantation of Crystalline
Estradiol Benzoate. S. H. Geist and U. J. Salmon, New York. —
P. 1759.

Dispensary Diabetics. A. H. Terry Jr. and S. Folk, New York. —
p. 1768.

Some School Hearing Surveys, Analysis and Observations. E. M.
Freund, Albany. — p. 1770.

Treatment of Acute Encephalitis by Intravenous Injection of Hypotonic
Salt Solution. G. M. Retan, Syracuse. — p. 1774.

Vaccine Therapy in the Rheumatic Patient. H. Weiner, Brooklyn. —
p. 1786.

Evaluation of Sulfanilamide Therapy in Acute Otitis Media and Mas-
toiditis. J. C. Seal, New York. — p. 1790.

Irradiation as Adjunct to Surgery :n Substernal Thyroid: Response of
Recurrent Fetal Adenoma. I. I. Kaplan and S. Rubenfeld, New York.
— p. 1795.

Rabbit Serum for Pneumonia. — Loughlin and his col-
leagues used unconcentrated and refined rabbit antipneumococcus
serum in the treatment of forty-one patients with pneumonia
due to the type V pneumococcus, forty-six due to the type VII
organism and thirty-eight with type VIII pneumonia. In the
first group the pneumonia had been present for an average of
ninety hours, with extremes of twenty-six and 192 hours, before
rabbit serum was administered. Nine patients had bacteremia
when first seen. The average dose of rabbit serum was 290,000
units, and crisis occurred in an average of fourteen hours. Forty
patients recovered, and one died. This patient, who was not
given serum until 120 hours after onset, died apparently during
a thyroid crisis. Thirty-two patients, six of whom had bac-
teremia, were successfully treated with one dose. In these
patients, crisis occurred in an average of eight and one half
hours; the average single dose was 246,000 units. The blood
stream was sterilized in every instance after the administration
of the projected dose. Serum sickness developed in eleven
patients. In the patients with pneumonia due to pneumococcus
type VII the disease had been present for an average of eighty-
three hours, with extremes of twenty and 192 hours, before
rabbit serum was administered. Sixteen patients bad bacteremia
on admission. The average amount of rabbit serum given was
340,000 units. Crisis occurred in an average of fifteen hours.
Forty-four patients recovered and two died. In these two fatal
cases a severe bacteremia was found and serum therapy was
delayed until ninety-six and 144 hours, respectively. One patient
was moribund on admission, had pulmonary edema and died

within twelve hours after treatment with serum was begun.
Thirty-six patients, seven of whom had bacteremia, were success-
fully treated with one dose. In these patients, crisis occurred
in an average of nine and one half hours; the average single
successful dose was 279,000 units. The blood stream was
sterilized in every instance after the projected dose. Serum
sickness developed in nine patients. In the remaining thirty-
eight patients the type VIII pneumonia had been present for
an average of seventy-nine and one half hours, with extremes
of fifteen and 336 hours, before rabbit serum was administered.
Twelve patients had bacteremia on admission. The average
amount of rabbit serum given was 300,000 units. Crisis occurred
in an average of twelve hours. All the patients recovered.
Thirty-four patients, of whom nine had bacteremia, were success-
fully treated with one dose. In these patients, crisis occurred
in an average of ten hours; the average single successful dose
was 269,000 units. The blood stream was sterilized in every
instance after the administration of the projected dose. Serum
sickness developed in nine patients. This generally consisted of
fever, urticaria and arthritis. These symptoms usually were
mild or moderate in severity, although in a few instances a
rather severe arthritis was noted. There were no instances of
lymphadenitis. The authors conclude that the effectiveness of
any therapy in pneumonia depends on (1) the rapidity with
which it can destroy the pneumococci in the tissues of the lung
and in the blood stream, (2) how quickly it can neutralize the
toxins and reduce the toxemia, (3) the rapidity with which it
can supply pneumococcus antibodies or stimulate their formation
and (4) the absence of untoward reactions that would endanger
the patient’s life. They find that the homologous unconcentrated
and refined rabbit antipneumococcus serum fulfils these require-
ments in the treatment of types V, VII and VIII pneumonia.

Ohio State Medical Journal, Columbus

35 : 913-1032 (Sept.) 1939

Present Status of Silicosis. A. J. Lanza, New York.— p. 929.

Fainting Attacks: Mechanism and Treatment of Certain Clinical Types.
E. B. Ferris Jr., Cincinnati. — p. 933.

End Results Following Common Duct Obstruction. F. M. Douglass,
Toledo.— p. 938.

Vitamins in Ophthalmology and Otolaryngology: Review of Recent
Experimental and Clinical Observations. W. H. Evans, Youngstown.
— p. 944.

Facts and Theories of Nasal Disease. R. J. Frackclton, Lakewood. —
p. 949.

Statistical Study of Alcoholic Psychoses. N. \V. Kaiser, Toledo. — p. 952,

Exploded Theories of Ovulation: Various Notions on When Ovulation
Occurs and Their Bases. R. D. Bryant, Cincinnati. — p. 955.

Important Features in Treatment of Fractures. A. F. Vosbell, Baltimore.
— p. 959.

Acute Abdominal Pain. E. A. Marshall, Cleveland. — p. 966.

Allergy and Nutrition. J. Forman, Columbus.— p. 973.

Pennsylvania Medical Journal, Harrisburg

43: 1425-1648 (Sept.) 1939

Syphilis Acquired from Transfusion and Its Control. F. J. Eichenlaub
and R. Stolar, Washington, D. C. — p. 1437.

Rational Application of Sulfanilamide Therapy to Streptococcic Infec-
tions. J. S. Lockwood, Philadelphia. — p. 1444.

Mechanism and Management of Surgical Shock. N. E, Freeman, Phila-
delphia. — p. 1449.

Scope and Problems of Plastic Surgery. H. May, Philadelphia.— p. 1453.

Growth m Diabetic Children. J. H. Barach, Pittsburgh.— p. 1459.

Chemotherapy in Treatment of Urinary Tract Infections. S. II,
Johnson 3d, Pittsburgh.— p. 1468.

Chemotherapy in Septicemia, F. G. Harrison, Philadelphia. — p. 1473.

Chemotherapy of Gonorrhea in the Male. F. P. Massaniso and F. S.
Schofield, Philadelphia. — p. 14/6.

Treatment of Tuberculosis in the Commonwealth of Pennsylvania.
Edith MacBride-Dexter, Sharon, and M. Behrend, Philadelphia. —
p. 3481.

Role of the Pediatrician in Relation to Surgery. J. Crump, Philadelphia.
— p. 1492.

Etiology of Hydronephrosis. B. C. Blaine, Pottsville. — p. 1498.

.Public Health Reports, Washington, D. C.

54: 1587-1624 (Sept. 1) 1939

“Influences" of Breast Cancer Development in Mice. J. J. Bittner.

Influence of Foster Nursing on Incidence of Spontaneous Breast Cancer
m Strain C*H Mice. H. B. Andervont and W. J. McElency.— n 1597
F C . C C. Tn°er.-p! ^ ° n D "clopment of Tumors in Mice!

54: 1625-1662 (Sept. 8) 1939

Dental Programs Sponsored by Health Agencies in Ninety-Four Selected
Counties J. W. Mountm and Evelyn Hook.— p. 1625.

Solubility of Lead Arsenate in Body Fluids. L. T. Fairhali — o 1616
j“j. Bi«ner.-p d UK*™ Rdation5hi P postered A Sto^k Mice.

1772

CURRENT MEDICAL LITERATURE

Jour. A. M. K
Nov. 4, is))

Rhode Island Medical Journal, Providence

22: 147-160 (Sept.) 1939

Selection of Patients for Surgery. E. C. Cutler, Boston. — p. 147.

South Carolina Medical Assn. Journal, Greenville

35 : 217-242 (Sept.) 1939

Acute Intussusception with Intermittent Spontaneous Reduction and
Recurrence. R. F. Zeigler Jr., Seneca. — p. 217.

Review of Cesarean Sections in Greenville County. R. M. Dacus Jr.,
Greenville. — p. 219.

Southern Medical Journal, Birmingham, Ala.

32 : S91-982 (Sept.) 1939. Partial Index

Compound Fractures and Their Treatment. A. T. Moore and J, T.
Green, Columbia. — p. 891.

Orthopedic Care of Convalescent Poliomyelitis: Report of Sixty-Three
Cases One Year Following Acute Onset. W. V. Newman, Little Rock,
Ark.— p. 900.

Metastatic Cancer in Lymph Nodes of Neck. H. G. F. Edwards, Shreve-
port, La. — p, 905.

Cancer of Larynx and Its Treatment by Total Laryngectomy. S. Israel,
Houston, Texas. — p. 911.

Sickle Cell A"emia with Cerebral Thrombosis. A. I. Joscy, Columbia.
S. C.— p. 915.

Extragenital Granuloma Venereum: Report of Case. E. R. Pund, A. D.
Smith, D. Y. Hicks and R. B. Dienst, Augusta, Ga. — p. 917.

Congenital Factor in Acquired Diverticulosis of Jejunum and Ileum.
G. H. Bunch, Columbia, S. C. — p. 919.

Head Injuries. A. W. Adson, Rochester, Minn. — p. 926.

Treatment of Congenital Syphilis with Intravenous Arsenical : Analysis
of 204 Clinical Cases. J. K. Howies, New Orleans. — p. 940.

Purpura Annularis Telangiectodes: Report of Two Additional Cases.
E. R. Hall and V. A. Hall, Memphis, Tenn. — p. 953.

*Nonpollen Factors Simulating Seasonal Respiratory Allergy. H. E.
Prince, Houston, Texas. — p. 956.

Industrial Hygiene as a Function of a State Department of Health.
G. W. Cox and C. A. Nau, Austin, Texas. — p. 960.

Nonpollen Factors Simulating Seasonal Allergy. —
Prince discusses some of the so-called miscellaneous factors
that have been so important in several of his cases that they
must be regarded as the primary excitants in what otherwise
appeared to be true pollinosis ; in other instances they have
assumed equal importance with pollens in determining seasonal
symptoms. As a basis for this report he has selected 150
patients with respiratory allergy studied during the past two
years. Of these, ninety-two have symptoms in one or more
well defined seasons and fifty-eight have definite yearly sea-
sonal exacerbations. Symptoms of this group are distributed
as follows : asthma thirty-eight, hay fever seventy-five and hay
fever and asthma thirty-seven. Grass is the most important
seasonal inhalant factor (91 per cent) encountered in the spring,
followed by trees with 58 per cent. But also 54 per cent of
the spring patients reacted to air-borne molds, 71 per cent to
danders, 83 per cent to. house dust and 25 per cent to orris
root, while only 5 per cent reacted to pyrethrum. Similarly
92 per cent of summer patients reacted to grass, and almost
as many to house dust (88 per cent) and danders (66 per cent)
as in the spring group. However, the percentage of mold
reactions is 75, compared with 54 for the spring ; orris root
is about the same (28 per cent) and pyrethrum is increased
to 17 per cent. In the fall group 90 per cent reacted to rag-
weed, 72 per cent to grass and 26 per cent to chenopodiales ;
to other factors, reactions occurred as follows: dust 90 per
cent, molds 68 per cent, danders 62 per cent, orris root 21
per cent and pyrethrum 7 per cent. In the winter only 35
per cent reacted to pollens (trees), while 98 per cent were
sensitive to house dust; 77 per cent reacted to danders, 66 per
cent to molds, 35 per cent to orris root and 14 per cent to
pyrethrum. In none of the four major seasons, then, can pol-
lens be considered as the entire cause of symptoms. Therefore
more attention should be given nonpollen factors which may
complicate what appear to be simple cases of seasonal allergy.

Western J. Surg., Obst. & Gynecology, Portland, Ore.

47: 507-560 (Sept.) 1939

Relationship Between Cause and Distribution of Spasticity in Childhood.

S. F. Stewart, Los Angeles. — p. 507.

Infective Prostatitis: Critical Review. W. R. Jones, Seattle. — p. 511.

Mucocele of Appendix; Report of Twelve Cases. J. C. Doyle, Beverly
Hills, Calif. — p. 515.

Treatment of Severe Thyrotoxicosis. W. O. Thompson, S. G. Taylor 3d,

R. W. McXealy and K. A- Meyer, Chicago. — p. 522.

Recurrent Toxic Goiter. R. F. Bowers, New York. — p. 536.

Surgical Approach to Hypertension: Division VIII. F. M. Findlay,
San Diego, Calif. — p. 5-13.

FOREIGN

An asterisk (*) before a title indicates that the article is abstract*!
below. Single case reports and trials of new drugs are usually omittt!

British Journal of Experimental Pathology, London

20: 297-370 (Aug.) 1939

Purification of Diphtheria Toxoid. C. G. Pope and F. V. Linrjood.-
p. 297.

Effect of Foreign Tissue Extracts on Efficacy of Influenza Virus Vac-
cines. C. H. Andrewes and W. Smith. — p. 305.

Experimental Acute Perchloride Intoxication. G. L. Montgomery--
p. 316.

Purification of Insect-Transmitted Plant Viruses. F. C. Bawden anil
N. W. Pirie. — p. 322.

Pantothenic Acid and Growth of Streptococcus Haemolyticus. H.
Mclhvain. — p. 330.

Glutamine and Growth of Bacteria. P. Fildes and G. F. Gladstone.-
p. 334.

Extravascular Development of Monocyte Observed in Vivo. R. H. Etert
and H. W. Florey. — p. 342.

Metabolism of Lactic Acid in Diphtheritic Toxemia. C. R. Dawson and
E. Holmes. — p. 357.

British Journal of Urology, London

11 : 207-304 (Sept.) 1939

Cysts of Kidney Due to Hydrocalycosis. K. H. Watkins. — p. 207.
*Role of Vitamin A Deficiency in Etiology of Renal Calculus. H. Lon?
and L. N. Pyrah. — p. 216.

Pyelograpluc Reactions. T. Moore. — p. 233.

Vitamin A Deficiency and Renal Calculus. — Long and
Pyrah studied twenty-five cases of upper urinary lithiasis for
vitamin A deficiency together with sixty-five control subjecls
drawn from healthy people of different economic grades of
society. Whereas 75 per cent of the control subjects gave a
normal dark adaptation reading, only 36 per cent of the patients
who bad suffered from urinary lithiasis showed normality. The
reading of the remaining 25 per cent of the normal individuals
fell just short of the required standard of normality. There
were no definitely subnormal readings, whereas among the
64 per cent of the patients suffering from urinary lithiasis 24 per
cent were slightly subnormal and 40 per cent were definitely
subnormal. After concentrated vitamin A therapy (13,000 units
daily for four or five weeks) given to selected patients, 4- per
cent gave normal and 58 per cent subnormal readings. One or
two patients showed a slight improvement, but this proportion
was small and 33 per cent remained definitely subnornia.
Therefore dietary deficiencies alone cannot account for IC
differences in readings between the selected patients and
control subjects, and it would certainly appear from the resu s
that a low 'body reserve of vitamin A is- commoner anions
patients who had had a urinary calculus even at some mt £r ' a
after operation than among other ordinary healthy members o
the community. The results are somewhat similar to those o
Ezickson and Feldman, and of Higgins, although the au |'°'
state they are not so definite. Too much importance mns

be attributed to the vitamin A deficiency found among
40 per cent of the patients with urinary lithiasis. The ger

the

neral

evidence and the results point to this deficiency as only a
tributory part in the etiology of urinary lithiasis. At the sa
time it is interesting that a course of vitamin A therapy
such poor results in raising the vitamin A reserves among
patients, when it is known that such therapy among I’ e ? p c c .
are suffering from dietary deficiencies can usually effect imp
ment in two or three weeks. Various explanations have ,,
advanced to explain these facts. The deficiency m'S 1
explained by excretion of vitamin A in the urine. The de a
and its apparent inability to be remedied by the oral atm
tration of the vitamin may be perhaps the result and n °
cause of the disease and may be related to impairment ot
function which may be found in some of these patients,
hypothesis the authors believe is worth further mves ig- ^
Those selected patients with a short clinical history an
evidence of derangement of kidney function and those wit > £

slight or no infection of the urine before operation usually £;
normal readings. On the other hand, those with a long c
history with its possible effects on the kidney tissue or
who presented evidence of long standing chronic urinary
tions, with blood, albumin and bacteria in the urine j.
operation, generally gave definitely subnormal readings,
this hypothesis were true, it would also provide an exp
for the normal dark adaptation reading of some of the pa

Volume U3
Number 19 .

CURRENT MEDICAL LITERATURE

1773

and for the lack of improvement among the subnormal ones
after vitamin A therapy. The urine of eight definitely sub-
normal patients was tested for the presence or absence of vita-
min A and also any obvious evidence of impaired kidney function
was observed. This investigation failed to show any definite
evidence of gross renal damage and in no case was vitamin A
to be found in the urine. It seems, therefore, that loss of vita-
min A by excretion in the urine cannot account for the low
vitamin A reserves found in these cases of renal calculi, and
it would appear that the deficiency is more likely to be cor-
related, as already postulated by Jeghers and Moore, with some
defect in the metabolism of the patient or with an inability to
absorb the vitamin from the diet. Nevertheless, it is the authors’
intention to continue with these investigations on similar patients
before operation so that the degree of the importance of this
vitamin A deficiency in urinary lithiasis can be interpreted more
exactly.

Edinburgh Medical Journal

4G: 581-612 (Sept.) 1939

Disseminated Sclerosis: Review of Modern Work on Its Etiology. A. J.
Rhodes.- — p. 581.

Periodicity of Influenza. J. H. D. Webster. — p. 591.

Indian Medical Gazette, Calcutta

74:449-312 (Aug.) 1939

Rat Bite Fever in Calcutta. R. N. Chopra, B. C. Basu and S. Sen. —
p. 44 9.

Treatment of Lobar Pneumonia with SuHapyridine. A. Caplan. — p. 451.
“Treatment of Nervous Diseases by Vitamin Bt, with Special Reference
to Trigeminal Neuralgia: Report of Seven Cases. I. Bakhsh. — p. 456.
Infection with Giardia Lamblia: Its Pathogenicity and Treatment.

R. N. Chopra, B. M. Das Gupta, B. Sen and Z. Ahmed. — p. 458.
Difficulties and Dangers in Providing Donors of Blood. S. D. S. Greval
and S. N. Chandra. — p. 461.

Chordoma. M. N. Dc and B. P. Tribedi. — p. 465.

Certain Cyclic Changes Observed in Blood Pictures of Cases of Untreated
Anemia Complicating Pregnancy in Tea Estate Coolies. K. P. Hare.
— p. 467.

Experimental Malaria Infections in Two Races of Anopheles Stephens!.

P, F. Russell and B. N. Mohan. — p. 469.

“Ionizable Iron in Cow's and Mother’s Milk. J. C. Pal. — p. 470.

Five Years of Antimalaria Work at Banvadih Railway Settlement. N.
Ahmed. — p. 472.

Moniliasis with Secondary Allergic Patch or Monilide: Case. L. M.
Ghosh. — p. 476.

Thiamin Chloride for Trigeminal Neuralgia.— Seven
cases of trigeminal neuralgia have been treated with thiamin
chloride and Bakhsh states that in six of these improvement
ranged from 100 (in four) to 30 per cent. The patient who
did not respond to this therapy gave a history of syphilis and
although the Wasscrmann reaction was negative he was given
a course of mercury and iodides by mouth without any relief.
The four patients who were completely relieved received 160,
210, 84 and 90 mg. of thiamin chloride each and in all of them
improvement commenced promptly and in two it was complete
when only 50 mg. of the vitamin had been gh'cn, although
treatment was continued for a few days more. The author has
also used thiamin chloride in doses of 10 mg. daily in a case
of early disseminated sclerosis for more than one month with-
out the slightest improvement. In another case of diabetic poly-
neuritis, oral and parenteral administration of from 10 to 20 mg.
of the vitamin without insulin for one month produced no effect
on the sensory changes ; in fact, the patient complained of an
exaggeration of tingling and burning sensations in the hands and
feet. When his urine became sugar free after insulin therapy
he was relieved within a few days. Two cases of arsenical
neuritis were uninfluenced by prolonged thiamin chloride therapy,
although similar dosage in four cases of polyneuritis of unknown
origin produced satisfactory results and the improvement was
noticeable in the first week of treatment. One patient with nerve
deafness did not respond to six weeks of treatment given by
mouth as well by injection. The clinical data are too scanty
to evaluate its efficacy in all the diseases for which it is advocated
but it seems to be of particular %’aluc in many forms of poly-
neuritis. Whether the action of the vitamin is due to its replac-
ing any deficiency or to some other action is not quite clear yet.

Ionizable Iron in Milk. — Pal determined the available iron
in ten different samples of cow’s milk from a dairy, a local
milkman and a local market and two mixed samples of mother’s
milk. Almost all the iron present in milk is in available form.

The average available or ionizable iron content in the cow’s
milk was 0.635 mg. per hundred cubic centimeters of milk. This
is almost equal to the total iron present in the samples. The
mean figure for ionizable iron in mother’s milk was also almost
the same as the total iron present and was found to be 0.625 mg.
per hundred cubic centimeters of mother’s milk.

Lancet, London

2: 629-674 (Sept. 16) 1939

"Postoperative Thrombosis and Embolism: Mortality and Morbidity. R.
Pilcher. — p. 629.

Erythrocytes-Plasraa Interface and Consequences of Its Diminution.
R. Fahraeus. — p, 630.

’‘Influenzal” Meningitis Treated with Sulfapyridine: Report of Two
Cases. E. H. Roche and J. E. Caughey. — p. 635.

Valvular Pneumothorax: Treated by Mechanical Valve and Obliterative
Pleurisy. F. G. Chandler. — p. 638.

“Iron Administration and Hemoglobin Levels During Pregnancy. E. M.
Widdowson. — p. 640.

Prophylactic Inoculation During Incubation Period. H. Schiitze. — p, 643.

Postoperative Thrombosis and Embolism.— Pilcher says
that a careful study has been made at the University College
Hospital in London for cases of thrombosis and embolism. The
records of the decade from 1929 to 1938 have been analyzed to
show the interrelation of thrombosis and embolism, and the
mortality of the latter. Prophylaxis was tried in the series
presented, but no specific treatment except embolectomy in one
case. Regarding the criteria of diagnosis the author says that
in both thrombosis and embolism there is a rise of temperature.

In simple thrombosis the rise is seldom of more than 1.5 degrees
F., but when embolism occurs the temperature rises higher. The
rise of temperature in a case of embolism often precedes the
symptoms and may be presumed to be due to undetected throm-
bosis. The signs on which thrombosis is diagnosed are delayed
cooling on exposure, pain and tenderness, edema,, slight cyanosis
and fulness of superficial veins. Of these the . most constant
are tenderness and delayed cooling; these .in conjunction with
a rise of temperature would be regarded' as evidence of throm-
bosis. The signs of thrombosis enumerated were not all present
in every case. In the diagnosis of embolism little importance
is attached to the presence of recognized thrombosis, and, in
fact, in the majority of cases no thrombosis was found. Unless,
therefore, gross errors are made in -the diagnosis of embolism,
it must be accepted that many, cases ' of ' thrombosis are not
diagnosed. The fact that thrombosis may be latent makes it
difficult to assess its risks on the evidence of diagnosed cases.
Pulmonary embolism in addition to 'fever has three important
features : pain, hemoptysis and signs of pleurisy or consolidation.

me zor cases ot tnromDosis ana embolism that are discussed
here are analyzed in several tables. The first table lists ninety-
eight cases of femoral or crural thrombosis only, forty-three
cases of thrombosis with nonfata! embolism, sixty-eight cases
of nonfatal embolism with recognized thrombosis, forty-four
cases of fatal embolism and eight cases of thrombosis or embo-
lism which were diagnosed in life but in which death resulted
from other causes. The second table analyzes the material from
the point of view of association of thrombosis and embolism and
the third table lists the mortality rates. The mortality rate
of the whole series was 16.8 per cent. The mortality rate of
the first attack of embolism was 21.6 per cent. The total mor-
tality rate of embolism was 28 per cent. Fatal embolism fol-
lowed 4.6 per cent of diagnosed thromboses and 8.1 per cent of
diagnosed nonfatal embolisms. This difference is not statisti-
cally significant. In the majority of nonfatal embolisms no
evidence of thrombosis was found. The majority of fatal embo-
lisms were unexpected. Thrombosis diagnosed in life is com-
moner on the left side than the right. This is the reverse of
the observations in a large postmortem series of fatal embolisms.

Iron and Hemoglobin During Pregnancy.— Widdowson
studied the hemoglobin levels of pregnant women before, during
and after periods of therapeutic medication with iron. Hemo-
globin determinations were made by the Haldane method of
100 women, all of whom were twenty weeks’ pregnant or less
attending the antepartum department of King's College Hos-
pital, London. The determinations were repeated a month later
Then half the women (those attending on Wednesdays) were
prescribed 1,000 mg. of iron, as ferric ammonium . citrate or
ferrum reductum, daily for six weeks. The level of hemoglobin

1774

CURRENT MEDICAL LITERATURE

Join. A. M. .1
Nov. 4, Dii

in the capillary blood was determined at fortnightly intervals.
The administration of iron was then stopped and the hemo-
globin estimated fortnightly until a week after delivery. The
other women (attending on Tuesdays) were given no medicine,
and their hemoglobin levels were observed at monthly intervals
until delivery and again a week later. In both groups an esti-
mation was always made within twenty-four hours after delivery.
At the end of the experiment it was decided not to consider (1)
women whose babies were born before the thirty-sixth week,
(2) women who had taken the last dose of iron within eight
weeks of delivery and (3) women in the experimental group who
had not taken the prescribed iron. After these omissions thirty-
one women were left in the “iron” group and forty-four in the
control group. In the control series the characteristic response
was a tendency to fall steadily throughout pregnancy and to
rise sharply after delivery. The cause of the fall, although
possibly in some cases the result of a true deficiency of iron,
is probably due largely to a rise in the volume of plasma unac-
companied by a corresponding rise in the number of circulating
red blood cells. The responses of the experimental "group are
much more complicated than those of the control because, besides
the effects of pregnancy and delivery common to the two groups,
two further stimuli were in operation: (1) the administration of
iron and (2) the cessation of its administration. The response
to iron was not an instantaneous increase in all the women’s
hemoglobin concentrations. A few of the hemoglobin curves
continued to fall, as though iron had not been given at all ;
several showed a break in the fall but no real rise, and some
of them rose. The cessation of administration of iron led almost
always to a fall in the hemoglobin level of those women in
whom its administration had initiated a rise. In the discussion
the author points out that, whereas the administration of iron
has been shown by others to check the fall of hemoglobin dur-
ing pregnancy, the fall after the administration has been stopped
is a new observation and one which is difficult to explain. The
tentative explanation offered by him is that one of the many
factors regulating the level of hemoglobin in the circulation is
the amount of iron in the plasma; the more there is, the more
active the marrow cells become. When iron is not being admin-
istered, the amount of iron in the plasma is maintained at a low
constant level by the high capacity of the storage organs. The
administration of iron, however, temporarily raises the plasma
iron, which stimulates the marrow to greater activity. It will
be noted that this theory emphasizes the amount of iron in the
plasma rather than the amount in the body as the regulator of
marrow activity. The problem arises: Does the raising of a
person’s hemoglobin with massive doses of iron prove that the
person was in need of iron; i. e., in a pathologic state? It
might reasonably be held that, if the hemoglobin fell to its
original level when the iron was discontinued, no pathologic
state had been disclosed. Against this view must be set the
weight of clinical opinion, which has pronounced definitely in
favor of raising the hemoglobins of babies and pregnant women.

Medical Journal of Australia, Sydney

2: 303-344 (Aug. 26) 1939
Pott’s Disease in Children. G. K. Smith. — p. 303.

Tumors and Malformations of Blood Vessels of Brain and Spinal Cord.
L. B. Cox and H. C. Trumble. — p. 30S.

Proceedings of Royal Society of Medicine, London

32 : 1191-1370 (Aug.) 1939
Town and Country Planning. G. L. Pepler. — p. 1191.

♦Familial Hepatitis. F. B. Parsons.— p. 1197.

Diagnostic Value of Hysterography. A. Davis, p. 121 L

Factors Influencing Attitude of Fetus in Utero. G. F. Gibberd. — p. 1223.

Effects of Stilbestrol on Labor. J. H. Peel— p. 1230.

Plasma Phosphatase in Jaundice m Children. W. w. Payne. — p. lAbb.
Porphyrins and Their Relation to Metabolism of Blood Pigments. U

Rimington. — p. 1263. ... . ~ t, i iota

Porphyrin Excretion Following Antipyretics. G. Brownlee.— p. 1276.
•Methemalbumin in Man (Pseudomethemoglobin). A. H. tairley.
p. 1278.

Familial Hepatitis. — Parsons reports familial hepatitis in
a family of nine children. Two of the children are alive and
well, two are alive and have hepatic enlargement, four have
died' from hepatic failure and one has died probably of some
other cause. No member of the family suffered from icterus
neonatorum and in no case has there been any suggestion of
retardation of growth. Both parents are alive and well. They

have not suffered from relevant illnesses in the past and, so
far as can be ascertained, there is no' history of hepatic dysfunc-
tion on either side. Although necropsies were done on only tno
members of this family, the appearances observed are common
to those of patients dying of cholemia. The picture in one cast
was that of a perilobular cirrhosis and in the other of a multi-
lobular cirrhosis, but in each case it appeared that an acute
hepatic necrosis was superimposed on a chronic hepatitis. Xo
satisfactory evidence was obtained of the ingestion of any sub-
stance known to provoke hepatic damage. The incidence of the
eases occurring over a period of twenty-two years is again.-!
this view. The occurrence of choreiform movements for four-
teen months before death in one case and the fact that the dis-
ease manifested itself in the second decade of life indicates that
the possible diagnosis of hepatolenticular degeneration cannot
lightly be dismissed, particularly as the changes in the brain
in this condition are not always visible to the naked eye on
postmortem examination and that they are sometimes elusive on
microscopic examination. The presence of cirrhosis of the
perilobular type, the absence of significant changes in the brain
and the occurrence of unilateral movements diagnosed as hys-
terical are, on the whole, not in harmony with a diagnosis ol
hepatolenticular degeneration, and it would seem that the family
should be regarded as an example of familial hepatitis.

Methemalbumin in Man. — Methemalbumin in man, accord-
ing to Fairley, is formed from extracorpuscular hemoglobin
when blood is destroyed in large quantities and remains in the
circulation for a sufficient time. During the extracellular catabo-
lism of hemoglobin, the molecule is split into globin and haem.
The haem is oxidized to hematin, which promptly unites wtn
serum albumin to form methemalbumin, the latter not passing
through the kidney and never appearing in the urine. Recent
work by Rimington indicates that hematin injected intravenously
produces an increased porphyrin excretion in the feces. )
appears that, like bilirubin, methemalbumin is disposed of y
way of the liver and would be present in greater concentration
in the circulation when intravascular hemolysis was associate
with liver disease. This, the author states, he has recently con
firmed clinically in cases of cirrhosis of the liver and spleno-
megaly" associated with hemolytic anemia and hemoglobinuria.

Tubercle, London

20: 485-532 (Aug.) 1939 -At:

♦Sedimentation Rate, White Blood Cell Count and Temperature m Acn
Lobar Pneumonia. I. Douglas-Wilson. — p. 485.

Radiologic Examination of Larynx. R. S. Stevenson.— P« 4 * .-gb.

Tuberculous Cervical Lymphadenitis: Epidemiology and
B. C. Thompson.- — p. 504.

Id.: Pathology and Treatment. E. S. Evans. — p. 510.
Sedimentation Rate, Leukocyte Count and Tempera
ture in Pneumonia. — Douglas-Wilson determined the r
between the sedimentation rate, leukocyte count and £

in forty-four cases of acute lobar pneumonia, in which tner
ten deaths. Estimations were made daily throughout tne
period and at regular intervals thereafter until recovery
complete. The mean sedimentation rate increased ro
second (40) to the fourth day (81.38) of illness and then
ated around a constant level for the following three aj >
the maximal figure on the sixth day (82.91), before decltning-
In the case of the leukocyte count the mean figure
the first (187.1) to the sixth day (111.8), whereafter t r -_
till the ninth day (161.3). A slow decline ensued. ( ] ie

tuations above and below the average were found o
sedimentation rate and in the leukocyte count Body temi t
had no influence on the sedimentation rate and leukocy
The only statistically significant correlation between
mentation rate and the leukocyte count occurred in
four days of illness, but the trend of the signs of the cm.
suggests that, whereas at first they tend to bc , ™ er *2 tions l,ip.
the tendency in the later days is toward a dire. ffic ; cn t
This was confirmed by calculation of the correlation i c t

for each day by Sheppard's method. The change n< j,- v jdtral
to direct variation occurred about the sixth day. m # uh

reel variation "V , ♦ i .^rvlnir

inverse variation was observed for a period >

with

ascs inverse vauauuii »u. --- - . . terl t!l

ie duration of fever and occasionally persisted up to
ay of illness. The maximal, minimal and mean ot l
lentation rate in the fatal cases did not i outcome

iat in the cases in which survival occurred.

Volume 333
Number 19

CURRENT MEDICAL LITERATURE

1775

invariably resulted with leukopenia but leukopenia was found
in only a half of the fatal cases. In the other half a moderate
and even increasing leukocytosis was found. In every fatal case
the sedimentation rate began to decrease either two or three
days before death, and this decrease continued up to the time
of death. This progressive fall of the sedimentation rate, espe-
cially when accompanied by a high or rising pulse rate, has
been found an excellent guide to the prognosis, resulting on
several occasions in the accurate forecast of a fatal outcome
which would have been otherwise unforeseen. In bronchopneu-
monia the same tendency as in lobar pneumonia toward inverse
relationship of the sedimentation rate and leukocyte count in the
febrile stage has been observed. The sedimentation rate remains
increased longer during resolution in bronchopneumonia than in
lobar pneumonia. As in lobar pneumonia, the sedimentation
rate returned to normal only when resolution was complete.

Chinese Medical Journal, Peiping

5G: 1-98 (July) 1939

•Hematuria, Renal Colic and Acetylsulfapyridine Stone Formation Asso-
ciated with Sulfapyridine Therapy. I. Snapper, S. H. Liu, H. L.
Chung, T. F. Yu and H. M. Sun.— p. 1.

Research on Typhus in Shanghai. J. H. Raynal, J. Fournier and E.
Velliot. — p. 11.

•Further Studies on Serum Treatment of Typhoid Fever. H. Yii. — p. 29.
Development of Leishmania in Chinese Sandflies Fed on Dogs with
Canine Leishmaniasis. L. C. Feng and H. L. Chung. — p. 35.

Natural Infection of Phlebotomus Chinensis in Peiping with Leishmania
Flagellates. H. L. Chung and L. C. Feng. — p. 47.

Mosquitoes of Hunan Province, with Special Reference to Anopheles.
T. L. Chang. — p, 52.

Plan for Malaria Control in Yunnan. H. Y. Yao.—- p. 63.

Tuberculosis in a General Hospital. T. C. Y. Sun and J. C. Thorough-
man. — p. 69.

Hematuria, Colic and Calculi After Sulfapyridine
Therapy. — Snapper and his associates report the occurrence of
hematuria during sulfapyridine treatment both in children and
in adults. Of the three adults, the first had asymptomatic
hematuria, the second hematuria and colicky pain, and the third
hematuria associated with a renal calculus composed of acetyl-
sulfapyridine. Several cases of hematuria in children have been
encountered by the authors. They report one in which hema-
turia developed after thirty-six hours of medication. They
believe that the recovery of a sulfapyridine calculus from the
urinary tract in man has not as yet been recorded. According
to recent experiments on rats, rabbits and monkeys, after con-
tinuous therapy with sulfapyridine the urine often shows small
concretions consisting of needle-like crystals. These crystals
prove to be acetylsulfapyridine. The same process appears to
occur in patients treated with the drug. The highly insoluble
acetylsulfapyridine which is formed during the metabolism of
the drug precipitates in the urinary tracts, giving rise to crops
of crystals and eventually to little calculi. Irritation or trauma-
tism by the calculi would result in hematuria with or without
renal colic. It is evident that in some cases, as observed by
Southworth and Cooke, obstruction of the ureter by these con-
cretions may lead to temporary anuria and nitrogen retention
in the blood. Different animal species vary in their suscepti-
bility to urolithiasis as a result of sulfapyridine administration.
Whereas monkeys needed 0.2S Gm., rabbits from 10 to 15 Gm.
and rats 5 Gm. per kilogram of weight daily for ten days,
acetylsulfapyridine calculi developed in one of the patients after
lie received approximately 0.1 Gm. of sulfapyridine per kilogram
daily for nine days.

Serum Treatment of Typhoid. — Yit treated sixty-four
cases of typhoid with serum prepared with alcohol killed and
live antigens. In thirty-three cases there was an immediate
drop in temperature and a decrease in toxic symptoms. In
nineteen there was a reduction in toxemia but no noticeable
effect on the temperature curve. There was no change in the
remaining twelve patients. The study substantiates the previous
reports from the Lester Institute and the reports of Felix and
other workers that the new antityphoid serum is definitely bene-
ficial. The beneficial effect of this batch of serum on toxemia
was more striking and constant than the effect on pyrexia. To
date, a total of 305 cases of typhoid have been treated with
this new serum. Although the number is still small, the good
results obtained in the hands of the various workers justifies
its routine employment in typhoid, more especially if toxemic
features are in evidence.

Archives des Maladies de l’Appareil Digestif, Paris

29 : 697-816 (July) 1939

Complicated Diverticulum of Duodenum. R. Gregoire. — p. 701.

•Primary and Secondary Hypotension and Metabolism of Carbohydrates.

H. G. D. Fiszel, — p. 710.

•Lipothymia in Chronic and Latent Appendicitis. A. C. Borcesco and V.

Ionescu-Movila. — p, 750.

Hypotension and Carbohydrate Metabolism— Fiszel says
that it was Ferrarini who first directed attention to a morbid
entity which he designated as constitutional angiohypotonia and
which is characterized by arterial hypotension resulting from
deficient tonus in the vascular system and in other tissues. Fiszel
says that this form of hypotension is characterized by a more
or less pronounced physical and psychic fatigue. Slight exer-
tions exhaust these patients. Moreover, they have frequent
painful sensations in the cardiac region such as retrosternal
constriction, palpations, sensations of emptiness, feelings of
anxiety, and pains radiating toward the left arm. Hypoglycemic
crises are known to occur in these cases. The sensations of
hunger are suppressed by a small amount of nourishment, espe-
cially • carbohydrates. Postprandial somnolence is a frequent
symptom in these cases and general malaise, vertigo, headaches,
dimness of vision, fainting, abnormal sensitiveness to cold on
the part of the extremities, acrocyanosis, paresthesias, constipa-
tion and painful menstruation are other symptoms often observed.
Since the clinical symptoms of hypotonia resemble those of hypo-
glycemic shock, Fiszel decided to investigate the carbohydrate
metabolism of patients with hypotonia by means of sugar toler-
ance tests. His studies were made on patients with primary
hypotonia and on some with secondary hypotonia, forty in all.
. He designates as secondary that form of hypotonia which is
encountered in the course of or after grave diseases such as
acute infectious diseases, intoxications and cardiovascular dis-
eases. After describing the characteristics of the blood sugar
curves which he obtained in the two forms of hypotonia, he says
that the clinical aspects and the studies on the carbohydrate
metabolism lead him to conclude that primary hypotonia is the
manifestation of an absolute displacement of the neurohormonal
factors ; that is to say, there exists an augmentation of the tonus
of the vagal system and hyperfunctioning of the endocrine glands
belonging to the insulin group. Secondary hypotonia is the
manifestation of a relative displacement of the hormonal factors,
that is, of hypotonicity of the sympathetic nervous system and
of hypofunction of the endocrine glands of the adrenal group, or
it is the expression of hepatic disturbances or of both hepatic
and endocrine perturbations.

Lipothymia in Chronic and Latent Appendicitis.—
Borcesco and Ionescu-Movila think that many cases of chronic
appendicitis are not recognized because either they do not present
symptoms permitting a definite diagnosis or the physician does
not think of this disorder. In the course of a long practice, a
careful search for symptoms indicative of chronic or latent
appendicitis revealed to the authors three which they consider
of great value. These are (1) appendicular vertigo, (2) lipo-
thymia (faintness) and (3) urgent diarrheal stools preceded by
colics which cease after evacuation. These three symptoms
when associated in one case constitute a veritable symptomatic
triad valuable for the diagnosis of chronic and especially of latent
appendicitis. In this report the authors direct attention espe-
cially to the second of the triad of symptoms; namely, to lipo-
thymia or faintness. After giving brief outlines of twenty
typical examples of faintness in cases of appendicular lesions,
they stress the following points: 1. Lipothymia is a symptom
which is of great value for the diagnosis of chronic and latent
appendicitis. Studies in 3,000 cases of appendicular lesions
revealed it in 244, that is, in 8 per cent. 2. Lipothymia is some-
times associated with vertigo and with urgent diarrheal stools
that are preceded by colics which disappear after evacuation.
3. Lipothymia can be considered as a symptom coming on unex-
pectedly with recurrences of chronic appendicitis, often announc-
ing an appendicular crisis or as the first symptom of the onset
of appendicitis. ^ 4. It is important that the physician know the
appendicular origin of lipothymia, so that in a case which, apart
- r “ n ot, ' cr digestive disturbances, presents lipothymia, the pos-
sibility of a chronic appendicitis will he taken into consideration.

1776

CURRENT MEDICAL LITERATURE

Journal Beige de Neurol, et de Psychiat., Brussels

39: 607-646 (Sept.) 1939

*Azoman (Triazol) in Therapy of Schizophrenia. H. Hoven. — p. 607.
Korsakoff s Psychosis with Polyneuritis in Course of Postpuerperal

Septicemia. M. Maere. — p. 616.

Pneumonococcic Meningitis Cured by Sulfanilamide. E. Evrard and A.

Bragard. — p. 622.

Therapy of Schizophrenia.— Discussing the various types
of shock therapy of schizophrenia, Hoven says that insulin
exerts a favorable effect especially on the paranoid, hallucinatory
type of dementia praecox and on catatonic dementia praecox
with agitation, whereas metrazol is most effective in stuporous
dementia praecox and in late schizophrenia. However, treat-
ment with metrazol presents certain inconveniences. It frightens
some patients because it causes anguish and the feeling that
death is imminent and so the patients refuse to submit to injec-
tion. Attempts have therefore been made to substitute other
preparations which do not have the shortcomings of metrazol.
In this paper the author discusses the use of azoman, which is
known also as triazol and the chemical composition of which
greatly resembles that of metrazol. After citing other investi-
gators who have employed this substance, the author says that
so far he has used it in twenty-five cases of schizophrenia and
that he can confirm the favorable results obtained by others.
He says that the substance is available in a 5 per cent aqueous
solution and that it can be administered by intravenous or intra-
muscular injection. In general remarks about the dosage he
cites studies by von Braunmiihl in which it was determined that
for intramuscular injection the dose should be 0.039 cc. of the
5 per cent aqueous solution per kilogram of body weight for
men and 0.037 cc. for women; for the intravenous injection
the corresponding doses are 0.023 and 0.021 cc. respectively. If.
a patient is in a hypoglycemic (postinsulin) state the doses are
slightly different. The computation of the dose to be injected
is not as complicated as it might appear; for instance, to a
patient weighing 56 Kg., 1.2 cc. of the solution was administered
by intravenous injection and to a patient weighing 59 Kg.,
2.2 cc. was given by intramuscular injection. The authors
report several cases in which they employed the substitute of
metrazol. They reach the conclusion that, if utilized with
caution, the new preparation has great advantages and produces
good results in schizophrenia.

Presse Medicale, Paris

47: 1285-1300 (Aug. 26) 1939

-Therapeutic Value of Autonomous Pleurotomy. F. Dumarest and P.

Pavie. — p. 1285.

Hematoporphyrin Therapy in Pyramidal Hypertonia. \V. Sterling and

W. Stein.— p. 1287.

Pleurotomy in Artificial Pneumothorax. — Dumarest and
Pavie evaluate the advantages of pleurotomy in pleural com-
plications of artificial pneumothorax. In their analysis of the
threefold objection to this surgical procedure, namely the
dangers of secondary infections, the risks to the organism of
prolonged suppuration and the irremediability of thoracic fistulas
when once established, they present the following considerations :

1. Pleural infections occur almost entirely in exceptional cases,
such as when surgical intervention is performed on cachectic
patients as a last desperate measure or when poor drainage
causes retention of infective matter. A correctly performed and
maintained drainage eliminates, in principle and practice, all
infectious evolution. 2. Clinical observations show that pleu-
rotomy is no hindrance to a gradual establishment of excellent
well being with a rapid gain in weight and that it does not
lead to amylosis. The inconveniences of prolonged suppuration
diminish in time. 3. The spontaneous occlusion of fistulas is of
frequent occurrence when drainage has not exceeded several
months. In thirty-nine recent pleurotomies the authors, jointly
with Rougy, their deceased collaborator, could report closing
of parietal fistula in eight cases, five with symphysis and three
with conservation of the pneumothorax. In their discussion of
the advantages of pleurotomy, the authors point out that its
pulmonary significance apart from any pleural value lies in the
fact that rarely homolateral or contralateral pulmonary evolu-
tions are found in cases in which an effective pleurotomy has
been performed. According to the authors, pleurotomy offers
the following pulmonary advantages : (1) It protects the oppo-

Joun. A. 31. A,
Nov. 4, 1935

site lung from infection in the event of perforated pneumothorax
and has surprising curative effects on existing contralateral
lesions ; ( 2 ) it completes the collapse of the lung under treat,
ment;' (3) it facilitates the occlusion and cicatrization of pleuro-
pulmonary fistulas in intermittent and latent cases in which
surgery is. performed without delay. Wide, open fistulas, how-
ever, persist but are easily endured by the patient if drainage
is properly continued. The clinical experiences of the authors,
therefore, do not confirm alleged dangers to the pleura and
lungs. On the contrary, surgical delay and prolonged pleural
lavage may convert an intermittent into a permanent fistula and
induce fatal consequences of pulmonary inundation. Nor are
tuberculous pleurisies of malignant evolution benefited by punc-
ture and lavage, rapidly becoming cachectic. Open pleural
cavities in cases of complete pneumothorax in which infection
is maintained by a permanent pleuropulmonary fistula can be
stabilized effectively for a long time by pleurotomy. The advan-
tage of pleurotomy over thoracoplasty in pleural infection rests
on avoiding the necessity of an early severe operation with its
high fatality when the patient is in a precarious condition and
in restoring him progressively to the resumption of at least a
partial customary activity of life. The inconveniences of perma-
nent drainage receive their proper evaluation in the scale of
relative human values in the sentiment expressed by one of the
author’s patients that it is better to live in ill health than to
die while being cured.

Revista Medica Latino-Americana, Buenos Aires

24: 983-1085 (July) 1939. Partial Index
Medical Treatment of Phlegmons of Dental Origin by Neoarsphenaminr.
J. Beltranena S. — p. 983.

Determination of Bilirubinuria. L. Galindez and E. Vanni.-— p. 994.
*Mammography : X-Ray Examination of Milk Ducts by Using Contrast
Mediums. A. E. Nogues and C. L. Gazzotti. — p. 9 99.

X-Ray Examination of Milk Ducts. — Nogues and Gaz-
zotti made an x-ray study of the milk ducts (so-called mam-
mography) of a group of nine women. They resorted to
Hicken’s technic, which was reported in Surgery, Gynecology
and Obstetrics in March 1937 and abstracted in The Journal
May 1, 1937, page 1575. The procedure utilizes a contrast
substance, which is injected into the milk ducts for x-ray sM-
The authors used a 30 per cent solution of thorium dioxide so .
They describe in detail and also by illustrations the x-ray aspect'
of the milk ducts in normal conditions, during lactation and m
the presence of mammary or intracanalicular tumors, as well as
in the presence of the bloody, white .and yellow discharge ito®
the nipple. The authors found that the procedure is harmlC"
if it is carried on by the proper technic. The method has proper
indications, namely ( 1 ) the diagnosis of intracanalicular tumors
or of inflammation of the milk ducts, ( 2 ) diagnosis of the m ta
canalicular tumoral (or nontumoral) origin of the bleeding WPP
and ( 3 ) the differential diagnosis of various types of white an
yellow discharge from the nipple. The authors found that ni'
ducts which harbor a tumor (papilloma or carcinoma) gu
mammograms with shadows showing ampullar dilatation an
lacunar image. The nature, either benign or malignant, o
tumor cannot be diagnosed from the aspect of the mamwogr •
Clinically intracanalicular papilloma shows by the bce . 7
nipple. Therefore the x-ray appearance of the bleeding iw
from intracanalicular papilloma is that of milk ducts bar
a tumor. Mammograms of breasts with a white or yellow -
charge which is due to any of the various types of aciu ^
chronic inflammation of one or several milk ducts, wj
without complicating canalicular abscess, are those wine
respond to the given type of inflammation and to the ev
of the conditions. The x-ray aspects m the condition
varied. Generally the mammograms give shadows si
more or less intense ampullar dilatation of the invoice ^
or else pseudocavities, retraction and anfractuositics.
mammograms can be differentiated from those of brcas
nipple which is due to mammary

the canalicular system, which 5 .

diagnosis of paradu

secretion from the
without involvement of
normal at the mammogram.

normal at the mammogram. In the j,.

tumors without involvement of the ductal system, mam ri

lias a secondary value. The seat, form and number of ( |. e

can be interpreted from the deformation of the due s
neighboring tumors. Cancer of the breast can be suspc

Volume 113
Number 19

CURRENT MEDICAL LITERATURE

1777

a mammogram which shows deformation of the milk ducts and
destruction of the ductal branches as they touch the tumor,
which is shown by a dark shadow which absorbs the ductal
branches as though the latter were amputated by the former.

Klinisclie Wochenschrift, Berlin

IS: 981-1012 (July 22) 1939. Partial Index

Experimental Investigations on lodophilia of Leukocytes. F. Hoff and
L. Bachmann. — p. 981.

New Objective Criterion for Detection of C-Hypovitaminosis. P. Worde-
hoff.— p. 9S4.

Parenteral Dextrose Tolerance Test. F. Axmadter and E. Funkc. —
p. 984.

•Development of Free Gases in Blood and Tissues in Rapid Decompres-
sion. G. Schubert and A. Gruner, — p. 988.

Behavior of Iron Content of Scrum During Influenza. P. Buchmann
and E. Heyl.— p. 990.

Limits of Metabolic Action in Dentin. T. Spreter von Kreudenstein. —

p. 992.

Free Gases in Rapid Decompression.— Schubert and
Griiner studied the question of the development of gases in blood
and tissues during sudden transition from extremely tow to
normal atmospheric pressures and aimed to determine whether
the danger of gas embolism can be averted by prompt return
to normal pressure. A solution of these questions seemed impor-
tant in connection with flying in the stratosphere. Experiments
on rats which were subjected to low atmospheric pressures
(70 mm. of mercury) and then were returned to normal pressure
gave information about the pathogenesis of atelectasis. The
development of gases and gas embolism were likewise investi-
gated on rats as well as on other species of animals (guinea
pigs, cats and dogs). The authors show that their experiments
give information about the dangers threatening persons who
fly at stratospheric altitudes, when the chamber or the pressure
suits suddenly become defective. They found that even a brief
transition (less than one minute) to pressures between 75 and
70 mm. of mercury, that is, to altitudes of from 16,000 to 17,000
meters, is not necessarily fatal if a return to greater pressures
is effected immediately. However, the longer the aviators stay
at this pressure, the more extensive are the tears in the pul-
monary tissues and the hemorrhages into the alveoli and bron-
chioles. These represent the life threatening factor, even if
the return to normal pressure lasts only seconds, whereas the
development of gases represents an entirely reversible process.
A stay of more than ninety seconds in pressures of less than
60 mm. of mercury is absolutely fatal, for a return to normal
pressure, even for seconds, produces not only a complete atelec-
tasis of the lung but also the development of such quantities
of gases that the circulation in the vital organs is at once
impaired and remains so permanently. The authors show that
there are physiologic and technical protective measures against
these dangers. The most effective physiologic one is that as
soon as the chamber or the pressure suit become defective a
voluntary hyperventilation is begun in order to effect equilibra-
tion of pressure between lung and external air and thus avoid
tearing of the pulmonary parenchyma and also to reduce the
tension differences of gases by increased diffusion. The technical
protective measure consists in provision with tanks containing
highly compressed oxygen. They should be discharged under
high pressure to be regulated automatically by the pressure of
the chamber. The same automatic regulation should be pro-
vided during steep descent.

Monatsschrift fur Kinderheilkunde, Berlin

70: 1-146 (July 6) 1939. Partial Index
Indication for Treatment in Climatic Chamber. S. I.iebe. — p. 1.
Suipestifer Infection During Childhood. YV. Coolers. — p. 27.

Hepatic Rickets. M. Klot 2 . — p. 39.

Parenteral Administration of Antirachitic Vitamin. M. Klotz. — p. 43.
Derm ©graphic Manifestations During Childhood. Ruth Husgcn. — p. 52.
Blood Forming Action of Soy Flour. T. Takuma and K. Sakurai. —

p. 62.

'Pathogenesis of Renal Hemorrhages During Diphtheria. II. Sticpel. —
p. 67.

Protein Metabolism of Nurslings in Light of Nitrogen and Sulfur Metab-
olism. P. Ujsaghy. — p. 79.

Pathogenesis of Renal Hemorrhages During Diph-
theria. — Sticpel points out that hematuria is occasionally
observed in cases of diphtheria. Reviewing different opinions
about the source of these hemorrhages, he says that Randerath
demonstrated in 1933 that renal hemorrhages in diphtheria
represent glomerular hemorrhages brought about by capillary

impairment and that the appearance of erythrocytes in the urine
of diphtheria patients does not permit the conclusion that a
glomerular nephritis exists. On the basis of his microscopic
studies, Randerath could exclude not only glomerular nephritis
but also glomerular irritation and glomerular hemorrhages as
the result of stasis, and he interpreted the hemorrhages as the
manifestations of impairment of the glomerular capillary walls.
He thinks that these hemorrhages can be regarded as equivalent
to the cutaneous and to the subserous and subendocardial hemor-
rhages of diphtheria patients. Since Randerath’s conclusions
were based on a single observation, Stiepel decided to reexamine
his results in a larger number of cases. He made microscopic
studies on the kidneys in fifteen fatal cases of diphtheria and,
in addition to purely nephrotic changes in the region of the
tubules, he observed in eight cases in circumscribed regions of
the renal cortex massive hemorrhages into the glomerular cap-
sules and into the lumens of the uriniferous tubnles. The
author agrees with Randerath that these hemorrhages originate
in the glomerular coils and that they are the result of an impair-
ment of the walls of these coils, which in turn is a manifestation
of the generalized capillary impairment during diphtheria. The
microscopic aspect of all eight cases demonstrate clearly that
the presence of erythrocytes in the urine does not permit the
conclusion that inflammatory processes exist in the kidney.
Their appearance in the urine is only an indication of the
severity of the existing capillary changes.

Vrachebnoe Delo, Kharkov

31:291-370 (No. 5) 1 939. Partial Index
Hepatopulmonary System. S. M. Leites. — p. 291.

•Hepatopulmonary Syndrome in Lobar Pneumonia. A. L. Vitkovisky.*—
p. 293.

Role of Lungs and of Liver in Carbohydrate Metabolism of Lobar Pneu-
monia. P. M. Perchik. — p. 299.

Alterations of Nitrogenous Component of Serum in Lobar Pneumonia.
M. I. Dunaevskiy. — p. 307.

Course of Sedimentation Reaction of Erythrocytes in Lobar Pneumonia
Treated by Intravenous Serum. A. G. Korfanti. — p. 313.

Venous Pressure in Pneumonia of Children. L. B. Krasik. — p. 315.

Hepatopulmonary Syndrome in Lobar Pneumonia. —
Vitkovisky sensitized rabbits by intravenous injection of horse
serum or of a dead culture of pneumococci or streptococci, after
which the horse serum was administered either by inhalation
or by the intratracheal route, or by the combination of the latter
with simultaneous injection of pneumococci into the blood
stream. The effect of cooling, analogous to “catching a cold,”
was likewise estimated. These experiments, carried out on
eighty animals, demonstrated the role of the allergic factor in
the genesis of lobar pneumonia, the possibility of producing
sensitization by various agents, such as heterogeneous proteins,
nonspecific or specific micro-organisms, the possibility of pro-
ducing pneumonia through hematogenous introduction of the
infectious agent, the relatively greater importance of the pneumo-
coccus as the determining factor, and the role of cooling, which
increases the hyperergic reactions but is of little influence out-
side the conditions of sensitization. The author points out an
analogy between some of the metabolic functions of the liver
and the lungs, such as the removal of excess lactic acid, and
the nitrogenous and the chloride metabolism. In order to study
the carbohydrate metabolism in experimental pneumonia, the
author first determined the glycogen content of the liver, the
muscles and the lungs of five control rabbits. A similar study
was made of fifteen rabbits in which experimental pneumonia
was induced by sensitization with intravenous injection of horse
serum, followed by intravenous injection of a culture of pneumo-
coccus, and by intratracheal introduction of horse serum. There
was noted a lowering of the glycogen content of the liver to
almost one tenth of the normal, while the muscle glycogen
content showed slight increase, whereas the glycogen of the
altered pulmonary tissue exceeded that of the control animals
by 167 per cent. These experiments demonstrated marked
alteration of liver function at the height of the hyperergic inflam-
mation of the lungs. Tissue metabolism of the liver, of the
unaffected lung and of the affected lung of nineteen rabbits was
studied. There was noted a marked lowering of tissue respira-
tion in the liver and a slight increase in glycolysis. In the
pathologically altered lung there was a fall in tissue respiration
and an increase in glycolysis. A diminution of respiration was
likewise noted in the normal lung, a fact having a bearing on
the anoxemia of pneumonia patients. Of the pneumonia patients

1778

Jour. A. M. A.
Nov. 4, 1939

CURRENT MEDICAL LITERATURE

observed by the author, 22 per cent had an enlarged and tender
liver. Many of these had urobilinuria. On the theory that the
detoxication function of the liver depends on its glycogen con-
tent, the author applied insulin-dextrose therapy, first suggested
by Kogau-Yasnyy in cases of lobar pneumonia. In a group of
seventy-four patients with pneumonia treated by the insulin
dextrose therapy, the mortality rate amounted to 5.4 per cent,
while in a group of 131 patients treated during the same period
on an orthodox regimen, the mortality amounted to 15.2 per
cent. The author believes that the beneficial influence of the
insulin-dextrose therapy is due to the improvement in the
glycogen synthesis with the resulting increase in glycogen
storage in the liver, which in turn increases the antitoxic func-
tion of the liver. The increased glycogen content also may
exert a favorable effect on the allergic reactions.

Nederlandsch Tijdschrift v. Geneeskunde, Amsterdam

31:3873-3980 (Aug. 5) 1939. Partial Index
Foreign Bodies in Esophagus. C. E. Benjamins.— p. 3874.

'Progestin in Repeated Abortion. M. H. G. A. Tholen and L. A. M.

Stolte.— p. 3880.

Fractures of Jaw. B. van Ommen. — p. 3888.

Blood Picture in Metastatic. Tumors of Bone Marrow and in So-Called

Leukanemia. F. S. P. van Bucliem and D. J. J. M. Hendriksen. —

p. 3S93.

Encapsulated Pericardial Exudate. J. II. Nauta.- — p. 3904.

Progestin in Repeated Abortion. — Tholen and Stolte first
review the present status of the knowledge about progesterone,
the hormone of the corpus luteum, giving especial attention to
its role in the preservation of pregnancy. They cite factors
which indicate that a deficiency of corpus luteum hormone plays
a part in habitual abortions and that the injection of this sub-
stance is a valuable aid in counteracting habitual abortion.
Further they review the clinical histories of nine women in
whom pregnancy usually terminated in abortion, twenty-nine
pregnancies producing only two living children. After treat-
ment of these women with progesterone was instituted, twelve
pregnancies resulted in eight living births ; to be sure, the authors
admit that these probably cannot all be ascribed to the action
of progesterone. Nevertheless, they are convinced that proges-
terone represents a valuable addition to the therapeutic armamen-
tarium of habitual abortion. They think that larger doses than
were employed by them might perhaps produce better results.
The small doses employed at present and the defective differen-
tial diagnosis still necessitate a combination with other thera-
peutics such as a salt-free diet, thyroid and vitamin E.

Acta Chirurgica Scandinavica, Stockholm

S3: 549-628 (Aug. 5) 1939

•Pneumococcic Peritonitis in Children. O. Haglind.- — p. 549.

Congenital Bilateral Hydro-Ureter in Man Aged 22. C.-H. Hirschlaff-

Hjortsjo. — p. 587.

•Pericardectomy in Fibrous Pericarditis: Two Cases. K. H. Koster. — •

p. 595.

Acute Porphyria Without Porphyrinuria. E. Schie. — p. 618.

Pneumococcic Peritonitis in Children. — Haglind says
that genuine or cryptogenic pneumococcic peritonitis, in which
the peritoneal fluid contains only pneumococci and in which
neither operation nor necropsy discloses a local point of origin,
has received considerable attention in different countries and
so he decided to review the cases that were treated in Swedish
hospitals during recent years. All of the seventy-seven patients
who were the subject of his review were children less than
16 years of age. In all of the cases the diagnosis was bacterio-
logically verified. The majority of the patients (92 per cent)
were girls and most of them were between 6 and 10 years old.
The pneumococcic peritonitis seems to be a primary process in
the majority of cases, for in only a small number did it appear
as a secondary phenomenon to other forms of pneumococcic
disorders. As regards the symptomatology, it is of especial
interest that the anamnesis frequently reveals diarrheas, that the
fever is high from the beginning and that the general condition
is poor from the onset. The mortality of pneumococcic peri-
tonitis is high, in the material reviewed here 66 per cent. The
differential diagnosis is difficult and efforts have been made to
find methods which will permit a definite diagnosis before an
operation is resorted to, because a surgical operation during the
acute stage of this form of peritonitis seems to increase the risk
of death rather than reduce it. The author shows that explora-

tory puncture has been recommended by some as a diagnostic
aid. In remarks about the pathogenesis he cites the various
possible routes by which pneumococci might invade the peri-
toneum. In view of the fact that the majority of patients are
girls, he considers a genital mode of infection possible; on the
other hand, he shows that there is considerable evidence for an
enterogenic infection. He says that in the treatment of pneumo-
coccic peritonitis a conservative tendency has been gaining
during recent years, although the debate about surgical or con-
servative treatment is still not definitely decided. The fact that
pneumococcus type I seems to be the cause of the peritonitis
in more than two thirds of the cases is of great interest for a
possible serotherapy. The author further suggests that in view
of the favorable results obtained with sulfapyridine in pneumonia
it might be advisable to try this preparation also in pneumococcic
peritonitis.

Pericardectomy in Fibrous Pericarditis. — After reviewing
the literature on surgically treated cases of fibrous pericar-
ditis and following remarks about the pathogenesis and diag-
nosis, Koster reports two cases in which the classic symptoms
of fibrous pericarditis were present: increased venous pressure
with protruding veins, coughing, ascites, enlarged liver, edemas,
reduced beat volume with lowered blood pressure, small pulse,
cyanosis, oliguria, exertion dyspnea, tachycardia and fatigue.
Before, during and after pericardectomy the oscillations of the
pulse volume were registered by means of Liljestrand-Zander's
method, in which 0.7 mg. of epinephrine is injected previous to
the registration of the pulse and the beat volume. This method
yielded results similar to those obtained by other investigators
with Grollmann’s method. In the surgical treatment of the two
patients, pericardectomy was preferred to Brauer’s operation in
spite of the fact that many regard the latter as adequate and
less dangerous. In the first case, although the symptoms had
existed a long time, the fibrous pericardium could be detached
fairly readily and extensively and the patient’s condition was
much improved after the intervention; she is able to work. In
the other case the condition developed rapidly after an attack
of acute pericarditis; technically the operation was extremely
difficult and only a small portion of the pericardium was resected.
However, in spite of the less radical intervention, this patient
made a more rapid and better recovery than did the first one.
Following remarks about the problem of drainage in pericar-
dectomy, the author says that after the operation the patients
were treated with digitalis and morphine. He thinks that the
postoperative prognosis seems to depend not so much on the
size of the resected piece of pericardium as on what damage
the heart has sustained under the influence of inactivity and
compression and to what extent the disorder which caused the
pericarditis (usually tuberculosis or rheumatic infection) j ias
subsided. Operation during the acute stage is technically easier,
but it involves greater dangers for the patient, and for this
reason some authors advise against pericardectomy during the
acute stage.

Nor disk Medicin, Helsingfors

3: 2133-2216 (July 15) 1939. Partial Index
Hospitalstidende

Vitamin C and Tuberculosis: II. Investigations on Resorption an
Elimination of Ascorbic Acid in Patients with Pulmonary Tuberculosis.

B. and E. Groth-Petersen.- — p. 2141.

Keratoconus in Siblings. Viggo A. Jensen. — p. 2145 . p

•Investigation on Magnesium Content of Red Blood Corpuscles i
nicious Anemia and Some Other Anemias. O. Bang and
0rskov. — p. 2147.

Magnesium Content of Red Cells in Anemias.— Bang
and 0rskov state that an increased magnesium content of the
erythrocytes seems frequently to follow in anemias origina
because of relatively acute loss of blood and is further demon
strated in some anemias of long standing. In anemias due o
hemorrhage as well as in experimental animals (0rskov and
Henriques) an increased magnesium content is believed to ut
a phenomenon connected with newly formed red blood corpuscles.

In the majority of cases of pernicious anemia high magnesium
values are present in the untreated stage and the relations
approach normal values during remission. The view is thus
supported that a short lifetime of red cells with concomitant
increased rate of destruction is a decisive factor m the develop-
ment of pernicious anemia.

The Journal of the
American Medical Association

Published Under the Auspices of the Board of

Trustees

Vol. 113, No. 20

Copyright, 1939, by American Medical Association

Chicago, Illinois

November 11, 1939

AFTER-EFFECTS OF HEAD INJURY

THE POST-TRAUMATIC CONCUSSION STATE (CONCUS-
SION, TRAUMATIC ENCEPHALOPATHY) AND THE
POST-TRAUMATIC PSYCHONEUROTIC STATE (PSY-
CHONEUROSIS, HYSTERIA) : A STUDY
IN DIFFERENTIAL DIAGNOSIS

WALTER F. SCHALLER, M.D.

SAN FRANCISCO

Head injuries from warfare and from industrial
and automobile accidents have in recent years occa-
sioned a constantly increasing number of claims for
awards, based on veterans’ and industrial compensa-
tion laws and on public liability. The economic impor-
tance of a proper understanding of the physical and
mental results of such injuries, from the standpoint
of both occupational disability and future outlook for
recovery, therefore is of great importance. Head
injuries may be classified as organic or functional,
dependent on the presence or absence of structural
changes in nervous tissue. In the first category, that
of organic injuries, are placed brain pressure by
depressed skull fracture, epidural or subdural hemor-
rhage, lacerations, contusions, softenings and compli-
cating infections such as meningitis or abscess. The
symptoms and signs of these more evident injuries
have been carefully studied and classified as to demon-
strated pathologic features, the treatment has been
standardized and the prognosis has been fairly well
evaluated, so they will not be dealt with in this paper.
In the second category, that of functional disorders,
are placed the post-traumatic psychoneuroses or trau-
matic hysterias, purely psychogenic states which develop
out of mental complexes following the acute symptoms.
Traumatic psychosis will not be considered here. Mid-
way between these two contrasting pictures is the post-
traumatic concussion state, an after-effect of injury
variously designated as traumatic encephalopathy, trau-
matic encephalitis, cerebral neurasthenia, post-traumatic
head syndrome, traumatic constitution, punch ylrunk,
or concussion neurosis. I shall hereafter use the term
post-traumatic concussion state, or simply concussion,
to designate this group. I propose to define the term
and describe the condition, particularly in differential
diagnosis from the functional state. The term con-
cussion, therefore, is employed to distinguish it from
brain bruising or contusion ; in an uncomplicated pic-
ture it indicates no gross primary brain injury. It is
caused by a different traumatic mechanism than con-
tusion and produces a temporary abeyance of brain

v . Read before the Section on Nervous and Mental Diseases at the
Ninetieth Annual Session of the American Medical Association, St. Louis,
May 18 , 193 9.

function ; severe concussion, however, may result in irre-
versible brain changes. Only the later effects of brain
injury are here considered, namely, those of patients
who have recovered from all acute symptoms and have
entered on a more or less chronic course.

THE POST-TRAUMATIC CONCUSSION STATE (CON-
CUSSION, TRAUMATIC ENCEPHALOPATHY)
Characteristic of brain concussion is a disturbance of
consciousness, with no immediate or obvious pathologic
change in the brain. It may or may not be followed
by brain edema and increased intracranial pressure,
depending on the severity of the injury. The early
definition of Koch and Filehne 1 well describes the
clinical picture.

Concussion is a state of more or less disturbed consciousness
with lost or practically lost reflexivity. The appearance is
that of sleep or apparent death, there is occasional vomiting.
The respiration is slow, shallow and regular, the pulse is weak,
slow and generally regular, the pupils are dilated and react
sluggishly, the temperature is subnormal.

Physicians do not know the neural mechanisms
which produce unconsciousness or, indeed, the anatomic
seat of consciousness. Concussion is a reversible and
recoverable phenomena in the great majority of cases;
however, in severe concussion states, both of the human
being and of the experimental animal, definite patho-
logic changes have long been recognized and described
as affecting the myelin (Schmaus 2 in experiments on
spinal cords), the ganglion cells (Jakob 3 ) and the blood
vessels (Kocher' 1 ). In the past, much experimental
research has been done on the nature of concussion ;
this was thoroughly reviewed up to the past few dec-
ades by Kocher . 5 A few of the most important of the
experiments may be briefly mentioned: Duret 0 pro-
duced concussion in dogs by the sudden and forceful
injection of fluid into the cranial cavity', and Koch
and Filehne 1 by hammering on a board applied to the
cranium. The latter authors studied the effects on
brain centers and concluded that the intracerebral
effects were general ; all centers — respiratory', vaso-
motor, vagus, and pupillary — were affected and in the
end became exhausted, so that function was impaired.

owrage zur expenmenteuen Uhirurgic:
oou die Comraot, ° cerebri, Arch. f. klin. Chir. 17: 190-231, 1874.

2. Schmaus, Hans: Beitrage zur pathologischen Anatomic der Rficken-
markserschutterung, Virchows Arch. f. path. Anat. 122:470 1890

3. Jakob Alfons: Experimentclle Untersuchungen fiber die traumati-
schen bchadingungen des Zentralnerven systems (mit besondercr Beruck*
s, chtigung - der Commotio cerebri und Komraotioneurose), in NissL Franz
5?* Alzheimer, Alois: Histologische und Histopathologischc Arbeiten fiber

shirnnnde, mU besonderer Berucksichtigung der pathologischen
^ ?8° miC der ^ clsteskran kheiten, J en a, Gustav Fischer, 1913, V ol. 5,

GeuMt^^eutsche^fschr.^f^Odr. 1 * 35^ 43 3 ^ ’ Jg 92^1 n e n du ~ h Stumpfe

I J h T ior , : , Hiroerschutterung, Himdruck und chirurgische

n.Sd/dePnri^is^ Ci >*-

1780

EFFECTS OF HEAD IN J DRY — SCHALLER

Ferrari 7 ingeniously placed capillary tubes filled with
colored fluid and cover glasses in various parts of the
main ; after concussion there was no breakage less
than 5 mm. from the surface. It was observed that con-
cussion effects were most marked in areas of transition
between gray and white matter, substances of different
densities. Apparently the transmitted force underwent
a change of rhythm or pace, producing disruption of
normal anatomic structure or disturbance of physio-
logic function. Kocher cited a celebrated case of cere-
bral softening, 8 reported by Hauser, which principally
affected the white substance, was not due to vascular
occlusion and caused death six days after injury. He
held that the main effect was in the direction of the
line of impact and that the vibrator}' method of experi-
mental concussion, “hammering,” was not reasonably
comparable to the impact blow ordinarily producing
concussion.

Scagliosi D first suggested that traumatic myelinic
necrosis without infarction was due to damage of the
neuroglia, an idea based on Cajal’s theory of the nutri-
tive function of this tissue; in support of this idea,
Rand and Courville 10 found swollen oiigodendroglia
cells in injured brains, cells which are in especial main-
tenance relationship to the nerve fiber. More recent
investigations have dealt with cerebral vascular changes
such as are produced by the vasovagal reflex, namely,
alterations in arteriolar, capillary and venous pressure
and in the size of vessels and the resulting changes in
blood flow and osmotic relationships. In this manner
stasis, edema and anoxemia are produced.

Bright and Rokitansky, according to Gussenbauer, 11
first called attention to the presence of “punctiform”
hemorrhages in concussion. It was Ricker 2 -' who first
suggested that these small hemorrhages were produced
by diapedesis and not by rhexis. He concluded that
neurovasomotor disturbances produced vessel dilatation,
stasis and consequent anoxemia. Cobb 13 stated that
he did not unconditionally accept Ricker’s vasomotor
theory of diapedesis because of the relatively feeble
nerve supply to the brain vessels. Interest in blood ves-
sel pathology has recently been revived by Cassasa’s 14
theory of capillary rupture by rhexis due to tearing of
the vessel wall by hydrostatic pressure suddenly trans-
mitted from the subarachnoid space to the perivascular
space. Osnato and Gilberti 15 and Martland and Beling 10
have described clinical syndromes of traumatic encepha-
litis and “punch drunk.”

With Dr. Tamaki and Dr. Newman 17 I examined
a series of brains of human subjects who had died of
head injuries. Serial sections were made of a number
of areas showing punctiform or petechial hemorrhages.
The petechiae were perivascular and fairly constantly

7. Ferrari, cited by Kocher, 0 p. 321.

8. Hauser, cited by Kocher, 3 pp. 293-294 .

9. Scagliosi, G.: Ueber die Gchirnerschutterung und die daraus im
Gehirn und Riickenmark hervorgerufenen histologischen Veranderungen,
Virchows Arch. f. path. Anat. 152 : 487, 1898.

10. Rand, C. W., and Courville, C. B.; Histologic Studies of the Brain
in Cases of Fatal Injury to the Head: III. Reaction of Microglia and
Oiigodendroglia, Arch. Neurol. & Psychiat. 27: 605-644 (March) 1932.

11. Gussenbauer, Carl: Die traumatischen Verletzungen, Deutsche
Ztschr. f. Chir. 15:47, 18 80.

12. Ricker, Gustav: Die Entstehung der pathologisch-anatomischen
Befunde nach Himerschutterung in Abhangigkeit vom Gefassnervensystem
des Hirnes, Virchows Arch. f. path. Anat. 226: 180, 1919.

13. Cobb, Stanley, in discussion on Schaller and others. 17

14. Cassasa, C. B.: Multiple Traumatic Cerebral Hemorrhages, Proc.
New York Path. Soc. 24: 101, 1924.

15. Osnato, Michael, and Gilberti, Vincent: Postconcussion Neurosis—
Traumatic Encephalitis: A Conception of Postconcussion Phenomena,
Arch. Neurol. & Psychiat. 1S:1S1 (Aug.) 1927.

16. Martland, H. S., and Beling, C. C. : Traumatic Cerebral Hemor-
rhages, Arch. Neurol. & Psychiat. 22: 1001 (Nov.) 1929. Martland,
H. S.; Punch Drunk, J. A. 31. A- 91: 1103 (Oct. 13) 1928.

17. Schaller, W. F.; Tamaki, K-. and Newman, Henry: Nature and
Significance of Multiple Petechial Hemorrhages Associated with Trauma
of the Brain, Arch. Neurol. 8: Psychiat. 37 : 1048-1076 (May) 1937.

Jour, A. Jf
Nov. ii, ]

found in these brains, but they varied in size. Tl
rarely affected the cortex but were found in the si
jacent white matter and in the deeper collections
gray matter and in the brain stem. Almost invarial
were the hemorrhages the result of diapedesis, c
observations thus not confirming Cassasa’s theory
ruptuie. Our study was extended to concussion expe:
ments on white rats, the controls being normal, untra
matized animals. By securing the animal on the ei
of a lever, which would be released at different heigh;
a traumatic head injury was produced similar to tli
effected by . propulsion impact, a mechanism comtrn
in automobile injuries and falls. Petechiae similar
those demonstrated in traumatized human brains wei
reproduced. A report on these results is as yet unptil
lished. The traumatized brains were studied at differei
intervals after trauma. For the most part there wei
no marked departures from the normal, but in sever;
brains perivascular gliosis was marked about a fe 1
vessels, as has been described and pictured by Ran
and Courville. 18 Other vessels were obliterated an
replaced by glia, and rarely vessels, obviously damagec
showed aneurysm-like degeneration and irregularitie
of their walls with fresh perivascular extravasations
We have therefore demonstrated in animals that ii
certain cases of brain concussion vessel damage is pro
duced which runs a definite course with tendency t(
reparation but which may cause late accidents by vesse
rupture, producing late apoplexies and softenings. As
yet, however, we have not demonstrated such a late
vascular accident in a series of thirty-five animals
This demonstration of structural brain effects following
concussion justifies the designation of “encephalopathy.”
Functional impairment from vasomotor irregularities
may be assumed, but as yet only assumed, to justify
the term concussion neurosis.

The course of a moderately severe case of brain con-
cussion is one of quick recovery from the immediate
symptoms of shock. The duration of residual symptoms
in severe uncomplicated cases rarely exceeds three
months and is often considerably shorter. Symptoms
of the postconcussional state are headache, vertigo,
tinnitus, nervousness (usually described as explosn’c-
ness and irritability), impairment of memory (which
may include events immediately preceding tire accident),
impairment of vision, fatigability, poor concentration,
sensitiveness to heat and intolerance to alcohol. Exami-
nation often reveals a hopeful rather than discouraged
patient, with a normal pulse but not infrequently a Ion
blood pressure and a far lower incidence of bvel)
reflexes, vasomotor disturbances and tremors than to
be found in the psychoneurotic group. _ . .

Severe cases of concussion may be complicated >}
laceration and contusion. Even moderately severe case-’
of concussion may be accompanied by small surface
hemorrhages of the pia arachnoid, by far the mo=
common of all traumatic lesions. As a rule, contuse
and lacerated wounds of the brain may be regarded a
subject to the same conditions of repair as elsevhcre
in the body. In the severest cases of brain injury,
complicated by contusion, it is probable that the genera
symptoms and disability, excluding epilepsy and los-
of specific function from focal lesions, are due to P e
manent concussion effects. The postconcussion p > ctu
differs from that following a gross lesion, as ap°P ,e *'_
or lobotomy for removal of a brai n tumor, as any

18. Rand, C. W.. and Courville, C. 11: Hfctoloeie Studies of it' Jpl
in Cases of Fatal Injury to the Head; IV'. Reaction ot t
Neuroglia, Arch. Neurol. & Psychiat. 27: 1342 (June) J93—

Volume 113.
Number 20

EFFECTS OF HEAD INJURY— SCHALLER

1781

rienced neurologist can testify. I am not prepared at
the present time to define precisely the mechanism or
pathology of severe concussion, but sufficient evidence
is at hand for one to recognize both the pathologic
picture and the clinical course, as distinguished from
those of laceration and contusion, on the one hand, and
the psychic counterpart, on the other.

the post-traumatic psychoneurotic state
(psychoneurosis, hysteria)

The psychoneurotic states following trauma have
been variously designated as traumatic neurosis, trau-
matic hysteria, litigation neurosis and compensation
hysteria. I have favored the term post-traumatic psv-
choneurosis as one which particularly describes this
condition, as it includes whatever psychic manifesta-
tions of the disorder may be present in the individual
case, whether they are of neurasthenic, psychasthenic,
hypochondriacal or hysterical nature ; it also places the
onset not at the time of trauma but after it. By defi-
nition a psychoneurosis is a condition of the mind
whereby unfavorable mental influences disturb the
function of the body through nervous mechanisms.
According to. Smith, 10 writing on neurosis in students,
a psychoneurosis always serves the patient a useful
purpose. Schwab 20 discerned in the war neuroses and
incipient neuroses a defense mechanism. To escape
from disagreeable situations there is a subconscious
flight or escape into invalidism and conversion of
normal bodily functions into abnormal ones. This is
typified by the hysterical picture of loss of function but
may be expressed by positive symptoms such as pain,
uncontrolled motor behavior, anxiety and compulsions.
I am aware that this extends the idea of hysteria
beyond the usual symptomatic picture. The theory of
conversion hysteria, however, should be valid not solely
for a conventional pattern of response but also for
such patterns as individual suggestibility and concepts
dictate.

It appears to me that classifications of the neurotic
state based on symptomatology have become unwieldy,
and this holds also for the complexities of mental
mechanisms sought to explain them. There is need for
simplification and more basic concepts. It also appears
to me that the compensation neuroses offer a particu-
larly favorable opportunity to study basic motivations
and fundamental life situations without the complica-
tions of fatigue and changed environment, as found in
the war neuroses. A psychoneurosis may be likened
somewhat to somatic disease having a comparatively
simple etiology but an exceedingly complex symp-
tomatology.

The term psychoneurosis will be used as the inclusive
term and hysteria for the usual picture. Oppenheim 21
unfortunately designated the symptom complex now
under consideration as traumatic neurosis, thus empha-
sizing the traumatic rather than the mental nature of
the condition. His theory of a molecular change in the
brain cells of course assumed something not in evidence.
As one now reviews his writings, one is impressed
with the admixture of symptoms now generally agreed
on as psychic, such as functional anesthesias and con-
centric contractions of the visual fields, with symptoms
due to concussion or even contusion. The Great War
definitely settled the essentially psychic etiology of the

19. Smith, S. K.: Practical Modes of Treatment in Handling Mental
Hygiene Problems in a University, Am. J. Psychiat. 13 : 57 (July) 1933.

20. Schwab, S. L: The War Neuroses as Physiologic Conservations,
Arch. Neurol. & Psychiat. 1: 579 (May) 1919.

21. Oppenheim, Hermann: Die traumatischen Xeuro«en, Berlin, Htrsch-
wald. 1SS9.

so-called traumatic neuroses. A comprehensive expo-
sition of the subject of the accident neuroses has been
contributed by Huddleson. 22 Whatever theory one may
apply to the cause of hysteria, the theory of suggestion,
of freudianism or of conversion, there is general agree-
ment (1) that the mechanism is purely mental, (2) that
the condition is curable, (3) that this cure is brought
about by mental readjustment and (4) that the cure is
often brought about with such dramatic rapidity as to
exclude any structural nerve change as playing any
role whatever in its production.

Many years’ experience leads me to believe that the
ultimate psychogenic factors underlying true hysteria
consist of the emotional and instinctive reactions of fear
and suggestion and of wishful thinking. Serious char-
acter defects and adverse mental influences often com-
plicate the picture. Hall and MacKay 23 discerned in the
post-traumatic neuroses “marked neurosis or marked
ineffectiveness of the personality before injury.” Does
a man refuse to work because he is covetous, indo-
lent, antisocial, querulous or resentful, dramatizing and
enjoying his invalidism; or is be of an essentially
apprehensive, suggestible temperament, fearful that by
returning to work and thereby forfeiting his compen-
sation he will jeopardize bis health by possible relapse
of symptoms and bis social security by inability to con-
tinue at occupation? Obviously, one should receive
greater consideration than the other and be more amen-
able to rehabilitation. Persons with marked character
defects are but too eager to capitalize on a minor
injury; this desire is often furthered by the sympathy
and solicitude of friends and relatives, by lack of occu-
pation and interest and by an undeserved' compensation
award, based on a complete misunderstanding of the
case and misdirected treatment, which tend to fix the
psychoneurosis. Following injury a period of meditation
ensues wherein inadequate personality traits and adverse
mental influences combine to create a psychic climax
and a point of negative departure from the natural
tendency to recovery. This point of negative departure
of efficiency is the “precipitation point” 24 and averages
three months and seventeen days after injury. It is
interesting to note that this approximates the inde-
pendent estimates of Fay 25 and Munro 20 of reasonable
recovery from the ordinary head injury.

In conduct and appearance the post-traumatic psycho-
neurotic patient is nervous and somewhat tense and
depressed, eager to establish his claim of disability
and voluble in detail. His good order of thought and
memory in regard to his accident and subsequent his-
tory are often in striking contrast to his assertion of
poor memory and concentration and mental fatigue.
He deals in superlatives, picturing in dramatic style the
seriousness of his injury and acuteness of his suffering.
He is apt to be emotional and querulous and often
asserts that he is doubtful of betterment. His com-
plaints are numerous and on recheck examination are
frequently amplified and augmented. Headache and
dizziness, especially the former, are almost constantly
complained of.

— Huddleson, J. H.: Accidents, Neuroses, and Compensation, Balli-
more, Williams & Wilkins Conipanv, 1932.

j. a. .wk^ioaVstolfuS'',^ r 9 34. The Post - Trauraa,ic *“«"»•

Precip“point- mT 0 “-

967-971 (Sept. 28) 1929. ’ J

J. A! M!TTo4fsw e {Feb. r i6) ^ tbe

TV) 1 ?"™; Craniocerebral Injuries, Oxford Loose-Leaf Medi-
cjne u . Ijd 1939.

17S2

EFFECTS OF HEAD INJURY — SC HALLER

Joue. A. JI. A.
Nov. 11, 1935

be too lenient in dealing with neurotic persons. Two
quotations are here relevant, one 20 from a lay journal
the other 30 from a medical journal, voicing the expe-
nence of physicians who served in the Veterans’
Administration. Those who have followed cases through
the courts and accident commissions have often been
greatly surprised by favorable decisions for the appli-
cant based solely on subjective symptoms. Further an
inconsequential injury is stressed which should he con-
sidered only as a point of meditative departure for the
establishment of a neurosis, and no clear distinction

The examination of the psychoneurotic person is
often a trial to the physician because of the flinching,
groaning and gasping which interrupt the different
tests. ^ These patients often complain of an actual set-
back m their illness because of the ordeal of the exami-
nation, despite its being made with considerate care.
Very often a tremor is present when the patient is
asked to extend his fingers; this may diminish or cease
on distraction. Sweating and lively reflexes are common.
Perhaps the most prominent trait of the neurotic patient
is his tendency to exaggerate in his response to tests

by a weakness incompatible with normal walking. He
will grip a dynamometer in a stiff-armed, effortless
fashion. If he claims hemianesthesia, he will respond
to sensory tests on both the affected and the non-
affected side with a meditated negativism which betrays
a lack of candid response. Often when the. limbs are
crossed the patient will make flagrant errors in his
responses, giving a ridiculous answer in the yes-no test.
It is therefore but little wonder that the general prac-
titioner and surgeon not trained in the complexities
of psychopathologic reactions consider these patients as
malingerers. It is generally held that “tests” for malin-
gering holding valid with reference to organic disease
are invalid with reference to hysteria. 27 A distinguished
psychiatrist, Aaron J. Rosanoff, 28 commented on this
statement by expressing the opinion that this is a dis-
tinction without a difference.

I myself do not feel that every post-traumatic neu-
rotic person of hysterical type is a malingerer, but I do
believe it is consistent with the facts to say that he is
at least a subconscious simulator. A conscious simu-
lator is a malingerer (to simulate: Latin, simnlo,
simulatus, to assume the signs or appearance of, to
imitate; to malinger: French, maUncjrer, to feign illness
or disability). Malingering, therefore, is of greater
moral implication than simulation and may in this
regard be likened to the legal term of perjury. As a
medical definition I should characterize malingering as
conscious, intentional and deliberate deception practiced
for profit or gain. Simulation is of milder implication
as regards motives and conduct. A patient may show a
complete sensory loss in an extremity but also show
in ordinary use of this extremity complete physiologic
function, namely, sensory orientation, proprioceptive
function and subconscious protection from injury. In
hysterical paresis unconscious function by conventional
patterns is often observed. In this sense, every hysteria
is a simulator ; simulation and malingering may coexist.

A hysteriac, in order to impress the examiner, may
consciously simulate. Certain tests have been devised in
order to determine the good faith of the subject and a
number of these are of doubtful value. For instance,
a pin may be suddenly thrust into an allegedly anes-
thetic extremity and the patient brusquely withdraw
this extremity. However, that this may be a purely
reflex phenomenon is established by a similar reaction
in a completely divided spinal cord. Pinching of the
allegedly anesthetic skin of the neck may cause a dilata-
tion of the pupil on the corresponding side. The pupil,
however, may dilate as a sensory motor reflex without
conscious perception.

It is my impression that there has been in late years
an increasing tendency of courts and commissions to

27. Jones, A. B., and Llewellyn, L. J.: Malingering, Philadelphia,

P. Blakiston’s Son & Co., 1917.

28. Rosanoff, A. J.: Traumatic Hysteria vs. Malingering, California
State J. Med. SO: 197 (March) 3929.

In many cases, therefore, a mildly traumatized neu-
rotic patient is compensated for defects in character
and temperament rather than for injury. For an alleged
injury to be etiologically valid, it should be of such
prominence and importance as to be an acceptably
dominant causative factor. The traumas or residuals
of trauma in the traumatic psychoneuroses are not
proximal or dominant factors but are remote and
secondary'. That this view is not extreme is evidenced
by the position of Claude, 31 in France, who has urged
that no compensation be awarded on account of trau-
matic neuroses of civilians, and in decisions of Gennan
courts 32 denying compensation for hysteria following
trauma.

The prognosis for recovery in the psyctioneuroses
depends on when and whether the patient’s character
and temperament, i. e., his personality, can strike a
balance with the adverse psychic factors arising both
from within and from without himself. In other words,
is the patient so mentally' constituted, controlled, and
desirous for recovery and work that he can overcome
adverse and uncomfortable situations and again take
his place as a useful member of society' and as a social
asset rather than a social liability? The greatest help
that a psychoneurotic patient receiving benefits can be
accorded is final settlement of his claim and return to
occupation. This is demonstrated by a follow-up inves-
tigation of cases reported by me 33 in 1918.

29. The Betrayal of Popular Government, editorial. Sat Eve. Post,

Nov. . 26, 1938: "The weaknesses that now beset popular governniefljf
especially our own foremost example of it, are not^ those of disaffection.
They are weaknesses of character, of faith, of convicition, and a re
fest in self distrust, in the flight from individual responsibility, orpa
of pain and hardship, a morbid anxiety about the pulse and circulation,
love of security, the habit of turning to the government in ever)' driemma.
the shameless struggle of groups and classes for access to the P ub, £
purse, and* a kind of cynicism that says, ‘Because those got theirs, noF
we shall have ours/ until at last we see a total failure of, the
parent tradition in American government, and in place of it the ioc
of beneficent government, a power at Washington, omnipotent and uis •
to absorb the^ people’s troubles, to feed and clothe and house them, .
divide the national income among them by a rule of wisdom, and mcrea
ingly to administer their lives." . XT •,

30. Aring, C. D., and Bateman, J. F.: Nurturing a National A enrcL*

J. A. M. A. 109 : 1092 (Oct. 2) 1957 : "The family life of vricraw
suffering from psychoneurosis was inquired into both from the

and from the wife who _ occasionally accompanied them. # rj
veterans as a rule report their families well and happy, but their .wi
tell a different storj'. It is not unusual for the wife when queried
private to note that a child is "just like his father/ with many o
same somatic complaints, iears, food fads and addition to medicm»>-
express rather indirectly her own dissatisfaction. This seemed sign j *

although we have no statistical data on tbe_ subject. It would well
an excellent subject for investigation. It is a remarkable fact tnz *
majority of these men assume the additional responsibility ot 3
(repeated marriages seemed quite high in these veterans) and t0

children, despite the lack of energy and numerous complaints^ l 633 ..* .
invalidism or semi-invalidism. We hold no brief for the strict e “
mentalist, but children raised 5n the enervating atmosphere crea • ^

these individuals are certainly not bettered by it. Imitation OIP CJ _
is a large and recognizable factor in the mental development ox a j' ^
The onus for sponsoring a national neurosis^ therefore is not too i f
indictment, when one considers what is taking place in our naiio.
as a result of this unenlightened method of the treatment ox a ia*f. h *
of the psychically ill." , . f ;„ f iicien*

31. Claude, Henri: He la necessite du traitmcnt prccose et
dans les nevrose trauraatiques. Arm. de roed. leg. 4; 393 {Vet./ J. ~

32. Kollmann, M. : Compensation in Traumatic Aeuroses, *
raed. Wclmsehr. 52:1814 (Oct. 22) 1926; abstr. J. A. M. A*

^33.’ SchaHerf’ W. F.: Diagnosis (Prognosis) in Traumatic Neuron*.

J. A. M. A. 71 : 338 (Aug. 3) 1918.

Volume 113
Number 20

EFFECTS OF HEAD INJURY — SCHALLER

1783

This article does not concern itself with treatment,
but it may not be amiss to assert that in the majority
of cases of post-traumatic psychoneurosis, especially
those of long standing, say over a year, there is no
medical treatment or psychotherapy which offers any
great chance of success. True, in some cases major
hysteria based on fear and suggestion clears up under

Taiu.e 1. — Comparison of Features Common to the Tivo
Conditions and of Work Efficiency*

Post-Traumatic

Post-

Concussion

Traumatic

State

Psychoneurotic

(Concussion,

State

Traumatic

(Psychoneurosis,

Encephalopathy)

Hysteria)

Headache

77

97

Lh’ely reflexes

46

76

Sweating

38

64

Tremors

33

54

Fast pulse

1

12

Low blood pressure -

Attempted work with symptoms,

13

3

unable to continue.

11

28

Back at work with symptoms

30

6

* In 100 selected cases of concussion with severe head injury and 100
selected cases of psychoneurosis with slight head injury and no appre-
ciable period of unconsciousness. The figures indicate percentages.

intensive persuasive methods reinforced by a lump sum
settlement, which also acts as a prophylactic against a
relapse. I am of the opinion that more of these patients
would recover, or their state perhaps not be established,
if no compensation law existed. The treatment of a
traumatic psychoneurosis is to recognize its onset at
the precipitation point and to make it unpopular and
unprofitable. In none of my cases of post-traumatic
psychoneurosis do I recall a single instance of the con-
dition following injury to boys at play or in college
athletics, boxers, wrestlers or jockeys. This fact, similar
to the experience of many others, needs no elaboration.

DIFFERENTIAL DIAGNOSIS

The foregoing discussion of symptoms brings out
the considerable difference between the two conditions
of organic and nonorganic brain syndromes following
trauma. These differences are set forth in the accom-
panying tables. The mental attitude of the one is dif-
ferent from the other. The neurotic person often resents
a diagnosis of minor injury and good prognosis, and
his manifest exaggeration and elaboration often pro-
duce a heavy strain on the examiner’s patience and
credulity.

In concussion the picture is one of a general lowering
of physical and psychic functions without the emo-
tional, complaining state; frequently distinct euphoria
is present. In concussion there is a natural desire for
recovery and return to work; this is seen in table
1, which shows that 30 per cent of such patients con-
tinued at work with symptoms, in contrast to but 6 per
cent in the neurotic group.

The concussion patient often shows amnesia of the
accident and for a definite period preceding it and
defects of general memory. Concentration is difficult.
The neurotic patient is mentally alert. With concussion
there is a history of an appreciable period of uncon-
sciousness with more or less severe head injury, often
indicated by skull fracture and scalp lacerations. Often
the neurotic patient has suffered but a slight blow on
the head, and there may be a considerable discrepancy
between his description of the accident and the state-
ments of witnesses. Those with concussion spontane-
ously improve, the neurotic tends to regress. In contrast

to the concussion case, the neurotic shows an incon-
stancy and variability of symptoms. In concussion
there is often a change of character; in the neurotic
patient there is an exaggeration of predominant char-
acter traits. The course of a concussion case is not
affected by settlement of compensation or litigation
features; the neurotic person often recovers on such
settlement.

Intolerance to heat and alcohol are frequently met
in concussion. The neurotic is more apt to show objec-
tive signs of nervousness than the patient with con-
cussion.

Twenty-three of 100 patients with concussion pre-
sented in table 1 made no complaint of headache.
However, headache is an almost constant complaint of
the psychoneurotic patient; in my analysis of 100 such
cases but three failed to list this complaint, and in
these cases the principal symptoms were focused on
injury of an extremity. It has been stated that whereas
paroxysmal, sharp and localized pain is characteristic of
the organic headache, a sensation of constant pressure
is typical of the psychoneurotic type. A tabulation of
my cases has failed to reveal this distinction, as the
headaches in both conditions are variously described
as to character, location and duration. This similarity
may be explained by the replacement of a true con-
cussion headache by its psychic equivalent in the psy-
choneurotic person, owing to psychic fixation, and thus
also may the difference in incidence be explained.

True vestibular vertigo, often found in the concussion
state, is described as a feeling of whirling, and this
type may be established by appropriate vestibular func-
tional tests. In the psychoneurotic state the complaint
of dizziness is more properly expressed by giddiness.

Table 2. — Differential Diagnosis of Major Symptoms

Post-Traumatic Psychoneurotic
State (Psychon euros is
Hysteria)

3. Does not wish to work

2. Depressed, emotional, complain-
ing

3. Mentally alert

4. Aggravation of inherent per-
sonality defects

5. Frequently slight injury

6. Hysterical symptoms and signs

7. Exaggeration and elaboration in
statement and behavior

8. Course: tendency to aggrava-
tion

9. Favorable effect of termination
of compensation or of settlement

10. Multiplicity, changeability, and
indefiniteness of symptoms

11. Headache rarely absent

12. Dizziness: giddiness

13. No disturbance of tolerance to
heat and alcohol

Post-Traumatic Concussion State
(Concussion, Traumatic
Encephalopathy)

Wishes to work

Euphoric, aggressive, periods of ex-
plosive irritability

Amnesia of^ injury; memory and
concentration difficult
Changes from original personality
makeup

Often severe injury, followed by
long period of unconsciousness
No hysterical symptoms and signs
No exaggeration or elaboration in
statement and behavior
Course; tendency to improvement

No effect of termination of com-
pensation or of settlement
Constant and precise symptoma-
tology

Headache frequently absent
Dizziness; vertigo
Intolerance to heat and alcohol

The foregoing material describes the contrasting pic-
tures of uncomplicated cases of concussion and psycho-
neurosis. Obviously, they may coexist in the same
patient or be further complicated by organic paralysis
from brain laceration and contusion and by malingering.
Such a complicated picture may be difficult at times to
evaluate, especially in a malingerer. A study of per-
formance in a suspected malingerer when he is unaware
of observation is of great value.

Finally, a word as to the responsibility of the physi-
cian in the production and recognition of the psycho-

1784

EFFECTS OF HEAD INJURY—, SCHALLER

JOM. A, 51. A
Nov. |1, |9J)

neurotic state. Too often the physician does not realize
the suggestibility and apprehension of the ordinary lay
person in any circumstance which affects his bodily
state or feeling of well-being. An unguarded state-
ment as to the severity of trauma or outlook for
recovery, if this carries the idea of any doubt, may
precipitate a psychoneurosis. Treatment of the neurotic
person for his original injury is often unduly prolonged
without the suspicion that his symptoms are mental in
origin.

However, the mental origin may be recognized fairly
early by the physician in charge of an industrial case,
and settlement or final rating of compensation award
may be strongly recommended ; in this event, respon-
sibility for long-continued treatment without improve-
ment rests on the court or the industrial accident com-
mission referee, who with the commendable intention
of protecting the interests of the claimant, refuses to
authorize a settlement and insists on further treatment,
adopting a “post hoc, ergo propter hoc” attitude. This
refusal constitutes a powerful suggestion of serious
injury, which falls on fertile ground in the mind of
the psychoneurotic, thereby further fixing his neurosis
and rendering useless efforts of subsequent treatment.

SUMMARY AND CONCLUSIONS

The term traumatic neurosis should be discarded
and replaced by a more fitting and descriptive classifi-
cation.

After-effects of head injury may be classified as con-
tusion, concussion, psychosis and psychoneurosis, all
essentially different conditions.

The post-traumatic concussion state produces reversi-
ble changes of brain function which, in severe cases,
may become irreversible, with demonstrable pathologic
change.

The post-traumatic psychoneurotic state, character-
ized by fear, suggestion and wishful thinking, is due
to the precipitation of psychic complexes, following a
period of meditation, in patients presenting inadequate
personality traits and subjected to adverse mental
influences.

909 Hyde Street.

ABSTRACT OF DISCUSSION
Dr. George W. Hall, Chicago: In cases of concussion the
patients are more susceptible to the effects of alcohol. I observed
a man with a history of having been able to take alcohol
moderately without any disturbances whatever until he became
a prize fighter. He was knocked out on one or two occasions
and after those incidents his personality changed. At present
he is most affable when not under the influence of liquor, but
two or three drinks now will make him extremely vicious. On
one occasion he threw a milk wagon driver out of his wagon,
threw the bottles on the driver and drove off with the car. He
drove into a garage, picked up another car and traveled a little
farther before he was arrested. He spent about six months in
jail for that offense, and a week or two ago he took his mother’s
new car out and it was found front-first down the stairs of an
empty basement as a result of his taking alcohol. Yesterday
Dr. Hartman stated that oxygen is tiie agent for the cure of
acute alcoholism. It may be that in these cases of concussion
the brain cells are so damaged that they are unable to absorb
the oxygen from the blood in the quantities which the brain
cells of a normal person can absorb it, and that is so, according
to Dr. Hartman, when the person is under the influence of
alcohol. I think that point is well taken in Dr. Schaller’s paper
as one of the differential points between concussion and psycho-
neurosis. The other point, of course, is the wish fulfilment in
the neurotic, whereas patients with concussion do not desire to
quit work. I recall another recent instance in which a man
worked four months with a headache following an injury, until

finally he suffered such vertiginous attacks that the manager ci
the concern caused him to lie off from his work. ' When k
came into the hospital he showed none of the signs that on;
expects to find in cases of psychoneurosis, no sensory distur-
bances whatever, and his whole ambition was to forget it all
and return to work.

Dr. Sidney I. Schwab, St. Louis : I do not know of any-
way to measure the effect of a head trauma which produces
so-called organic changes. Some of the most difficult cases to
handle have been cases in which the trauma was insignificant
and the long-distance effects, even assuming that they were
organically produced, were long and continuous. On the other
hand, if we consider the psychoneurosis, we shall have the same
difficulty in measuring the effect and violence of the blow or
of the trauma in relation to the remote or recent symptomatic
results. Whether one calls these after-effect neuroses or con-
cussive syndromes, or whatever designation one chooses to
place on them, the question at issue is What is the nature of
the damage to the individual ? It does not make a lot of differ-
ence if the patient is distorted from a personality point of view
owing to an organic destruction of brain elements or whether

he is distorted from a personality point of view by virtue of
the development and evolution of a neurosis. I see no evidence
at present by which an organic disease or a neurosis can be
differentiated in terms of mechanism and changes or alterations
within the neural mechanism. What we are dealing with here
in this artificial separation of these two categories of disease
is with the method of examination. We do not have delicate
enough instrumentations to determine where in between the

dividing line, as the author of this paper has so sharply differen-
tiated, organic changes end and other changes begin. While
this differentiation clinically is of value, I do not see that it
throws any light on the nature of the changes which involve
the personality of both the organically affected individuals and
those so-called inorganically affected individuals. This type of
traumatic disease cannot be differentially diagnosed on parallel
symptomatic groups, certainly in any kind of series of cases
which have hitherto been published. The percentage of error
in personality and personal reaction is so great that the small
200 or 500 cases amounts to no more than imaginative con-
tributions to the truth. This is a valuable paper because >t
opens up those vital questions which are facing neuropsychia-
trists, neurosurgeons and internists the world over, the associa-
tion and the coordination and penetration of what was formed)
called organic changes into the total life of the organism. <Jur
neuropsychiatric duty is to assess the damages to the person an
not to assess the damages in points of litigation.

Dr. Harry E. Mock, Chicago: Dr. Schaller’s paper con^
tains material of value to general practitioners, who see a S r “
number of head injuries and first come in contact with ^
complications following head injuries. It is natural that a
neurologists we should discuss the cerebral pathology and 1
terminology. The chief point, whether we call it “concussm
syndrome” or “persistent cerebral contusion,” is that somctiiia
has happened to that individual’s brain from the bead inju h
be it a slight injury or a serious injury, which causes persisfen
of symptoms. The skull fracture exhibit which we have at
meeting is visited by many doctors from the smaller comma
ties, and the commonest question asked is What would > ou
in this case? The histories are usually the same: _ This ho
wife, this farmer, this school child had a slight injury, a ’
a fall or an automobile accident and remained unconscious
or three hours. Most of these patients are treated in
homes, most of them remaining quiet in bed for a short P cr ' ’
but after a few days of activity they complain of hea a ’
dizziness and ringing in the ears, they become despon en
they cry easily or are aggressive. Some of these inq »
doctors think the condition is simply mental, others tha
traumatic neurosis, while others are anxious to know w i ^
there is any remaining pathologic condition in t he brai .
my work many cases arc referred for. examination " (

statement from the referring doctor or insurance company
the patient is a malingerer or a traumatic neurotic.

30 per cent of these will show some neurologic mamlcst
jr evidence of persistent increased pressure by spina p
ind manometer reading, while the remaining 20 per c . j
m signs and belong in the psychoncurotic group. A

Volume 11 o
Number 20

ABSORPTION OP CAROTENE— CURTIS AND BALLMER

1785

study of this so-called post-traumatic concussion group reveals
incomplete treatment during the acute stage, an unsympathetic
attitude and a misunderstanding of the condition of the patient
during his convalescent stage by his doctor and his family and,
in many instances, a prolongation of the condition into a true
psychoneurotic condition by compensation and litigation prob-
lems. Too many are prone to consider all the cases as belong-
ing in the latter class. This is wrong, for many a true traumatic
syndrome following a head injury continues even after the
settlement is made. The majority of these require a regimen
of treatment quite similar to that which they should have had
during the acute condition, namely, absolute rest in bed, reduc-
tion of the persistent increased intracranial pressure, sometimes
by lumbar puncture, usually by a carefully guided dehydration
program, and, above all, the avoidance of all disturbing influ-
ences until their symptoms have abated. Only a few of them
will require encephalography and neurosurgical treatment.

Dr. R. P. Mackay, Chicago: It is not a problem as to
whether the patient has either structural damage or psychologic
damage but as to how much of each he has. That means that
we must not only evaluate the extent to which a neurosis may
be present but we must attempt to find out, even if a neurosis
is present, to what extent there is also an organic lesion. One
syndrome is exceedingly common in these cases. I refer to
the postural vertigo and headache which at least half the patients
with considerable head injury show, and it is so stereotyped
that it could not possibly be due to psychologic factors. The
patients report that if they lie in a particular position they have
rotary vertigo or that turning the head in a certain direction
will produce the vertigo. Not infrequently the headache will
be brought on by a certain position or movement of the neck
or head. This is one more syndrome which seems to indicate
that structural changes have occurred. What the mechanism
for the production of the syndrome is I do not know, but I am
sure it is "organic” in nature.

Dr. Leopold Brahdy, New York: I want to state briefly
my experience. I tried lump sum settlements in industrial
compensation cases but they proved a failure. I now tell the
postconcussion patient that he may have lighter work at his
regular wages for a specific period of time; that a job is there
for him if he wants to take it; that if not, his compensation
will continue; that if he cannot resume his usual work at the
end of the specified time he will be put back on compensation.
I have had excellent results with this method. The symptoms
have not always disappeared (some complain of headaches from
one to three years afterward) but these men are working and
are in good health. Dr. Schaller said that the onset of psychic
symptoms is about three and one-half months after injury. I
think my procedure has shown that the important factor in
preventing development beyond the organic damage done by the
concussion is to get such a patient back to work. That is a
form of therapy the beneficial effects of which cannot be obtained
by occupational therapy in an institution, useful as that may
be in other conditions. Such a patient must get back to his
normal environment among his fellow workers, doing something
he regards as real work for wages. This procedure has been
successful with me. I should like Dr, Schaller to comment on
whether in some oE these cases the differential diagnosis by
laboratory methods, especially encephalograms, isn’t undertaken
too early. It does not matter whether we find out from two
months to six months after an injury that we are dealing with
encephalopathy. If the symptoms are psychoneurotic, we do
not help a psychoneurotic patient by subjecting him to encephalo-
grams when a delay of a few months will clarify the diagnosis
without such procedure. If it is an encephalopathy, we shall
know soon enough that we cannot help him.

Dr. Walter F. Schaller, San Francisco: In answer to
Dr, Hall: It was the question of the significance of traumatic
petechial hemorrhages that led me to the consideration of con-
cussion pathology. The majority of these punctiform hemor-
rhages in brains showing no gross lesions are due to diapedesis
and not to rliexis. Such petechial hemorrhages are not lesions
which arc produced or which cause damage at the time of
accident. Patients do not die from petechial hemorrhages, and
these are probably not the most important pathologic change in
concussion. It was difficult to present a paper on a subject of

this scope and importance in fifteen minutes. Perhaps five
years ago I should have accepted Dr. Schwab’s position as to
the impracticability of a differential classification between the
two conditions discussed, but since I have studied the minute
pathology of brain trauma and clinically analyzed a large group
of cases of both functional and organic nature I have arrived
at the conclusion that it is high time that a differential diagnosis
be formulated and all these cases, even though their symptoms
and signs may be somewhat similar, not be thrown into the
grab-bag of what is often called “post-traumatic head syndrome.”
I am not aware that any such tabulation as I have made has
been attempted heretofore. If my tables do not show the
differentiations that I believe are possible and desirable between
concussion and psychoneurosis, better tables should be prepared.
Serious concussion effects may occur from slight injuries in
individuals who are particularly vulnerable. In answer to Dr.
Brahdy: I consider laboratory methods of undoubted value in
differential diagnosis, particularly when we wish to rule out
gross lesions and contusions. The cases here reported were seen
an appreciable time after injury, and in such cases, and also in
those in which the acute symptoms have subsided, I do not
consider encephalography contraindicated.

THE PREVENTION OF CAROTENE
ABSORPTION BY LIQUID
PETROLATUM

ARTHUR C. CURTIS, M.D.

AND

ROBERT S. BALLMER, M.D.

ANN ARBOR, MICH.

It has been shown by several workers 1 that, when
rats were fed diets supplying the provitamin carotene,
vitamin A deficiencies developed if liquid petrolatum
was added to the diets in amounts comparable to the
accepted dosage for human beings. Dutcher, Harris,
Hartzler and Guerrant 2 have reported experiments
showing that the carotene of a mixture of carotene and
liquid petrolatum was not utilized when fed to animals
but that the vitamin A of a carotene-free cod liver oil
concentrate mixed with liquid petrolatum was absorbed
■quite readily from the gastrointestinal tract. They
believed that the lack of absorption of carotene was due
to the greater solubility of the hydrocarbon carotene
in the hydrocarbon liquid petrolatum and that vita-
min A was absorbed because of the greater solubility
of the sterol vitamin A in the sterols of the gastrointes-
tinal tract. Further work by Mitchell 3 and by Jack-
son 4 confirms the difference in the effect of ingested
liquid petrolatum on the absorption of carotene and
vitamin A in animals. Dutcher, Harris, Hartzler and
Guerrant 2 have shown that animals eating a diet of
known carotene content apparently absorbed most of
it, for but little carotene was excreted in the stools.
This small amount, however, was constant and did not
increase even though the carotene content of the diet was
considerably increased. When liquid petrolatum was
given to animals on this diet the amount of carotene

y ro ™ *'« Department of Internal Medicine, University of Michigan
Medical School. b

I. These include:

BU 24: V 7i9 M (Ap;il) an ,g2f. arr ' W ‘ K ‘ : Proc Soc - Exper - Bio1 & Med.
DU ( l Junej ^ 927 ^’ E!y ’ ^ ami Hon eywell, H. E., ibid. 24 : 953
M0 (Cto) |'r, and Christiansen, W. G.: J. Am. Fharra. A. 18:997

Rountree, J. i.: J. Nutrition 3:3-15 (Jan.) 1931.

Jackson, R. W., ibid. 4:171 (July) 1931.

Dutcher, Harris, Hartzler and Guerrant •

Mitchell. 1

Jackson. 1

K - B- : 2«MSe&) E - R ” Md Gucrrant -

tSSKi J^Nufritlon 7:°607 & (June) »«•

1786

ABSORPTION OF CAROTENE— CURTIS AND BALLMER

Jous. A. M. A
Nov. 11, 1935

excreted in the stools was roughly proportional to the
amount of liquid petrolatum ingested.

One of us 5 has reported experiments on adult
patients showing that plain liquid petrolatum given in
amounts of 20 cc. before each meal or 20 cc. before the
morning and evening meals would lower blood carotene

Table 1 . — The Effect of Various Preparations of Liquid Petro-
latum, Taken in Amounts of 20 Cc. Three Times a Day
Before Meals, on the Blood Carotene Levels of
Patients on a Constant High Carotene Diet
of 24,089 International Units of Vitamin A

Blood Carotene Determinations, Dichromatc Units

Diet Plus Liquid
Diet Only Petrolatum Prep.

Preparation

Fast-

ing

4th

Day

8th

Day

11th

Day

14th '
Day

4th

Day

0th

Day

12th

Day

Liquid petrolatum,
agar and water....

8.0

11.5

13.0

12.0

12.5

10.5

S.O

6.0

Emulsified liquid
petrolatum

7.0

8.0

13.0

14.0

14.0

12.0

10.0

7.0

Liquid petrolatum
with 0.26% carotene

17.0

19.0

23.0

24.0

25.0

23.0

22.0

21.0

Liquid petrolatum
with 0.28% carotene

6.0

9.0

10.0

12.0

12.0

12.0

12.0

12.0

levels previously elevated by a high carotene diet. In
each study the patients ate weighed diets of known
constant high carotene and caloric values. In part of
this experiment the liquid petrolatum was discontinued
and only the diet continued. The blood carotene values,
which previously had remained constant or even
decreased, would rise appreciably. Plain liquid petro-
latum in the amount of 30 cc. taken before retiring
seemed to us at that time to have little measurable
effect on carotene absorption.

Because many human beings obtain much of their
vitamin A by conversion of the provitamin carotene into
vitamin A and in view of the frequency that one of the
many preparations of liquid petrolatum is prescribed for
the relief of constipation or as a substitute for fat in a

Table 2. — The Effect of Various Preparations of Liquid Petro-
latum, Taken in Amounts of 20 Cc. Twice a Day Before
the Morning and Evening Meals, on the Blood Caro-
tene Levels of Patients on a Constant High
Carotene Diet of 30,000 International
Units of Vitamin A

Blood Carotene Determinations, Dicliromate Units

A

Diet Plus Liquid
Diet Only Petrolatum Prep.

Preparation

Fast-

ing

3d

Day

7th

Day

10th

Day

3d

Day

8th

Day

15th

Day

20th

Day

Liquid petrolatum,
agar and water —

7.0

10.0

10.0

10.5

10.0

8.5

G.O

5.5

Emulsified liquid
petrolatum

6.5

8.0

10.0

12.0

10.0

9.5

8.0

7.0

Liquid petrolatum
with 0.26% carotene

6.0

S.O

11.0

13.0

12.5

10.5

9.0

8.5

Liquid petrolatum
with 0.2S% carotene

7.0

9.0

10.0

10.0

12.0

12.0

12.0

33.0

reduction diet regimen, it seemed to us important to
determine whether a 65 per cent emulsified solution of
liquid petrolatum, agar and water and an 80 per cent
emulsion of liquid petrolatum would have the same
relative effect on removing carotene from the food of
the gastrointestinal tract as plain liquid petrolatum. It
also seemed important to determine whether liquid

5. Curtis, A. C-, and Kline, E. M.:
on the Blood Content .of Carotene in
63:54 (Jan.) 1939.

Influence of Liquid Petrolatum
Human Beings, Arch. Int. Med.

petrolatunr, presaturated with carotene both at room
and at body temperature, would protect the carotene
contained in the food of the gastrointestinal tract.

METHODS

In general, three types of experiments were carried
out. In each of the three experiments, four different
patients were given diets of constant caloric and caro-
tene values. The diets were weighed and consisted oi
two menus, which were alternated daily to afford
variety. The patients remained on these diets through-
out the experiment. The vitamin A value of the daily
diet in the first experiment was 24,089 international
units of vitamin A. The vitamin A value, expressed in
international units, of the second and third experiments
was 30,000.

In the first experiment each patient ate a weighed
diet for a period of fifteen days. Following this interval
the first patient in this experiment was given 20 cc. of
a solution of liquid petrolatum, agar and water three
times a day before meals. The second patient received
the same amounts of a solution of emulsified liquid

Table 3. — The Effect of Various Preparations of Liquid Petro-
latum, Taken in Amounts of 30 Cc. Before Retiring,
on the Blood Carotene Levels of Patients on
a Constant High Carotene Diet of 30,000
International Units of Vitamin A

Blood Carotene Determinations, Dicliromate Units

Diet Plus Liauid Petrolatum
Diet Only preparat ion

Prcpn- Fast- 3d 0th 7th 0th 30th '4th 5th 7th 8th 10th
ration ing Day Day Day Day Day Day Day Day Day Day u i

Liquid

petrolatum,

agar and
water

10.0

12.0

13.0 ....

13.0

.... 13.0 ..

... 33.0 ..

.. «0

Emulsified

liquid

petrolatum

8.0

11.0

11.0

.... 13.0

12.5

.. u.o ■■

.. 11.3

Liquid
petrolatum
with 0 . 26 %
carotene. . .

7.0

8.3

10.0

.... 9.0

9.0

.. 8.5 ..

.. S-0

Liquid
petrolatum
with 0.2S%
carotene. . .

14.0

20.0

22.0

22.0

27.0

.. 27.0 ..

.. 2S0

petrolatum. The third patient received the sain
amounts of a solution of liquid petrolatum saturate
with carotene at room temperature (0.26 per cen
The fourth patient received similar amounts of a so u
tion of liquid petrolatum saturated with carotene 3
body temperature (0.28 per cent). All patients m ’
first experiment received the various preparations
liquid petrolatum for eleven days. No attempt ''
made to mix the preparations of liquid petrolatum
the food, but since the liquid petrolatum was P .
before mealtime there must have been such a mixing
the gastrointestinal tract. Blood carotene deternu
tions were done at intervals throughout all three c*P .
ments by the method of White and Gordon-
mixture of carotene and liquid petrolatum was
unpleasant to taste. It was orange in color wm
aromatic odor like fresh raspberries and tasted s
what like fresh pumpkin. r st

The second experiment was a counterpart ot ti
except that before the morning and evening
patients were given 20 cc. of solutions of liqum P
latum, agar and water; emulsified liquid P etr ‘ j
liquid petrolatum with 0.26 per cent of caro c -

6 White, F, D., and Gordon, E. 31.: J. Lab. & Clin. Med-
ct.) 1931.

Volume 113
Number 20

ABSORPTION OF CAROTENE— CURTIS AND BALLMER

1787

liquid petrolatum with 0.28 per cent carotene. The four
patients in the second experiment remained on the diet
of 30,000 international units of vitamin A for eleven
days and then, in addition to the diet, took one of the
several preparations of liquid petrolatum for twenty
days.

The third experiment was likewise a counterpart of
the first experiment except that, before retiring, when
the upper part of the gastrointestinal tract was prob-
ably empty, the patients were given 30 cc. of solutions
of liquid petrolatum, agar and water ; emulsified liquid
petrolatum; liquid petrolatum with 0.26 per cent of
carotene, and liquid petrolatum with 0.28 per cent caro-
tene. All patients in this group received the. diet of
30,000 international units of vitamin A for ten days
and the diet plus one of the preparations of liquid
petrolatum for eleven days thereafter.

RESULTS

It will be seen in table 1 that all patients had a rise
in the blood carotene levels during the period when they
were taking only the high carotene diet. However, when
either of the solutions of liquid petrolatum, agar and

Chart 1.' — A comparison of the effect of 20 cc., taken three times a day,
of plain liquid petrolatum, liquid petrolatum, agar and water, emulsified
liquid petrolatum, liquid petrolatum saturated^ at 22 C. with carotene
and liquid petrolatum saturated at 37 C. with carotene on the blood
carotene levels. The plain and emulsified types of petrolatum have about
the same relative effect. Liquid petrolatum, presaturated with carotene at
room temperature, slightly protects the ingested carotene. When liquid
petrolatum presaturated with carotene at body temperature is given, the
blood carotene level remains constant.

water or emulsified liquid petrolatum was given in
amounts of 20 cc. before the three meals the blood caro-
tene levels promptly fell. When a solution of liquid
petrolatum with 0.26 per cent carotene was given the
blood carotene level remained more constant than with
the other two preparations, thus partially maintaining
the higher blood carotene level reached when the high
carotene diet alone was eaten. When a solution of liquid
petrolatum with 0.28 per cent carotene was given, the
blood carotene level remained constant.

Table 2 again shows the rise in blood carotene values
which occurred when the diet alone was eaten for a
period of eleven days. When 20 cc. of either the solu-
tion of liquid petrolatum, agar and water or emulsified
liquid petrolatum was taken for a period of twenty days
before the morning and evening meals, the blood caro-
tene fell to a level lower than the original in the first
instance and just short of the original level in the second
instance. When a solution of liquid petrolatum with
0.28 per cent carotene was given, the blood carotene
level rose three dichromate units in twenty days.

Table 3 shows that when 30 cc. of solutions of liquid
petrolatum, agar and water, emulsified liquid petro-
latum, liquid petrolatum with 0.26 per cent carotene, or
liquid petrolatum with 0.28 per cent carotene is used
nightly for eleven days following a period of ten clays
on constant diets of 30,000 international units vitamin

Blood
carotene
Di chromate
Units

Chart 2. — When 20 cc. of the same preparations is used twice a day
before meals the same relative effects are noted as in chart 3.

HIGH CAROTENE OlET
30.000 I. VIT. A. UNITS

Diet only 20 cc. Solutions i.2,3.or4 BTD AC

A, the effect of the petrolatum on the absorption of
carotene is variable. The administration of the solution
of liquid petrolatum, agar and water caused no reduc-
tion of the blood carotene level. The solution of
emulsified liquid petrolatum possibly caused a slight
reduction of the blood carotene level. This slight reduc-
tion was also evident when plain liquid petrolatum
containing an added 0.26 per cent carotene was admin-

HIGH CAROTENE DIET

< 39.000 x. vir. a . units - :

OICT OKU 30 CC SOLUTION* 1,2,3 O* 4 HS.

Chart 3. — When the five different preparations of liquid petrolatum are
given in amounts of 30 cc. before retiring-, none have any marked effect
on blood carotene levels except the preparation of liquid petrolatum prc>
saturated with carotene at body temperature (37 C.). The increase in
blood carotene levels when this preparation was given suggests that even
30 cc. of plain or emulsified liquid petrolatum given before retiring affects
the ability of the intestinal tract to absorb carotene from ingested faid.

istered. When liquid petrolatum with added carotene
in amounts of 0.28 per cent was taken, the blood caro-
tene level actually rose.

COMMENT

The results of the experiments listed show that solu-
tions of liquid petrolatum, agar, water and emulsified
liquid petrolatum taken in amounts of 20 cc. three times
a day before meals or 20 cc. twice a day before

1788

EXTRACTION OF TEETH— PALMER AND KEMPF

Jom. A. M. A
Nov. 11, ij:j

the morning and evening meals interfered witli the
transportation of carotene across the epithelium of the
intestine, if the fasting blood carotene levels may be
used as an index for such absorption. Liquid petrola-
tum, saturated with carotene at room temperature
(0.26 per cent) and taken in similar amounts still inter-
fered with the carotene absorption from the food of the
intestinal tract. When liquid petrolatum saturated with
carotene at body temperature (0.28 per cent) was taken
in amounts of 20 cc. either three times a day or twice
a day before meals, the blood carotene levels remained
constant or even increased slightly.

The effect of the two emulsified types of liquid petro-
latum was not striking when taken in amounts of 30 cc.
before retiring. The 0.26 per cent carotene saturated
liquid petrolatum also seemed to have little effect. But
when the effect of these three preparations are com-
pared with the 0.28 per cent carotene saturated liquid
petrolatum, it suggests that even in doses of 30 cc.
nightly liquid petrolatum' interferes with the organism’s
ability to absorb carotene from the ingested food.

In a previous experiment one of us 0 showed the effect
of 20 cc. of a plain liquid petrolatum taken three times
daily, twice daily and in amounts of 30 cc. taken before
retiring on carotene absorption from ingested food.
If the results of these experiments are compared
with the effects of . similar doses of liquid petrolatum,
agar and water, emulsified liquid petrolatum, and

0.26 per cent and 0.28 per cent, carotene saturated
liquid petrolatum (charts 1, 2 and 3)’ it is apparent that
the emulsified types of liquid petrolatum remove about
the same amount of carotene from the food of the
intestinal tract even though the oil content of the emul-
sified types of liquid, petrolatum is 65 per cent and
80 per cent respectively. When added carotene is
present- in amounts of 0.26 per cent at 0.22 C. the
absorption of carotene by liquid petrolatum from
ingested food is reduced, hut it still occurs. When
liquid petrolatum saturated with carotene at body tem-
perature (0.28 per cent at 37 C.) is given, the ingested
carotene bearing foods are protected and the blood
carotene levels do not decline.

It was not apparent at first why liquid petrolatum
saturated with carotene at room temperature failed to
protect the carotene of ingested food while saturation
at body temperature did so, for the difference in satu-
ration was only 0.02 per cent. Is is easily explained,
however, if one expresses the saturation of liquid petro-
latum with carotene at these temperatures in inter-
national vitamin A units. At body temperature it
requires 280,000 international vitamin A units of caro-
tene to saturate 60 cc. of plain liquid petrolatum. At
room temperature it requires 240,000 international vita-
min A units of carotene to saturate 60 cc. ofplain liquid
petrolatum. This difference of 40,000 units in the
saturation of liquid petrolatum with carotene at room
and body temperatures is greater than the total number
of vitamin A units in our high carotene diets. These
calculations also show the relative unsaturation of liquid
petrolatum as far as carotene is concerned and also
make it understandable why even 30 cc. of liquid petro-
latum interferes with the absorption of carotene by the
gastrointestinal tract.

CONCLUSIONS

1. Two emulsified types of liquid petrolatum, the
first containing 65 per cent liquid petrolatum, 1 per cent
agar and 34 per cent water, and the second containing
SO per cent liquid petrolatum, 1 per cent agar and 19

per cent water, were given in amounts of 20 cc. three
times a day before meals, twice a day before meals
and 30 cc. before retiring. The effect of these emul-
sified preparations of liquid petrolatum on the absorp-
tion of carotene from the gastrointestinal tract was
compared with the effect of similar doses of plain liquid
petrolatum and found to be comparable.

2. Plain liquid petrolatum, saturated at room tem-
perature with carotene (0.26 per cent at 22 C.) still
removes carotene from ingested food, but in lesser
amounts.

3. Plain liquid petrolatum saturated with carotene
at body temperature (0.28 per cent at 37 C.) prevents
the petrolatum from removing carotene from the food
in the gastrointestinal tract.

STREPTOCOCCUS VIRIDANS BACTER-
EMIA FOLLOWING EXTRACTION
OF TEETH

A CASE OF MULTIPLE MYCOTIC ANEURYSMS IN

the pulmonary arteries: report of

CASES AND NECROPSIES

H. D. PALMER, M.D.

AND

MYRNA KEMPF, B.A.

ROCKFORD, ILL.

Streptococcus viridans is constantly present in alveolar
infection and frequently enters the blood stream when
these infected areas are traumatized. Other organisms
are less regularly present and Streptococcus viricians
enters the blood stream from this focus much n>? re
frequently than all others combined.: The resulting
bacteremia is usually transient, but a' knowledge of the
frequency and mechanism of its occurrence is essentia
to an understanding of the pathogenesis of the sec-
ondary foci of localization — notably subacute bacteria
endocarditis. It is our purpose in this paper to re u ‘ a
our experience as to the frequency of bacteremia folio"
ing tooth extraction and to portray the consequence
incident thereto through the report of. (1) well stu \
clinical cases with postmortem examinations and ( )
bacteriologic examination of the' teeth and blooc
persons undergoing tooth extraction.

REPORT OF CASES

Case 1. — History . — A white man. aged 44, a patient

_ - , . a . * f 1 VlP

of D 1 *

Arthur Pearman, had always enjoyed satisfactory . health ^
spite of the known presence of a congenital car iac ^ ccn
Because of the congenital anomaly of the heart he ia ^
spared strenuous activities but had been able to carry i a ; n t.
ordinary school and business life without physica c ® (, er
Immediately after the extraction of several teeth in ; on
1936 he complained of vieakness,' sweating and mild P (urc
and had a fever of the septic type. The morning emp ^
was usually normal, but there was a temperature o ^

to 101 F. each evening. The pulse was 110 an “ , ..i nM s

pressure 138 systolic, 75 diastolic. The area of car ' a

was enlarged approximately 2 cm. to the left. „ rc atc.'t

loud harsh roaring ‘‘machinery murmur, with i ^

intensity at the second and third interspace, to ‘ ,c widely

sternum. In spite of the great intensity, it was j; rec tion
transmitted and did not extend more than 5 cm. m an j 0 [[ c
from the area of the pulmonic valve. The murmur \\ I ^ £
in time and continued throughout most of the ('•>- • jj

spleen was palpable but not painful. The bemog ce Jls

Gm. ; red blood cells numbered 4,290,000 and. Mute
8,350. Blood culture yielded Streptococcus viridans.

From the Laboratory of the Rockford Hospital.

S^}^n h %^’r ation of 0() TI0N 0p TEE1

^ **

of Paw r P y dur «ff the ' ° P/nff Pa/for' S ' ht ^^at, T f ? 6rane a
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S*^Sa 4s ">»««„ c s "fej

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ab °rtion SUcc essful l bercu, °us f rec “ rr ftJc Pt J ee ofd ' Dr -

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SS - '^s iS re Jelled ho£ V ^h r ^ , *k«l Bon *

mmmrn

1790

Jour. A. JI. A.
Nov. 11, 1939

EXTRACTION OF TEETH — PALMER AND KEMPF

with splinter hemorrhages. The hemoglobin was 8.5 Gm. ; red
blood cells numbered 3,300,000 and white blood cells 16,200.
Urine contained 1 plus albumin and a trace of chemical blood,
and the sediment was loaded with pus cells.

The course had a duration of six months. There were fre-
luent showers of emboli to the spleen and into the skin. A
ligb grade of sepsis with increasing evidence of cardiac failure
iharacterized her illness.

Fig. 3 (case 1). — Close view of mycotic aneurysms in tile radicles of
the left pulmonary artery shown in figure 2.

Necropsy . — Petechiae in the skin and mucous membranes,
slight clubbing of the fingers and slight dependent edema were
iound on external examination. There was fluid in all the
:avities. The pericardial sac was filled. It measured 20 cm.
n diameter and reached the lateral wall of the chest on the
eft. The heart measured 12 cm. in transverse diameter and
weighed 310 Gm. The left auricle was enormously enlarged,
measuring 10 cm. in depth. Along the posterolateral wall of
this cavity were a number of coarse thrombi and smaller vege-
:ations varying from gray to red. The mitral valve was greatly
liickencd and the chordae tendineae were shortened (fig. 4).
The leaflets were fused and the orifice, which was fixed and
measured only 1 cm. in diameter, was closed by a fresh throm-
botic mass which was continuous with older gray vegetations
m the valve. The aortic valve presented similar changes. There
,vas an old rheumatic lesion and the ventricular surfaces were
studded with vegetative masses. The edges of the cusps showed
moderate ulceration. The spleen weighed 480 Gm. It showed
lyperplasia of the reticulo-endothelium and numerous areas of
infarction in various stages of development. The kidneys
weighed 320 Gm. They were gray, mottled with red streaks.
Microscopically they showed multiple embolization of the glom-
erular capillaries. The changes in the other organs were those
yf sepsis and chronic congestion.

In this case, though no teeth were extracted, there
is a history of very closely connected onset of sepsis
with dental manipulation, including the traumatization
incident to injection of procaine hydrochloride. A
chill with high fever marked the onset almost immedi-
ately after the manipulation of the focus. An old
rheumatic lesion furnished the “suitable soil” for
implantation. Richards ’ 2 experiments are of interest
in relation to this case. He obtained positive blood
cultures in three of seventeen cases following massage
of the gums. About the same percentage of his cases
yielded positive blood cultures after massage of the
tonsils. In two of his cases there was a chill following
the massage of the tonsils. The condition is apparently
comparable to catheter fever.

Case 3.— History.— A girl aged 18 years, a patient of. Dr.
H. D. Countryman, had rheumatic fever with endocarditis at
the age of 8 years. Following the acute attack she had evidence
of mitral stenosis with insufficiency. At the age of 14 some
teeth were removed and a dental bridge was fitted without

o Richards, J. H.: Bacteremia Following Irritation of Foci of Infec-
tion.' J. A. M. A. 98: 1496 (Oct. 29) 1932.

accident. Three years later she returned to the dentist for

extensive repair work.” Her health at this time was “as well
as usual. Several of the teeth were devitalized and filling of
the root canals was undertaken. Most of the work was done
under infiltration with procaine hydrochloride. Within a few
days after this dental program had been started, she complained
of chills, fever, night sweats and loss of strength. She con-
tinued to keep dental appointments for a week but then found
it necessary to give up. Painful finger and toe pads developed.
There was a harsh systolic murmur over the mitral area, with
a presystolic thrill. The murmur was transmitted to the axilla.
The border of the left side of the heart was outside the mid-
clavicular line. The spleen was palpable and tender. It reached
4 cm. below the costal margin. The hemoglobin content was
65 per cent; red blood cells numbered 3,330,000 and white blood
cells 5,150. Blood cultures taken on three successive days
yielded pure cultures of Streptococcus viridans. There were
more than 50 colonies per cubic centimeter of blood. Cultures
taken bimonthly were positive throughout the course, which
lasted five months, ending fatally. The urine contained small
amounts of albumin and a small number of pus cells throughout
the course.

Necropsy . — The pleural and peritoneal cavities contained large
amounts of fluid. The pericardial sac was obliterated by dense
fibrous adhesions. The heart weighed 550 Gm. and presented
marked enlargement of the left auricle and both right chambers.
The mitral leaflets were thickened and fused and the chordae
tendineae were thickened and shortened. Large vegetative
masses were found on this valve and extended from it upward
on the septal wall of the left auricle and downward over the

Fig. 4 (case 2).- — Vegetative endocarditis engrafted on scarred mit
valve.

papillary muscles. The left coronary artery was occluded nc ®^
its orifice by an embolus made up of vegetative material. - IC ,
scopically the capillaries of the kidney glomeruli contain
emboli.

This child, with a healed rheumatic lesion in ^
mitral valve, had the onset of a septic course dun a
the progress of extensive dental repair under to
anesthesia. Death was due to coronary embolism-

Volume 113
Number 20

EXTRACTION OF TEETH— PALMER AND KEMPF

1791

Case 4. — History . — A man aged 60, a patient of Dr. Anna
Weld, experienced chills and fever and was confined to his home
for six weeks following the extraction of his lower teeth. Prior
to this he had complained of “heart trouble,” but there is no
accurate description of a preexisting cardiac lesion. He had
reccwered sufficiently to return to work when removal of the
teeth from the badly diseased upper gum area was decided on.
This experience was followed immediately by chills, afternoon
fever, lassitude, loss of strength, loss of weight and night sweats.
Streptococcus viridans was recovered from the blood stream.
There was physical evidence of a mitral lesion. The course
was septic and he died within six months. Necropsy was not
permitted.

The clinical history suggests that bacteremia was
established following the first extractions, with possible
recovery. Progressive fatal bacteremia with evidence
of Streptococcus viridans endocarditis followed immedi-
ately on the massive extraction of the upper teeth.

BACTERIOLOGIC STUDY: RESULTS OF BLOOD CULTURES
FOLLOWING EXTRACTION OF ONE OR TWO TEETH
In an unpublished bacteriologic study of the roots,
root canals, pulp and periapical tissues of a large num-
ber of diseased deciduous teeth extracted in the Chil-
drens Hospital in Iowa City in 1927 and 1928, we
were impressed by the presence, usually in pure cul-
ture, of Streptococcus viridans in more than 90 per
cent of the teeth from which cultures were taken. 3
Beta-hemolytic strep ' ’ : and diph-
theroid bacilli were _ n this work

the teeth were removed with technic as nearly aseptic
as possible; the root was separated with a sterile saw
and placed in 70 per cent alcohol for from three to
five minutes. It was then washed with two changes of
sterile physiologic solution of sodium chloride and
dropped into a tube of deep meat broth (1 per cent
dextrose fresh veal infusion broth with a cube of beef
at the bottom of each tube, p H 7.4). Subsequently the
broth was streaked on blood agar. It has been our
experience and the experience of others 4 that adult
teeth, when diseased, yield the same high percentage of
Streptococcus viridans.

During the past year, with Joseph A. Hopkins,
D.D.S., cooperating, we have made blood cultures on
eighty-two patients who had dental extractions under
local anesthesia. We purposely selected patients who
were not to have more than two teeth removed and
made no attempt to determine whether or not there
was infection in the apical areas. Okell and Elliott 5
in 1935 reported a very high percentage of positive
blood cultures immediately after massive extraction of
teeth from highly diseased alveoli. We were interested
in learning the result of blood cultures in persons who
have one or two teeth pulled for any reason. The
teeth in our series were removed because they were
dead, diseased beyond repair or for other reasons not
related to this study. All the patients had negative
cultures of blood taken immediately before operation.
Fourteen of the eighty-two, or 17 per cent, gave posi-
tive cultures with blood taken immediately after the
extraction. In thirteen of the fourteen positive cul-
tures the blood was sterile ten minutes later. The
other bacteremic case yielded organisms in the circula-

.3. This work was done in the Department of Pathology and Bac-
teriology of the State University of Iowa College of Medicine. The
department was directed by Dr. G. H. Hansmann,

4. Kosenow, E. C.: Oral Sepsis in Its Relationship to Focal Infection
and Elective Localization, J. Am. Dent. A. 14: 1417-1438 (Aug.) 1927.
Henry, G. \\\, and Doyle, Mary C. H. : Focal Infection in Teeth, Am. J.
Psychiat. S: 5 (March) 1929. Hadcn. 1

5. Okell, C. C., ana Elliott, S- D.: Bacteremia and Oral Sepsis, with
Special Reference to Etiology of Subacute Bacterial Endocarditis, Lancet

869 (Oct. 19) 1935.

tion ten minutes after the operation. The patient,
a man aged 65, suffered from arteriosclerotic heart
disease. He left the community soon after the extrac-
tion and passed out of our control. We learned that
he had a continuous fever and died after several weeks.
A necropsy was not performed. Elevation of tempera-
ture did not develop in the other thirteen cases of
transient bacteremia. In eleven of the cases yielding
positive blood cultures the organism was Streptococcus
viridans; in two Staphylococcus aureus (hemolytic) was
cultured, and in the remaining case a diphtheroid
bacillus was recovered.

COMMENT

Streptococcus viridans, admitted to the blood stream
by extraction of teeth, occasionally localizes in areas
of the vascular system other than the heart. The follow-
ing record is an example: A woman aged 59 who
suffered from hypertensive heart disease had several
teeth extracted. This was followed by severe occipital
headache and dizziness. There was a rise in tempera-
ture, which within a week reached a level of 104 F.
Coma developed and she died eight days after the
extraction. A ruptured mycotic aneurysm of a sclerotic
cerebellar artery was found at necropsy. Streptococcus
viridans was recovered from the brain tissue.

From the oral and pharyngeal mucous membranes
there are two paths by which bacteria break through the
protective lining of the dental arches. Miller 0 writes:
“The first is by bacterial penetration through defects
in the crown of the tooth produced by caries, erosion or
accident. The second break is in the epithelial covering
occurring at the junction of the gum and the crown
of the tooth.” By the first route the pulp and periapical
area become infected. The second route results in
pyorrheal pockets and infection of the hone of the
alveolar process; the cementum becomes exposed and
in severe cases the apical area is reached. The dental
pulp then becomes strangulated and infected. It is
evident, therefore, that the apical area and pulp may
be reached by either route. The second route probably
is frequently considered important to the health of the
teeth but too infrequently as a portal of entry in the
pathogenesis of distant infection.

Rosenow, 4 Henry and Doyle 4 and many others have
recovered streptococci from a high percentage of pulp-
less teeth, irrespective of whether roentgenograms were
positive or negative for periapical infection. In 1926,
Russell Haden 1 published a very careful study of cul-
tures from the periapical tissue of 1,500 teeth. Strepto-
cocci were present in 92.5 per cent, staphylococci alone
in only 1.3 per cent, gram-positive bacilli alone in
3.8 per cent.

Okell and Elliott 5 found that a transient Strepto-
coccus viridans bacteremia occurred in eighty-four
(60.9 per cent) of 138 patients who underwent dental
extraction. In cases of severe alveolar infection,
75 per cent of the patients who underwent multiple
extractions had positive blood cultures immediately
after the operation. In general, these authors found
that the occurrence and degree of bacteremia depended
on the severity of the alveolar infection and the amount
of damage done at the operation. That the bacteremia
was of short duration was shown by the fact that blood
cultures taken in all their cases ten minutes or more
after the operation was completed remained sterile. In
this series Okell and Elliott also found twelve positive
blood cultures in blood taken before operation from 110

nc ?'l «■'! sT Wmhfmo. Inf<xl!on an<J Systemic Disease, Dent. Digest

1792

ACNE IN STUDENTS— LYNCH

Jour. A. JI. A.
Nov. 11, 153)

of the patients. In other words, 10.9 per cent had
bacteremia irrespective of operative procedures. They
speak of this as a “leak” of bacteria into the blood
stream from the focus and quote Lewis and Grant as
referring to an “almost physiological entry” of organ-
isms into the blood stream of the average person.

The direct historical relation between foci in the
mouth and the onset of subacute bacterial endocarditis
has been stressed by some writers. 7 This group of
authors report twelve cases of subacute bacterial endo-
carditis with onset following the extraction of teeth.
Necropsies were not performed in nine of the twelve
cases, and bacteriologic studies were not made in six.

Three of our four case reports are from a group
of twelve cases in our necropsy records. Of the twelve,
two additional cases gave suggestive histories of onset
following manipulation of infected alveoli. The other
records are not complete in this respect ; it is necessary
that the history taker be conscious of this possibility if
accurate records are to be made.

Cecil 8 has reviewed the bacteriologic studies reported
and has suggested clinical application of the informa-
tion gained. Carr 0 has reviewed the literature. He
writes “The unfavorable or harmful results following
the surgical treatment of such foci, especially in connec-
tion with cardiac disease, are events of sufficient impor-
tance to impose on us the duty of caution.” Evidence
that the teeth and tonsils are of first importance as
portals of entry for this organism has become pre-
dominant. This evidence has provoked serious thought
and makes the treatment of oral sepsis in the presence
of a debilitating condition, particularly a cardiac lesion,
a serious problem. A more widespread understanding
of the simple fact that organisms are easily disseminated
from such a focus is necessary for better treatment.

SUMMARY

Seventeen per cent of a group of eighty-two patients
who had not more than two teeth extracted had transient
bacteremia. In 13.4 per cent the organism was Strepto-
coccus viridans. In four cases of subacute bacterial
endocarditis the onset of septic symptoms dates from
the time of dental manipulation.

Bacteremia is present in an appreciable percentage of
cases of severe oral sepsis independent of operation. 0
Organisms “leak” into the circulation from such foci.
Traumatization of the diseased alveoli laden with
Streptococcus viridans causes dispersion of these organ-
isms through the blood stream in a high percentage of
cases. The percentage is roughly parallel to the severity
of the infection in the gums and to the extent of the
operative procedure. This may be purely mechanical
dispersion rather than invasion. In persons with a
normal vascular system and a normal defense mecha-
nism, this form of bacteremia is relatively unimportant.
The circulation is usually cleared of the invaders within

7. Bernstein, Mitchell: Subacute Endocarditis Following Extraction
of Teeth (Case), Ann. Int. Med. 5: 1138-1144 (March). 1932. Brown,
H. H : Tooth Extraction and Chronic Infective Endocarditis, Brit. M. J.
1: 796-797 (April 30) 1932. Calvy, P. J.: Dental Surgery and Organic
Heart Disease, J. A. M. A. 74: 1221 (May 1) 1920. Vanderhoof,
Douglas, and Davis, Dewey: Subacute Bacterial Endocarditis Following
Extraction of Teeth with Report of Two Cases, Virginia M. Monthly GO:
151-154 (June) 1933. von Phul, P. V.: Subacute Bacterial Endo-
carditis: Three Cases Following Extraction of Teeth, Northwest .Med.
32: 188-191 (May) 1933. Abrahamson, L.: Subacute Bacterial Endo-
carditis Following Removal of Septic Foci, Brit. M. J. 2 : 8-9 (July .4)
1931. Rushton, M. A.: Subacute Bacterial Endocarditis Following
Extraction of Teeth, Guy’s IIosp. Rep. SO: 39-44 (Jan.) 1930.

8 Cecil R. C.: The Bacteriology of Dental Infections and Its
Relation to’ Systemic Disease, New York State J. Med. 32:21 (Nov. 1)

193 ?

9* Carr, T G.: Relationship Between Dental and Cardiovascular Dis-
ease, J. Am. Dent. A. 24: 1979-1988 (Dec.) 1937.

a few minutes. 10 Hypersusceptibility of the tissues
duetto long continued oral sepsis is speculated on by
Cecil. 8 In persons who have preexisting rheumatic
valvular lesions or congenital defects in the heart,
localization of the organism on such vulnerable areas
during the transient bacteremia, which so often follows
dental operations, may herald the beginning oi an
engrafted bacterial endocarditis.

A CLINICAL STUDY OL ACNE IN
UNIVERSITY STUDENTS

FRANCIS W. LYNCH, M.D.

ST. PAUL

The etiology of acne remains obscure in spite of
the investigative opportunity afforded by the high inci-
dence of this disease. It has been studied from the
point of view of specific infection, focal infection, allergy
and disturbed metabolism of carbohydrates, fats and
halogens, but none of these factors have been accepted
as a specific etiologic agent. Recent interest has been
directed toward a relation with the endocrine system,
suggested by the onset of acne at puberty and its usual
disappearance with sexual maturation, the frequent
exacerbation with the menses and its reported absence
in eunuchs.

A number of observers have demonstrated abnormal
amounts of estrogenic or androgenic principles in the
blood or urine of patients with acne. Although these
studies suggest a relationship between acne and the
endocrine system, the individual variations are consid-
erable and there must be some doubt as to the sig-
nificance of averages among groups of patients when
there is so little uniformity within each group. These
apparent hormonal deficiencies can as yet be regarded
only as associated with acne rather than as a demon-
strated cause of the disease. Particularly disappoint-
ing are the relatively poor results of treatment of acne
with estrogen or androgen.

It is the opinion of many that acne is often accom-
panied by clinical evidence of endocrine disease, an
this association is regarded as etiologically sigmncaii ■
It has also been said that acne is frequently accompanie
by menstrual irregularity, but no one has recorded su
cient clinical evidence to prove a causal relationship-

In order to determine how frequently acne is asso
dated with other clinical phenomena, observations " e
made on three groups of students at the University
Minnesota. Routine physical examination of stu ea
at the time of their registration in the university p ^
vides a large amount of general data, but there is ‘
lack of detailed information as to the condition o
hair and skin; the presence or absence of acne
recorded by the staff physicians but its character, se '
ity and extent are not accurately described. n
first and largest group of students, these data "
analyzed to determine the relation between acne •
the character of the menses in 3,119 cases and t ,c ,
tion to the form of the body and the weight in >- -
cases. —

). Progressive septicemia due to highly vi™1erit “of^ridered >'■
sional accident following dental operations hut is not cen ^

'rom the Student Health Service, Dr. Ruth Bo> A to ^ ^“umverjitr c!
Sion of Dermatology, Dr. II. E. M.ehelson, Director, un

lead' before the Section on Dermatology and Syplulolora’ a <

Annual Session of the American Medical Association, o
■ 17, 1939.

Volume 113
Number 20

ACNE IN STUDENTS— LYNCH

1793

In the second group were 481 consecutive new stu-
dents subjected to more careful dermatologic examina-
tion. Their records were reviewed for additional
diagnoses resulting from the general examination as
well as for the weight and form of the body and the
character of the menses. They were questioned as to
their habits of facial and scalp hygiene and the fre-
quency of bowel movement. In each case the scalp was
examined for evidence of seborrhea and the face and
trunk were observed for acne. Although no attempt
was made to count the individual lesions, the acne was
graded as mitd, moderately severe or severe. The
duration, extent and distribution of the eruption were
also recorded. The color and texture of the hair were
similarly classified by practical rather than scientific
standards.

In the third group were students who came to the
health service for treatment. Of these patients, 251
were studied in the same manner as those in group 2.
For an additional 120 students applying for treatment
the basal metabolic rate was determined, and they
were carefully questioned as to the character of the
menses and the course of their eruption. Repeated
changes in the length of the menstrual cycle were
regarded as significant if there was a variation cf more
than three days from the accepted average of twenty-
eight days. Since there is considerable doubt as to
the endocrine influence in dysmenorrhea, this symptom
was reviewed separately and was disregarded unless it
required going to bed each month. A menstrual flow
having a duration of three days or less was regarded
as significant oligorrhea.

INCIDENCE OF ACNE

The incidence of acne as recorded on the routine
examination was of little value because of the large
number of examiners and the tendency for minor
degrees of the disease to be ignored by some of the
physicians. Among the 481 students undergoing the
special examination on admission, the boys were sub-
ject to the disease more often than the girls and the
severity of their eruption was considerably greater.
This increased incidence was observed at each age level
from 17 to 21 years.

Table 1. — Incidence of Acne Among 481 Students

Boys (229),
Girls (2S2)

Acne, per Cent

ao Acne, r-

A

per Cent

i+

2-f-

3-t-

43

29

24

4

54

31

14

1

Since all these patients were university students, the
incidence at various ages does not give a true picture
of the course of acne. The median age of the boys
was 19 and of the girls 18 years. The fact that the
median age in the severe cases was no higher than
that in the mild ones suggests but does not prove that
severity is not related to the duration of the disease.
The higher incidence among boys may be due only to
the age of the group; acne develops at a later age in
boys than in girls.

CHARACTER OF THE ERUPTION

A greater severity of involvement among the boys
was further demonstrated by the character and distribu-
tion of the eruption. Pustular forms of acne were
more common among boys, while papular eruptions
were present equally in the two sexes.

In a group of 277 boys and 219 girls the trunk was
involved much more often among the boys, but in both
sexes the face was the most common site, with the
back next and the chest least often involved.

COURSE OF THE DISEASE

It was found that the course of acne was seldom
regular and that irregularity was about equally com-
mon to boys and girls. In most cases having an
irregular course, the exacerbations were associated with
the menses. Abnormal menses were twice as common
among girls having such a premenstrual flare-up.

RELATION TO BODY BUILD

In a group of 4,235 boys and girls whose body build
was classified as hypersthenic, sthenic or asthenic there

Table 2. — Relation of Acne to Body Build Among
4J235 Students

Without Acne,

With Acne,

per Cent

per Cent

Boys

Hypersthenic

8

9

Sthenic

81

Asthenic

C

7

Girls

Hypersthenic

30

12

Sthenic

52

5G

Asthenic

38

32

was no relation between the form of the body and the
presence of acne. The boys showed fewer variations
from the sthenic build than did the girls.

For the group of 666 students examined more care-
fully, similar observations were recorded. The only
statistically significant variation was the observation
that asthenic girls are unlikely to suffer from severe
forms of acne.

The classification of body build as hypersthenic,
sthenic or asthenic is admittedly not the most satisfactory
from an endocrine standpoint, but it was thought that
significant endocrine abnormalities might become evi-
dent because of the large number of students examined.
Since there is no doubt that variations in endocrine
function may affect the form of the body, probably
in relation to the thyroid, pituitary, adrenal and
gonadal secretory activity, it may be worth while to
review another group of patients following more
accurate morphologic classification such as has recently
been established for girls. 1

RELATION TO BODY WEIGHT
Deviation from normal standards of weight are occa-
sionally but not always an indication of endocrinopathy.
In these records a variation from standard averages
greater than plus or minus 10 per cent was regarded
as abnormal. In neither series of students were signifi-
cant differences noted with reference to the presence or
the severity of acne. (Regardless of the presence or
absence of acne, girls were likely to weigh less and boys
more than the “normal” figures.)

BASAL METABOLIC RATE

Of the methods used for determining endocrine
abnormality, the metabolism test is the only one which
allows accurate comparison of the results with accepted
standards. This test is chiefly' a measurement of the
activity of the thyroid gland but abnormal rates may
also result from disease in other glands.

It is well known to students of metabolism that girls
utilize less energy than boys. This difference is taken

Build in Relation to Menstrual
Obesity, Endocrinology 24 i 260 (Feb.) 1939.

Disorders anj}

1794

ACNE IN STUDENTS— L YNCII

J ova. A. 51. A.
Nov. 11, 19!)

into account in the establishment of normal standards
of metabolic rate as expressed in percentages. Thus,
although ±0 per cent represents a lower level of meta-
bolic activity in girls than in boys, the figure is in each
case the normal or average for other persons of the
same sex, age and body area. This point is emphasized
because in a series of forty-three boys and seventy-seven
girls with acne the average basal metabolic rate of the
girls was significantly lower than that of the boys.
Rates deviating from the normal by more than ±10
per cent were equally numerous in the two sexes, but
in the girls more of the abnormal rates were low and

Table 3. — Relation of Acne to Body Build Among 666
Carefully Examined Students

Without

With Acne, per Cent

Acne,

*

per Cent

i+

2+ 3 +

Boys

Hypersthenic

4

7 8

Sthenic

SG

S9

82 81

Asthenic

7

11 11

Girls

Hypersthenic

10

9

9 9

Sthenic

G3

87 91

Asthenic

12

23

4 0

in the boys more were high. When the patients were
not classified by sex, those having plus rates were equal
in number to those having minus rates.

In boys or girls plus rates were twice as common
among those having involvement of the trunk as among
those whose acne was limited to the face. When the
eruptions were graded as to severity but not extent,
the records suggested that higher rates were found in
the more severe cases among both boys and girls, but
statistical methods of analysis failed to demonstrate that
this apparent trend was significant. A larger series
might clarify this point.

RELATION TO THE MENSES

One of the best clinical means of estimating the
normality, of endocrine function is the menstrual his-
tory. Since the patient’s statement of character of the
menses is usually accepted by the physician, it is unfor-
tunate that such histories are not dependable. It has
been shown in college students that at least one third
have only an inaccurate knowledge of their menstrual
cycle. 2 Thus it is obvious that no menstrual history
or group of histories can provide conclusive evidence
unless the patients have kept written records.

Since any significant difference might become evident
because of the large number of persons studied, these
data based on routine questioning of 1,214 girls with
acne and 1,905 without acne are reported, even though
probably inaccurate. Analysis of the percentage of
subjects with each type of menstrual difficulty showed
striking agreement in the two groups. Thirteen per
cent gave a history of irregularity, menorrhagia or
amenorrhea, and an additional 4 per cent in each group
suffered from severe dysmenorrhea. Further subdivi-
sion of these students according to age did not signifi-
cantly change the proportions, perhaps because only a
relatively small number were over 21 years of age
(S per cent of those with acne and 1 1 per cent of those
without). A similar lack of relation to the menses was
also noted by Cunningham and Lunsford. 3

Eighty girls with acne were questioned in greater
detail and among them the apparent incidence of abnor-

2. Boynton, Ruth, and Treloar, A.; Personal communication to the

3Ut 3? r Cunninpham. R. L., and Lunsford. C. J.z Acne: A Statistical
Study of Possible Related Causes, California & West. Med. 35: 22 (July)
1931.

mal menses was considerably higher (40 per cent).
This figure is in agreement with the statements of many
writers but it is not known whether this represents a
significant difference from girls without acne. The
facts could be obtained only by requiring a larger group
to keep a written record for at least six months. In
this smaller series of girls, the incidence of abnormal
menses was apparently greater as the severity of the
acne increased.

TEXTURE AND COLOR OF THE HAIR

Texture of the hair was investigated because it was
thought that the size of the hair follicles would be likely
to influence the tendency to acne. Fine hair was much
more common than coarse hair in the entire group. It
was noted that severe acne was slightly less common in
girls with fine hair, but statistical methods indicated
that the amount of variation was probably not sig-
nificant.

There was no relation between the color of the hair
and the presence of acne. In Sallenbach-Keller’s series*
there was an increased incidence of acne among those
with darker hair, but Cunningham and Lunsford 3 in
records of the complexion found that brunettes bad a
slightly better chance of escaping acne.

ASSOCIATION WITH SEBORRHEA, HYGIENE, CONSTI-
PATION AND FOCI OF INFECTION

Boys were noted to have seborrhea more often than
girls. In both sexes seborrhea was more common
among those with acne and the incidence increased with
the severity of the acne.

The results of inquiry as to the frequency of washing
the face indicated that girls without acne wash less
frequently, as had been noted by Hinrichsen and Ivy-
This lack of attention is perhaps a natural result o
lack of need for attention. Among the boys there was
no association between the incidence of acne and tie
frequency of washing. .

The incidence of constipation was negligible in ho i
sexes whether or not acne was present.

Table 4. — Basal Metabolic Rales of Forty-Three

and Seventy-Seven Girls

Boys

Lower than — 10% 6

—1 to —10% U

17 (10%)

+1 to +10% 18

Higher than +10% 8

26 (60%)

Girls*

16

26

li(tsf

21

10

* A result of ±0% was reported for two girls. •

A wide variety of additional diagnoses was recorded
but the only condition which appeared to have an J ,*A
nificance was focal infection of the nose or throat, v
was much more common in boys than girls- R ,s P •
sible that this infection is related to the increase
dence of papular and particularly pustular lesio
boys as compared with girls.

THERAPY

The age of onset and the course of acne suggest
this disease is related to the endocrine syse > - n
chemical determinations of estrogen an d antirog — —

InsusurA

the ChteW

4. Sallenbach-Keller, Lily:
issertation, Zurich, 1930.

Akne Vulgaris und Pubcrtat.

sertation, Zurich, 1930. In the

5. Hinrichsen. Josephine, and Ivy, A. C: Incidenc n . j9Jg ,
jion of Acne Vulgaris, Arch. Dermat. & Syph. 37. u

Volume 113
Number 20

ACNE IN STUDENTS— LYNCH

1795

the urine or blood indicate that there may be some
association with the gonadal secretions, but the results
of endocrine therapy of acne have not been satisfactory.
The administration of thyroid substance, estrogen,
androgen or the sex-stimulating principle of the pitu-
itary gland may in selected cases result in considerable
improvement, but there are many failures after the rou-
tine use of such preparations. There are obvious objec-
tions to giving active hormonal therapy to a group of
adolescents having no gross evidence of endocrine dis-
ease; in particular the prolonged use of estrone or
testosterone might easily have an undesirable inhibitory
action on the pituitary gland. In order to avoid some
of the objections to injection therapy and yet to give
the estrogenic agents another 'trial, a series of patients
was treated by use of a cream containing a modified
estrogen. The cutaneous application of estrogen is
known to be followed by a systemic effect and also by
a local action on the epithelial structures.

A series of forty-nine girls with acne were treated by
the external use of the dihyro form of estrogen.
Improvement was noted in 72 per cent of these patients,
a proportion which would suggest that this is a thera-
peutic method of value; but the validity of this con-
clusion is questioned after observation of similar
improvement in 64 per cent of girls in a control series
who used the same ointment base without estrogen.
This lack of response to local estrogenic therapy and the
relatively unsatisfactory results of estrogenic and andro-
genic injections are disappointing to one who seeks to
link acne and the secretory organs. 0

COMMENT

The purpose of this study was to search for clinical
evidence relating acne and endocrine imbalance, an asso-
ciation suggested particularly by the age of onset and
the course of acne. The microscopic pathology, the
clinical appearance of the eruption and the results of
treatment give little evidence to prove or disprove such
a relationship. Chemical and biologic studies of the
urine and blood show some variations in hormone con-
tent but do not prove that acne is an endocrine disease.

A number of observers have made statements which,
if true, would be further evidence for associating the
endocrine glands and acne. For example, it has been
said that acne does not occur in persons with alopecia,
a statement with which I cannot agree. Others have
said that acne always disappears with marriage, but
there are numerous exceptions to this rule. Riley 7
stated that irregular sex practices possibly cause acne
persisting after marriage.

Several serious attempts have been made to correlate
acne and other clinical symptoms, 8 but none of them
have been very successful. Sallenbach-Keller established
a relationship between the onset of acne and the appear-
ance of the menses, and Cunningham’s evidence sug-
gests an association with enlargement of the thyroid
gland. Numerous writers have commented on the inci-
dence of irregular menses in about a third of girls
having acne but have not shown that this rate is sig-
nificantly higher than normal.

In my series of 3,119 girls the incidence of abnormal
menses was not related to the presence or absence of

6. The result of treatment of these patients is reported in greater detail
in a brief paper (Arch. Dermat. & Syph., to be published). The material
was^provided by Dr. Gregory Stragnell, Sobering Corporation, Bloomfield,

7. Riley, Ian D.: Testosterone Propionate in Acne Vulgaris, Brit. J.
Dermat. 51: 119 (March) 1939.

8. Cunningham and Lunsford.* SaUcnbach-Kcller. - * Hinrichsen and
Ivy. 5

acne. Although girls with severe acne had a greater
tendency to abnormality of menstruation, it is not
unlikely that the incidence of abnormal menses is higher
when associated with severe examples of any disease
whether or not the disease is endocrine. Abnormal
menses were twice as common among girls having a
premenstrual flare-up.

The records of 4,235 university students did not show
any significant association between acne and the weight
or form of the body except that asthenic girls may per-
haps be less likely to suffer from severe forms of acne.
This is obviously not an observation on which extensive
conclusions can be based.

Girls with acne were found to have lower metabolic
rates than boys with the disease. Higher metabolic
rates were recorded for both sexes when the eruption
was extensive. These observations are probably sig-
nificant but I am unable to explain them.

Study of the color and texture of the hair failed to
indicate any association with acne.

Seborrhea, more severe involvement with acne, more
extensive eruptions and a pustular tendency were
observed more commonly in the boys, hut these features
have no evident association with endocrine disease.

SUMMARY

As a result of this review I am unable to point out
any clinical evidence which might aid in establishing
an etiologic relationship between acne and endocrine
imbalance. There appears to be a relationship to abnor-
mal thyroid function, but this is demonstrable only by
changes in the basal metabolic rate and is not a clinical
observation. In severe cases of acne there is some
association with menstrual irregularity hut in milder
cases this association is not evident. With reference
to acne of a mild or moderate degree, it is hardly pos-
sible to say more than that it accompanies the process
of puberty and sexual maturation.

350 St. Peter Street.

ABSTRACT OF DISCUSSION

Dr. J. G. Hopkins, New York: Dr. Lynch’s collecting and
analyzing of this great body of data puts us all in his debt.
We now have some facts to study and from these some of us
may draw different conclusions. The outstanding tiling seems
the age incidence, 47 per cent in girls and 51 per cent in boys,
wasn’t it, in a group of the mental age of a college freshman?
I suppose that would be a calendar age of about 18.

Dr. Lynch : The age was 19 in the males and females.

Dr. Hopkins : Well, at that age Bloch reported even higher
percentages, which may be due to the different populations
sampled or to a different interpretation of what are the lower
limits of acne. Both reports lead to the conclusion that at that
age the person with acne is the normal; the person without
acne is the abnormal. Now the fact that it is in a sense a
normal occurrence at the time of arrival at sexual maturity or
shortly thereafter does not, of course, prove that it is of endo-
crine origin, but it seems to me strongly suggestive of an
essential endocrine basis. In his data one other tiling stood out
confirming the general belief that an exacerbation, by which we
probably mean a development of pustules, occurs quite regu-
larly- with the menstrual period. I think it is hard to dodge
the .implication that that means endocrine action. As to this
we have more direct evidence in reported studies on excretion
of estrogen in these patients. While the observations of Kurzrok
and Rosenthal of a complete absence of excreted estrogen in
the majority of acne patients have not been confirmed, I don’t
think they liav e been controverted and subsequent reports of
similar^ studies have pointed somewhat in the same direction.
These interesting data give us much to think about and analyze.
I think it is possible to draw slightly different conclusions from
those winch Dr. Lynch presented.

1796

VA CCINA TION—D ON NALL Y

Dr. R. L. Sutton Jr., Kansas City, Mo.: My interest in
acne is the practitioner’s problem of curing the patient. I offer
a hypothesis about its etiology. Bloch wrote : “Only the comedo
[first] phase of acne can be brought into direct relationship
with endocrine processes. The second phase is characterized by
an inflammatory process on the basis of infection. It may follow
the first, but this is not inevitable.” If the inflammatory phase
were the result of infection with Corynebacterium acnes, said to
be present invariably, the second phase ought to be inevitable.
It is not, and I believe that the saprophyte has been unjustly
maligned. Bloch assumed that inflammation implies infection,
overlooking the fact that the inflammatory phase of acne is
foreign body reaction to lipoid. It is a tuberculoid reaction
which has caused pathologists to confuse acne with tuberculosis.
It results from the introduction of lipoid into mesodermal tissues
and has nothing to do with parasitism. It may result from
bruising a comedo or from injecting lipoidal material into the
skin as Sabin injected fractions of Mycobacterium tuberculosis.
Hass injected fatty acids of olive oil and cod liver oil and learned
that less saturated fatty acids are more irritating. A comedo
once formed, like a xanthomatous deposit, cannot be resorbed
easily. Its resorption requires an inflammatory lesion. Phago-
cytism perhaps is instigated by discontinuity of the epithelial
barrier separating comedo from mesoderm. Trauma can cause
the breach. Foreign body reaction may take place shallow or
deep, and phagocytes may attack either solid, well saturated
lipoid or liquid, less saturated material. The clinical picture
varies with the location and severity of the inflammatory process.
Acne vulgaris I define as the disease which consists of tuber-
culoid inflammatory reaction to sebum which is abnormal because
of improper metabolism of lipoid. Acne is a kind of pustular
lipoidosis. In contrast with primarily mesodermal lipoidoses
(xanthomatoses), acne is primarily epidermal lipoidosis with
secondary inflammation. Acne depends on excessive ingestion
of oil : milk, cream, ice cream and butter are chief offenders ;
so are pork and cod liver oil. Girls get acne when they try to
gain weight by drinking milk and taking cod liver oil. Acne
depends on hormonal influences through the interrelationship of
thyroid function and lipoid metabolism. Lipemia designates
hypothyroidism more dependably, Hurxthal proved, than basal
metabolic rate determinations. Vitamin A is concerned, for its
excess counteracts the patient’s autogenous supply of thyroxine.
When one’s intake of lipoid and vitamin A exceeds one’s ability
to metabolize them, one may develop deposits in the sebaceous
glands, to which may develop inflammatory reactions. Treat-
ment based on this etiologic interpretation works in practice.

Dr. J. D. Farris, Richmond, Ky. : Dr. Lynch’s paper is
particularly interesting to me because as a college physician in
a state college I deal with this age group of young people and
the sexes are about equally divided. I wish to corroborate the
many points that he brought out in this particular subject and
wish to state that I have found many of the same points to be
true in the examinations of several thousand boys and girls over
the last few years. He mentioned using estrogenic substance
in the paste or ointment and I wonder what his experience has
been in using it hypodermically, or some product such as
antuitrin-S. I myself have had some rather good results in
these cases, quite satisfactory to the young people, by injections
of these substances.

Dr. Francis W. Lynch, St. Paul : I have no report on the
results of treatment by the injection of estrogenic agents because
I have not felt justified in administering such treatment as a"
routine to these students. Dr. B. A. Watson of the student
health service has been in communication with Dr. Sutton and
we have been stimulated by Dr. Sutton’s theory as to the patho-
genesis of acne. A boy' with a severe, chronic, papular and
pustular acne involving the face and trunk was placed, on a
measured and weighed diet for two months, part of the time
with low, normal and high fat content. With these diets we
failed to note any influence on the blood cholesterol level or any
significant association with the course of the eruption. At one
period the eruption improved noticeably while the diet was high
in fat content. This one case is reported not as conclusive
evidence but merely as a single experiment. I hope that Dr.
Sutton will report on a series of patients treated according to his
suggestions. Dr. D. W. Cowan at the health service has recently

Joue. A. M. A
Nov. Il, Du

performed vitamin C determinations in the blood of several
hundred students. In reviewing the results of these studies,
he failed to observe any association between the vitamin C level
and the presence or absence of acne. I did not acquire this
information in time to include it in my report but thought that
it might be of interest to the members of the section, particu-
larly because of the relationship between vitamin C and the
adrenal glands and the possibility that the a mount of vitamin C
in the blood may be some indication of the functional activity
of the adrenal glands. I agree with Dr. Hopkins that there are
many reasons for assuming a relationship between acne and the
endocrine system. I should have made clear that the conclu-
sions I presented today are based only on the studies and material
of this report and are to be regarded as only one portion of the
evidence which must be reviewed in making a final judgment
of the cause of acne.

SMALLPOX VACCINATION OF INFANTS

REVACCINATIONS AFTER TWO TO THREE YEARS
IN CHILDREN PRIMARILY VACCINATED WITH
CULTURE VIRUS (RIVERS), COMPARED
WITH THOSE PRIMARILY VAC-
CINATED WITH CALF
LYMPH VIRUS

HARRY H. DONNALLY, M.D.

WASHINGTON, D. C.

Revaccinations of children from 2 to 3 years of age,
among those who had been vaccinated 1 in 1935 and
1936 in the newborn nurseries of Gallinger Municipal
Hospital within a few days of their birth, were clone
in June and July 1938. The total number of these
revaccinated children followed through to involution of
the skin reactions numbered seventy, almost exactly
half of whom (thirty-six) had had successful primary
takes at birth with culture vaccine virus (Rivers)

Fig. 1. — -Primary vaccination when child was 3 hours old- r3
virus (Rivers) M60, intradermally; unsuccessful. June it r y c rk

scar. Revaccination when child was 2 years 8 months 0,d ' iraf3 ^ of
calf lymph; thirty needle pressures cutaneously. Early »PP. . c „ c !e:
skin reaction: Present within twenty hours. Rapidity ox va reactioai

Not increased; eighth day at or near peak. Intensity or s
Large take. Estimate of immunity: None. A, thtrd day; £>,

C, eighth day.

inoculated intradermally, and the other half
four) had had successful takes at birth with calf j i ,
two thirds (twenty-three) by the intracc_____

T r.L~I

Dm the Pediatric Department. George Washington U •

:dicine, and the Allergy Clinic of Children sH P 'j 5 ^ 51 ^
ad before the Section on Pediatrics at the J .q-ig

American Medical Association, St. Louis, May 1 A Coar.cl
.de possible in part by a grant from the National RcsearW
grant from Lcderle Laboratories, Inc., Pearl Kivc , * g rtf*

Donnally, H. H-; Nicholson M. M-S rn with Cri'

mor, M. H.: Intradermal Vaccination of atJoB * 1 *

Virus (Rivers) Compared with Intraderm published.

1 Calf Lymph in Over 1,000 Bah.es, to be publish™

i Volvue 113
Number 20

V ACC I NAT I ON — DON NALL Y

1797

method and the other third (eleven) by the cutaneous
method (Leake’s 2 multiple pressures). The skin reac-
tions were essentially the same whether the intradermal
. vaccination had been performed with culture virus
(Rivers) or diluted calf lymph virus (New York
Bureau of Laboratories) but tended to appear earlier
• with calf lymph. Each of these viruses could give
marked variation in intensity of skin reaction in differ-
ent babies.

The scars of these primary takes were readily found
because newborn infants were vaccinated uniformly on
■ the outside of the left leg just below the head of the
fibula. In the culture virus takes the scars were absent
in 35.1 per cent and not over 5 mm. in diameter in
32.4 per cent, whereas in the primary calf lymph takes
there were scars in excess of 10 mm. in diameter in
62 per cent, and no visible scar in one child (3 per cent).
Intradermal inoculations of diluted calf lymph virus, 1
. part in 100 of 0.85 per cent sodium chloride solution
; gave as a rule a smaller skin reaction and a smaller
scar than the cutaneous multiple pressure. The per-
" centage of successes was 93 per cent, the same whether
the calf lymph was inoculated intradermally or cuta-
neousiy (table 1).

Table 1. — Sisc of Primary Scars

No No

Virus Used Record Visi- 2 Mm. 2 Plus 5 Plus 10 Plus

in Primary Total o £ hie or to to to Over

Vaccination Cases Scar Scar Less 5 Mm. 10 Mm. 20 Mm. 20 Mm.

(VI)

- Culture virus
r (Rivers) intra-

dcrmal 37 3 13 G 0 0 3 0

: (S.1%) (33.1%) (10.2%) (10.2%) (10.2%) (8.1%)

Call lymph virus 34 0 1 0 4 8 11 10

(3%) (U.S%) (23.5%) (32.4%) (29.4%)

Intradermal... 23 1 4 8 10 0

. Cutaneous li 0 0 0 1 10

Sires of scars resulting Iron) successful intradermal vaccinations with
culture virus (Rivers) at birth, after two to three years: no scars in 35
per cent, and in the remainder small scars. Calf lymph virus scars
resulting from successful intradermal or cutaneous vaccinations at birth,
showed no scar in 3 per cent, and scars over 10 mm. in diameter in
02 per cent.

i

J

|

j

In a former publication 3 in discussing the duration 3a
of immunity to vaccination and to smallpox, the follow-
ing statement occurs summarizing facts 4 which relate
to the subject : “Skin reaction to revaccination indicates

2. Leake, J. P.: Questions and Answers on Smallpox and Vaccination,
Pub. Health Rep. 42:221 (J an. 28) 1927.

. 3. Donnally, H. H., and Nicholson, M. M. : A Study of Vaccination

in Five Hundred Newborn Infants, J. A. M. A 103 : 1269-1275 (Oct.
27) 1934.

3a. Rivers, Ward and Baird (Amount and Duration of Immunity
Induced by Intradermal Inoculation of Cultured Vaccine Virus, J. Exper.
Med. 69:857 [June) 1939) state: “It is known that infants shortly
after birth (Donnally, H. H., and Nicholson, Margaret M. : A Study of
Vaccination in 500 Newborn Infants, J. A. M. A. 103 : 1269 [Oct. 271
1934) are somewhat resistant to infection with vaccine virus. Further-
more, it has been demonstrated (Donnally and Nicholson, loc. cit.) that
such infants after a successful vaccination rapidly lose their immunity,
many being fully susceptible a year later." Our conclusion was contrary
to this. The completely immune are two and one-fourth times the number
of nonmumme, as reported in 1934 for revaccinations of fifty-two infants
from thirteen to sixteen months after successful vaccination at birth.
Rivers, Ward and Baird state also that reports in the literature concerning
uie duration of immunity in children to vaccine virus are conflicting.
This we have found to be true. Sergent and Trensz (De la perte
dim minute vaccinate, Bull. Acad, de med., Paris 107 : 625, 1932) state
that the # anti-smallpox vaccine prepared at the Institut Pasteur d'AIgerie,
which gives 100 per cent positive results with primary vaccinations on the
newborn, gave the results presented below on persons previously success-
fully vaccinated and followed: Percent of

Reactions Reactions of
Re vac- of the the Primary

Age dilations Primary Type Type

From 2 to 10 years 1,947 1,243 63%

From H to 20 years 946 539 56%

The detailed tables of these writers show that the proportion of successful
revaccmations does not vary significantly from childhood to the age of
20 years.

* "V Clenrens: KUnische Studien uber Vakzination und vak-

zmnic Allergic, Leipzig and Vienna, 1907.

the individual’s degree of protection; in the early
months following first vaccination he may be complete!}'
insusceptible; he may show varying alterations in skin
reactivity, particularly after the first vaccination, the
early appearance of these, the rapidity of the cycle, and
the intensity of the skin reaction being indications of

Table 2. — Early Appearance of Skin Reactions

Virus Used in
Primary Vaccination

Observed Later Total Number
in Day and on of Early
Following Day Reactions

Culture virus (Rivers) intradermal 38

IS (100%)

Calf lymph virus.

19 39 (100%)

Intradermal.

Cutaneous...

13 13

6 G

Primary takes with calf lymph in new-
born, cutaneous 19

Incubation: Two days 4
Three days 3i
Four days 4

0

Early appearance of skin reaction was present in all of the two
groups, those primarily vaccinated with culture virus and those pri-
marily vaccinated with calf lymph virus, the skin reaction appearing
within twenty-four hours.

his state of immunity. The strength of smallpox pro-
tection is closely related to that of skin protection to
revaccination; complete immunity or insusceptibility to
revaccination is a temporary state.” In each revaccina-
tion of the seventy children, a record was made when
possible with regard to the early appearance, the rapid-
ity of the vaccinal cycle and the intensity of the skin
reaction. With these data an attempt was made to make
an appraisal of the degree of immunity present in each
of the children.

A control group of twelve children of similar age
who had never been successfully vaccinated before were
vaccinated in the same manner, at the same time and
with the same batch of calf lymph virus.

VIRUS USED AND METHOD OF REVACCINATION
A fresh lot of calf lymph virus was obtained from
the Bureau of Laboratories of the Department of
Health of New York when we were ready to start the
revaccinations. This was carefully protected in transit
and while in our hands by keeping at low temperatures
until actually used. Both groups, (1) the children

Table 3. — Rapidity of Vaccinal Cycle

Virus Used in Primary Vaccination
Culture virus (Rivers) intradermal....
Calf lymph virus.,...

Intradermal.,..,

Cutaneous.

Vaccinal Vaccinal

Total

Cycle

Accel-

Cycle
Not Accel

Oases

(71)

erated

crated

Unknown

37

17

19

1

(46%)

(51.4%)

(2.7%)

34

29

5

0

23

(85.3%)

39

(14.7%)

4

11

10

1

Children primarily successfully vaccinated Intradermally at birth with
culture virus (Rivers) showed on rcvaceination with calf lymph cutnne-
ously after two to three years no acceleration of the vaccinal cycle in
nineteen (31.4 per cent) of thirty-six revaccinations. Children primarily
successfully vaccinated intradermally or cutnncously at birth with calf
lymph virus showed on rcvaceination with calf lymph virus cutaneous!)*
after two to three years acceleration of the vaccinal cycle in twenty-nine
(S3.3 per cent) of thirty-four children.

primarily vaccinated with culture virus (Rivers) and
(2) those primarily vaccinated with calf lymph virus
(New \ork Bureau of Laboratories), either bv mul-
tiple pressure and rubbing or by intradermal inocula-
tion of diluted calf lymph, were revaccinated vigorously
by thirty multiple pressures with the needle through

1798

VACCINATION— DONNALLY

a drop of calf lymph on the skin, followed in each
instance by moderate rubbing with the shaft of the
needle and with the identical batch of virus. The
plan was to use a “hot virus” and a severe technic of

Fig. 2. — Primary vaccination when child was 23 hours old. Culture
virus (Rivers) i\I54, intradermally; successful. Culture mediums unseeded
as control. A, second day; B, third day; C, fourth day; D, fifth day;
E, sixth day; F , seventh day; G, eighth day; H, ninth day.

immediately to the Children’s Hospital, Washington,
D. C., for observation during five days. Of the chil-
dren admitted to the hospital, eighteen had been
primarily inoculated successfully with culture virus,

Table 4. — Intensity of Skin Reactions

No. ol Greater Similar Less
Virus Used in Cases Than to Than

Primary Vaccination (71) Primary Primary Primary Unknown

Culture virus (Eivers) intra-

dermnl 37 34 2 0 1

(92%) (5.4%) (2.7%)

Call lymph virus 34 5 2 27 0

(14.7%) (C%) (79.4%)

Intradermal 23 5 2 1G 0

Cutaneous 11 0 0 11 0

Intensity ol skin reaction on revaccination: Thirty-seven children
successfully vaccinated at birth with culture virus (Bivcrs) intradermally
showed on revaceination with call lymph virus cutaneously greater
intensity ol skin reaction in thirty-iour (92 per cent). Thirty-lour chil-
dren successlully vaccinated at birth with calf lymph virus Intradermally
or cutaneously showed on revaccination with call lymph virus cutane-
ously greater intensity ol skin reaction in live (14.7 per cent) and less
intensity of skin reaction in twenty-seven (79.4 per cent).

nineteen successfully with calf lymph virus, and one
unsuccessfully with culture virus. Their temperatures
were taken regularly. The skin reaction was observed
and recorded from three to five hours after inoculation,
from eighteen to twenty hours after and from twenty-
eight to thirty hours after. They were observed daily
for the next three days during their stay in the Chil-
dren’s Hospital. They were then discharged as inpa-
tients to report in the outpatient department until
involution of the skin reaction. Photographs of the
skin reactions were made in each child on the third
day (fortv-eight hours) after inoculation, the fifth day

Jove. A )U
Nov. 11 , 1)3

and the eighth day after and occasionally later. Records
of the sizes of the papilla, redness, crusting, areola
and adenopathy were also made.

EARLY APPEARANCE OF SKIN REACTIONS
In every instance among the children previously
inoculated successfully with culture virus or with call
lymph virus, the skin reaction (table 2) appeared bj

Table 5. — Estimate of Immunity as Disclosed by Severe
Cutaneous Revaceination

(New York Bureau of Laboratories, calf lymph, thirty
needle pressures cutaneously)

Virus Used in
Primary Vaccination

No. ol
Cases
(70)

Slight

or

None

Fair

Good

Jmmnc*

Reaction

Culture virus (Rivers) intra-

derma]

SC

29

5

2

0

Calf lymph virus

31

(80.5%)

7

(14%)

2

(5.5%)

14

11

Intradermal

23

(20. G%)

. G

(0%)

0

(41.2%)

10

(Ml

5

Cutaneous

11

1

0 '

4

6

Estimate of immunity: Among thirty-six children successfully vac-
cinated intradermally at birth with culture virus (Rivers), revaccinatloa
after two to three years with calf lymph virus cutaneously showed
twenty-nino (S0.5 per cent) to have apparently slight or no Immunol
and fivo (14 per cent) apparently to have fair and two (5.5 per cent)
good Immunity. Among thirty-four children successfully YflccfajtM
intradermally or cutaneously at birth with calf lymph virus,
tion after two to three years with calf lymph vims cutaneously showed
seven (20.0 per cent) to have apparently slight or no immunity and
73.5 per cent apparently to have good immunity.

the following day. In one child, unsuccessfully vac-
cinated at birth with culture virus, there was an identical
early appearance of the skin reaction. The incubation
period in nineteen consecutive newborn vaccinations
were as follows : two days, four babies ; three days,
eleven babies ; four days, four babies. This is a"
unsatisfactory control group because in the previous
study s it was emphasized that newborn infants were

T;. ' >

*' * , V . ' ‘ * ' T

. *, V' _ r

v '* _

.»'***’ ’ , l ■’

[ "

[ ^

\ ■ ■ j

I : v3Kv-\ \

;■ '/ -ys*

. dK.-A 1

- ■

Y-M" y; j

1 ci Wkc j-'l

P ::

"r's

■ ■■'■ 1

'ig. 3 (same child as in figure 2). — Primary yaccirmti succ(J ,fiil.
i 23 hours old. Culture virus (Rivers) M54, intranermal y, „ ct3CC ira-
e 22, 1938, size of scar 12 by 10 mm. slightly d *Pf“ $ r c ,, ca uw''>' J,Jr '
when child was 2'A years old; thirty needle JT“ s “r ^ cc inal U* :
ly appearance of skin reaction: Unknown. Rapidity Larce trV-
reased; eighth day involuting. Intensity of skin r" c !l° ' A. ***
iter than primary. Estimate of immunity: blight,

successfully vaccinated somewhat less readily * i vef)
dren of 3 years. It is a common observation, n
among children primarily vaccinated at 3 )' c ^ r ’ $u p
the skin reaction appears first on the third day a „,
sequently. No group of children of 3 years 3

Sj » av ai7aWe HATION - D 0 NNally

^nTlr- heater 1

p . er . cent y , m 14.7

* ln »hr to /' £ c .h J ldren)

6 Per cent /, Pnnj ary
an iles s tkfy children)

« 79.4 P S in «* Prhnar r
SGVen children) (t ' Ve nt y -

1802

DELAYED PARALYSIS— NIELSEN

Dean Lewis 0 stated his experience, which is that of
many surgeons.

The changes occurring in a nerve fiber following a constric-
tion and its removal, attended by a rapid return of function,
have not been established. Clinical experience would seem to
indicate that the conducting power of a nerve may be totally
suspended for months and that within a few days following
removal of the constricting band motor function may return.
I have seen return of function in the extensors of the forearm
within ten days following the removal of a very delicate con-
stricting band which reduced the diameter of the musculospiral
nerve by one half. The paralysis had been present for six
months. Delicate scar tissue about a nerve in which there
are no evidences of intraneural scar may cause the same sus-
pension of function.

There may thus be changes in the muscles, fasciae or
sheaths about nerve trunks which later may constrict
them, even though they have escaped direct effects of
the compression.

A report of five clinical cases follows.

REPORT OP CASES

Case 1 . — Stumble while carrying heavy object. Sudden pain
in leg and appearance of weakness of peroneal group of muscles
in two hours. Partial reaction of degeneration.

Stanley B., a white man aged 48, a truck driver, whose family
history was irrelevant, was well until March 5, 1937, when he
had an accident. He had had two previous accidents, in one
of which his left leg was injured and in the other his back
was strained, but neither seems to have any bearing on the
present problem.

On March S at about 4 : 30 p. m., while he was carrying one
end of a showcase through a doorway, he stumbled with his
right foot and immediately felt a sharp pain in the leg (peroneal
region) but continued with his work. His foot began to tingle
but he drove his truck back to his place of business, reaching
it at about 5:30 p. m. He went to his home and had to wait
a short time for his supper; thus one and one-half to two hours
had elapsed from the time of the accident. On arising to walk
to his dining room he noticed that he could not raise his toes
from the floor. He massaged the foot and leg with liniment
and soaked the foot in a solution of magnesium sulfate.

On the following day he was unable to work because he could
not teil when driving his car whether his foot was properly
pressing on the brake or accelerator, and when I examined
him eighteen days later he still had foot drop.

Examination showed the patient to be well nourished and
in good general physical health except that he had considerable
sclerosis of the arteries. His blood pressure was 140 systolic
and 106 diastolic. The osseous system was normal. There
was, as stated, foot drop on the right, and the right leg at the
calf was slightly smaller in circumference than the left (the
peroneal group a little smaller). Extension of the toes was
weak but not so weak as flexion of the ankle. There was
hypesthesia in the' area of skin supplied by the common peroneal
nerve. Otherwise results of the neurologic examination were
entirely negative.

Electrical reactions showed loss of faradic irritability in the
right peroneal group of muscles, but the cathodal closing was
greater than the anodal closing contraction. There was thus
a partial reaction of degeneration.

Case 2 . — Patient fell 15 feet, alighting on his feet, fracture
of right os calcis but foot drop on the left. Examination after
eleven mouths showed complete reaction of degeneration of
common peroneal nerve.

James W. T., a white man aged 52, a mechanic, was well
until March 30, 1934, when, while working at his usual occu-
pation of moving a safe, he lost his balance. Realizing that
he was about to fall lie leaped clear of obstructions and landed

9. Lewis. Dean: Some Peripheral Nerve Problems, Boston M. & S. J.

1 SS-.97S (June 21) 1923.

Jovs. A. M. A
Nov. 11 , 19J9

on his feet on concrete 15 feet below. He had immediate severe
pain in both feet and was unable to stand.

Taken to the hospital, he was examined by surgeons and the
right os calcis was found fractured. The left foot was dis-
colored and badly bruised but the bones were not fractured. The
patient was hospitalized for only five days, and when he was
allowed to go home foot drop was discovered on the left. He
was confined to his home for -five weeks and then he got shout
on crutches, resuming work in October.

When I saw him on Feb. 18, 1935, there was essentially
nothing wrong with the patient except for foot drop on the
left- There was no arteriosclerosis or other physical abnor-
mality, and no predisposing cause for the foot drop could be
found, but that condition was complete. The toes could not
be raised. An area of anesthesia was found corresponding to
the distribution of the common peroneal nerve. Electrical reac-
tions showed complete absence of faradic and galvanic irrita-
bility, and there was atrophy of the peroneal group of muscles.

Case 3. — Healthy man suffered fall astride a plank aid
reached fonvard and upward with right hand to grasp support
but failed to reach it. Usual signs of urethral injury but alto
paralysis of right serratus anterior muscle. Partial reaction
of degeneration of long thoracic nerve.

Isidor L., a man aged 37, Jewish, a laborer, with an irrelevant
family and past personal history, was well and working at
his usual occupation until March 10, 1930, when he suffered
an accident. He was walking along a plank entering a new
dwelling before an entrance had been constructed when he lost
bis balance and fell astride the plank. He reached forcefully
forward and upward for support, which he failed to attain.
However, he held to the plank with his legs and did not fall off
it. He suffered for some hours with pain in his shoulder.

He was taken to a hospital because of the local injury and
hematuria and remained there for three weeks. Weakness of
the right shoulder appeared after some days, but as lie remained
in bed this gave him no particular trouble and he did not realize
its seriousness. When he was discharged to return to work
he was unable to do so.

When I saw him on May 21 he had been studied by several
surgeons and the Wasscrmann reaction and roentgenograms of
the shoulder had been examined, but no light had been thrown
on the case from those points of view. Dr. Wallace Dodge
believed the patient had a neuritis of the long thoracic nerve
and referred him for possible reaction of degeneration.

There were the classic features of paralysis of the serratus
anterior muscle on the right. At rest there was hardly any
deformity, but when the arms were extended the angle of th £
right scapula projected far backward and the patient was unable
to raise the arm well above the shoulder. The paralysis "'3 s
so complete that one could with case insert one’s fingers between
the scapula and the dorsal muscles and take hold of the scapu a.
This facilitated the test for reaction of degeneration because
one could feel the contraction of the serratus anterior muse c
when the nerve was stimulated. Other muscles were no
involved.

The blood pressure was found to be 126 systolic am '
diastolic. The pulse rate was 72 per minute and the ar * c T
were in good condition. The heart and lungs were norma , i
short, there was nothing of moment in the general Pb sl
examination, and the neurologic examination gave, on >
evidence incident to the paralysis of the serratus anterior muse
on the right. Some difficulty was encountered in attemp '
to stimulate the long thoracic nerve alone with the e cc ^
current. Because of a fairly good panniculus adiposus a
good musculature in general the current tended. to spread.
ever, after considerable effort success was obtained and s * ,nI11 .
tion with a small pole gave a contraction in the serratus anien
muscle alone. The cathodal closing contraction was. foun
be greater than the anodal closing, but no irritability a
to the faradic current was found. .

At that time I was not acquainted with paralyses occurn.^
from such accidents and was inclined to believe that an > • •
pendent neuritis had developed. For this reason the P 3 •

Volume 113
Number 20

DELAYED PARALYSIS— NIELSEN

1803

sought another physician, who diagnosed, without knowledge
of the details just described, a separation of the muscle from
the scapula; he surgically fixed the scapula to the posterior
thoracic wall.

Case 4.— Sudden thrust of right arm upward during impending
fall. Pain in region of right shoulder still present one month
later. Gradual appearance of atrophy of right trapezius, spinati
and rhomboid muscles. Diminished faradic irritability of right
dorsalis scapular nerve.

Herbert R., a white man aged 55, a laborer, had had typhoid
in 1902 and an appendectomy in 1924. He was referred to
me on Aug. 29, 1936, because of pain in the region of the right
shoulder dating from an accident July 21 of the same year.
He gave a history of being perfectly well and working as usual
packing cases in the warehouse of a soap factory when his left
foot slipped forward. He threw his right arm upward over
his head to balance himself and immediately felt a very sharp
pain in the right shoulder joint. He became nauseated and
vomited and was unable to continue work.

He was treated at his home for four days with massage and
liniment before he returned to work. When he did return he
continued to have the pain, which was worse at night. When
the pain was severe he obtained some relief by placing his
arm over his head. He was referred five weeks after the acci-
dent because of lack of improvement.

The patient was well nourished and in good general physical
condition. The blood pressure was 164 systolic and 90 diastolic.
The radial and brachial arteries were palpable but not materially
sclerosed. The teeth were in poor condition. The essential
changes were referable to the muscles of the right shoulder
region. There was atrophy of the infraspinatus and supra-
spinatus, rhomboid and trapezius muscles, all on the right side
only. There was a little winging of the right scapula, appar-
ently from the weakness of the rhomboids and the trapezius.
There was otherwise essentially no pathologic feature.

Electrical reactions showed reduction of faradic irritability of
the right dorsal scapular nerve as compared with the left. The
relations of the two types of galvanic reactions were normal.

Case 5 . — Slipping of foot from rung of ladder to ground.
Pain, progressive paresthesia, folloivcd by foot drop after four-
teen hours, 'which increased for tteo days. Splinting of foot.
Gradual recovery.

P. M. M., a white man aged 41, suffering from chronic but
well compensated valvular disease of the heart, was referred
by the state industrial accident commission because of dropping
of the left foot. Except for "heart trouble” resulting from
scarlet fever at the age of 8, tonsillitis at one time early in
life and mild influenza during the World War, he had always
been well and able to carry on his work as a carpenter.

On Nov. 22, 1938, he had a minor accident affecting the left
foot. He was about to ascend a ladder with 30 pounds of
shingles on his left shoulder and had placed his left foot on
the first rung, when he turned at the sound of an automobile
horn behind him. The distraction caused his foot to slip off
the rung and strike the ground with some force, so that he
immediately felt a sharp pain across the ball of the foot. How-
ever, he climbed up the ladder and continued with his work
as usual for the one and a half hours of the day still remaining.
The foot continued to pain him and swelling gradually appeared
along the dorsal region of the transverse arch.

When the day’s work was done he drove his own car home,
and he slept as usual that night. When he arose the next
morning he still had some pain in the ball of the foot, and
numbness had appeared over the dorsum of the great toe and
over the adjacent portion of the foot. The swelling of the
dorsum of the foot had increased. As the patient attempted
to walk he discovered that the toes of the injured foot tended
to drag. Because of shortage of building materials there was
no work for him to do on that day, so he remained at home
and nursed the foot with hot fomentations and massage.

The second day following the accident was a holiday so he
again remained at home. The foot drop was then found to

be complete and the numbness had extended half-way up the
anterior surface of the leg. On the third day, as he was unable
to carry on his work, which was then available, he consulted
a physician, who found the foot drop complete and applied a
cast. This was removed on the following day and a splint
substituted to prevent stretching of the paralyzed muscles.
Physical therapy was started, and the patient remained at home.

I saw the patient thirteen days after the injury. He stated
that his foot was much improved, so that he could raise his
toes slightly off the floor. He was a heavily built man weighing
218 pounds (99 Kg.) and was 70)4 inches (177 cm.) tall. Aside
from a little lateral enlargement of the heart and a booming
first sound, plus six badly infected teeth with surrounding
pyorrhea, the left foot was the only element worthy of note
in the physical examination. The patient was able to stand
on the ball of either foot separately but was unable to raise
the toes of the left foot when attempting to stand on his
heels. There was hypesthesia to touch and pin prick on the
dorsum of the foot and ankle, above which it gradually shaded
off to normal. There was neither pain nor swelling in the
tissues of the foot. Electrical reactions showed a slight diminu-
tion to faradic stimulation in producing dorsiflexion of the toes
and foot. Otherwise conditions were normal.

A diagnosis was made of compression neuritis of the left
common peroneal nerve, due to muscular action, in the stage
of recovery.

This case seems unusually dear as one of the type here pre-
sented in that the paralysis progressed for two days after the
injury in spite of rest. The paralysis seemed to begin fourteen
hours after the accident and progress to completion in another
twenty-four hours.

COMMENT

When it is recognized that muscular contractions,
even a single forceful or unusual contraction, can thus
after a latent period of hours or weeks give rise to
functional paralysis of a nerve, there is danger of
ascribing any obscure paralysis to some muscular action,
especially if minute inquiry is made in every case. I
would postulate that in a given case before paralysis
is ascribed to muscular action certain conditions must
be present: 1. There must have been some sort of
sensory discomfort in the affected area at the time
of the accident. 2. There must have been a recurrence
or continuation of the discomfort for some hours or
daj's. 3. The paralyzed nerve must be anatomically so
situated that the muscles involved in the unusual strain
compressed it in the act considered etiologic. 4. The
paralysis must have appeared within, say, two months
of the strain.

SUMMARY AND CONCLUSIONS

Attention is called to paralysis of peripheral nerves
resulting from a single unusual muscular contraction
and also to the delayed appearance of the paralysis.

As such paralysis may result from such action as a
stumble, a sudden reaching forward or a sudden thrust
of the hand upward for the purpose of regaining one's
balance, the etiology is easily overlooked and in indus-
trial work the industrial nature is often not conceded.

It is quite probable that more than one type of
etiology' may be. concerned in such cases, e. g., intoxi-
cation, general anesthesia or chilling, but the muscular
action with resultant contusion of the nerve is the
exciting cause.

To avoid the danger of ascribing any obscure
paralysis of a nerve to hypothetic muscular action I
postulate that for a given case to be valid as belonging
to this group there must have been (1) some sort of
sensory discomfort in the affected area at the time
ot the mjurv, (2) continuance or recurrence of the

1804

DERMATOSES— CORNBLEET ET AL.

Jour. A. M. A
Nov. 11, I 5 j)

discomfort for hours or days, (3) possibility of com-
pression of the affected nerve by the muscular con-
traction assumed responsible, and (4) appearance of
paralysis within, say, two months of the strain.

727 West Seventh Street.

ABSTRACT OF DISCUSSION

Dr. L. J. Pollock, Chicago : Lesions of the peripheral nerves
are rare in civil life as compared with those that we saw in
the war, and lesions of the peripheral nerves that occur as a
result of indirect trauma are still rarer, and those that occur
some time after trauma are rare indeed. One of the causes of
a lesion of a peripheral nerve is a sudden, strong contraction of
a muscle. Such a contraction could be the result of stretching
such as would occur if you were falling off a ladder and you
suddenly reached for a rung. Even if you do not grasp the
rung of the ladder, you have produced a stretching. Another
type is that which is produced by dislocation of a nerve, which
might occur in an ulnar nerve resting in a rather shallow groove
of the olecranon, where a contraction of the triceps might pro-
duce dislocation of the ulnar nerve, or you may produce a
compression against a sharp edge of a muscle, just as Dr.
Nielsen reported where the long thoracic nerve was compressed
by the scalenus muscle, or at times the pronator teres may be
compressed against the median nerve. If a nerve is injured by
compression or by stretching or contusion, the effect on the
nerve is immediate. If you ligate a nerve or if you bruise a
nerve there is an immediate loss of function of that nerve of
varying degree; therefore I think that in these instances of
indirect trauma to nerves in which the symptoms occur some
time after the injury we must consider the possibility of some
other intermediate action whatever it might be. Among them
are hemorrhages. There may be some inflammatory reaction
of tissue adjacent to the nerve. Finally, one must give thought
to the hypothetic consideration of what are known as the
instances of traumatic mononeuritis, in which case they usually
occur after some time, the bridging period of course also being
held to some hypothetic reasonable duration where, under the
condition of cachexia, chronic infection, chronic alcoholism or
diabetes, a nerve that is what we would ordinarily consider
mildly injured might then become the site of a mononeuritis. I
am dubious as to the occurrence of such a condition. There is
another circumstance that is apparent from these cases. The
first patient noted a foot drop one and one-half hours after
injury. The second patient landed on his feet and fractured
the os calcis of one leg. He was put to bed, I take it, and on
the fifth day it was noted that he had a foot drop on the left
side. I have had that experience numbers of times, but does it
mean that the foot drop occurred on the fifth day, and I should
like to know whether they actually in examining the patient said
that the foot drop was not present on the first day. A patient
may come to us and have noted, for example, that he had a
marked atrophy and the atrophy was progressive but the paral-
ysis was immediate and perhaps not noted. I would conclude
from this study that this is a rare group of cases to which our
attention should be called, but we should be careful in evaluating
the interval between the time of injury and the actual onset of
loss of function and not the time when it is noted by the patient
or some one else that some loss of function has occurred.

Dr. R. B. Raney, Los Angeles: From a surgical point of
view, the conditions seen at operation in cases of nerve injury
are almost too well known to be worthy of mention. However,
cases are occasionally seen in which the paralysis appears later
and extreme changes in the structure are observed at operation.

I have had the opportunity of seeing only one such case, and
changes had occurred not only in the overlying muscle but also
in the nerve roots. This was the case of a 20 year old girl
who had suffered an injury to the right brachial plexus. In
attempting to avoid injury to her face from a breaking wind-
shield during the automobile accident she turned her head sharply
to the right, and the sudden stop of the car snapped her neck.
She suffered at the time pain in the shoulder, arm and hand.
There was some numbness and local tenderness, which largely
disappeared in a few weeks. As far as neurologic signs follow-
ing the injury were concerned, they were not definitely estab-
lished since a neurologic examination had not been done. About

five weeks after the injury, pain and impaired motor function
of the affected arm reappeared. Examination several month
later showed involvement of almost the entire brachial plexus;
impaired sensation and motor weakness were striking. Explora-
tion revealed the scalenus anticus muscle largely replaced by
fibrous tissue, adherent to the roots of the plexus. The scalenus
anticus muscle was removed, showing the roots of the plexus
extremely flattened. Recovery of function was remarkable but
not complete. This case illustrates the profound changes in
perineural structures and the delayed paralysis that can occur
from a single muscular contraction with, of course in this case,
other factors playing a part. Therefore it is not only conceivable
but reasonable to assume that less severe muscular contractions
can cause local injury to the perineural structures. Finally,
secondary injury to the nerves themselves by contraction of
fibrous tissue seems decidedly reasonable.

Dr. Percival Bailey, Chicago: I should like to ask Dr.
Nielsen whether he had a reason for choosing two months as
the upper limit or whether he was merely guided by the principle
that the longer the time elapsed the less probable would be
the causal association and thought merely that after two months
it probably would be too slight to consider.

Dr. J. M. Nielsen, Los Angeles: As to the onset of the
paralysis, I cannot say because I did not see the patient until
some time afterward, but the records of the hospital in which
the patient was placed gave the usual results of physical exami-
nation as made by the physician at the time and the usual ■visits
without any mention of any paralysis. As to Dr. Bailey’s ques-
tion, I am guided by the improbability of things developing
later, and I have tried to state the reasons for this mote
accurately in the paper. I have taken the attitude that some-
thing should be evident within two months. Weakness may
develop as it did in some cases and continue to develop for
many months, but there should be some indication before the
end of the two months.

THE USE OF COLLOIDAL CALOMEL
OINTMENT IN DERMATOLOGY

THEODORE CORNBLEET, M.D.
ALBERT H. SLEPYAN, M.D.

MICHAEL

AND

H. EBERT,

CHICAGO

M.D.

Mercury ointments in various forms have long l ,ecn
a standby for the dermatologist. First, metallic mer-
cury ointments were employed, and in recent times tie
ammoniated mercury ointment has enjoyed tremendous
vogue. In the last few years, calomel ointment has
been used in the so-called clean inunction method m
the treatment of syphilis.

Calomel ointment, first prepared in France during
the last century, contained 10 per cent of calome n
petrolatum. The British used 20 per cent of calom
in lard. A 30 per cent ointment with white poFola u'
was introduced into the National Formulary V (1
under the name of Ointment of Mild Mcrcnro »
Chloride. In N. F. VI (1936) the base was changed w
equal parts of white petrolatum and hydrous woo ' '

Dr. Lewis C. Britt, 1 chemist of the Oregon b
Board of Pharmacy, first pointed out that the ) • •
VI ointment gave a narrower inhibitory ring m ^
agar plate test for antiseptics than did the a. i ■

ointment. , . r n !•

Mr. E. E. Vicher - at the University of Illinois
lege of Pharmacy undertook the study of the omtn( _^

Pharmaceutical
. Medicine {Dr. CornL.c-1

Assisted by a grant from the American * n

From the University of Illinois College o{ >Icdjcine {u
and Rush MediraJ College (Dr, Slepyaii and # Dr. f Eucrl h.

and

1. Britt, L. C.: The Antiseptic

iyan ana ut. twmD v

Value of Calomel Ointment .V

r. v.

Calomel

X. F. Yl.‘ J.' Am. Pharm. A. 20: 646-647 (July) 1937. . ..

Vicher, E. E.; Snyder. J!. K-. and Gathcrcoal._E.X-: A" J
mel Ointment, J. Am. Pharm. A. 26: I24I-124a (Dee.)

Volume 113
Number 20

DERMATOSES— CORNBLEET ET AL.

1805

He developed calomel in which the particles were very
small, 0,5 micron or less in diameter. This calomel in
aqueous suspension with gelatin was incorporated into
the ointment base. The new calomel ointment produced
an inhibitory ring from three to six times as broad as
did the official calomel ointment.

The improved or “colloidal” calomel ointment has
been extensively investigated from the chemical, bac-
tericidal, pharmacologic and toxicologic standpoints.
It appears to be no more toxic than the N. F. oint-
ment, which has never been considered as toxic for
human beings in doses of 1 drachm (4 Gm.). It has a
prophylactic value in syphilis at least equal to that of
the N. F. VI ointment.

As it is not unreasonable to expect that a colloidal
calomel application with its demonstrated efficiency as
a superior bactericidal agent should find use in certain
cutaneous disorders, this colloidal calomel ointment has
been used in the dispensary of the dermatologic clinics
of the Cook County Hospital to a sufficient extent to
justify a preliminary report.

USE IN IMPETIGO CONTAGIOSA

We have found its greatest therapeutic value to be
in impetigo contagiosa. In about 130 cases of this
infection colloidal calomel ointment has served as an
extremely efficient remedy. The use of ammoniated
mercury ointment has long been a standard agent in
impetigo, but all experienced dermatologists attest the
observation that for some reason this medicament is
not as efficient as it was in the past. According to our
observations, colloidal calomel ointment clears the erup-
tion in an average of one third to one half the time
required by ointments of ammoniated mercury (chart)-.
This is particularly gratifying since the colloidal
calomel ointment is both cleanly and, so far as our expe-
rience goes, not toxic. In not more than three or four
instances it has produced a slight irritation, but this
was not great enough to necessitate its withdrawal.
Its cleanliness is to be emphasized because it gains the
patient’s cooperation and makes it a favorite over other
efficient agents, such as applications of gentian violet
solution.

Colloidal calomel ointment was found useful in other
superficial pyodermas in addition to impetigo. In
ecthyma, the base of the lesion is so deep as to require
removal of the overlying crust, whereupon the colloidal
calomel ointment proves curative. In Bockhart's
impetigo, which is a more superficial infection of the
hair follicles than that in furunculosis, and in furun-
culosis itself, no benefit was obtained from the use of
colloidal calomel ointment.

ERYTHEMATOUS DERMATITIS BEHIND EAR

There is a condition which produces a superficial
erythematous dermatitis in the fold behind the ear
which is diagnosed most often as seborrheic dermatitis
and which some authorities think is due to a strepto-
coccic infection. This is particularly resistant to treat-
ment and especially so in that form in which the disease
process reaches around to the front of the ear. In
several cases of this disorder, the use of colloidal calomel
ointment has been of benefit. It has been more effective
than any other agent we have used.

INFECTED LEG ULCERS

Three patients with leg ulcers which, by their appear-
ance, were undoubtedly continued or aggravated by
secondary pyogenic infection, received much benefit

from applications of colloidal calomel ointment. With
no other treatment than the usual advice to the patient
to remain off his feet as much as possible, these ulcers
healed. In a number of other instances of leg ulcers
on a basis of poor circulation, these applications were
of no benefit.

OTHER DERMATOSES

Several patients with early psoriasis were benefited
by applications of colloidal calomel ointment. It must
be emphasized that these early cases are as a rule easily
improved by ammoniated mercury ointment and that
improvement with the calomel ointment represents no
great triumph. In older cases of psoriasis and in the
inveterate ones, colloidal calomel ointment did not
improve the lesions.

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Dermatoses treated with colloidal calomel ointment.

Since colloidal calomel ointment proved to be so
efficient in some of the superficial infections, it was
hoped that it might likewise be beneficial in the super-
ficial fungous infections such as eczematoid ringworm.
Unfortunately, colloidal calomel ointment did not influ-
ence these infections.

There is a relatively superficial, sharply defined,
exudative, patchy dermatitis that occurs on the backs of
the hands and forearms particularly, but which may
appear elsewhere also, called infectious eczematoid
dermatitis. This probably results from the secondary
infection of an already irritated base. Several of these
cases were improved by applications of colloidal calomel
ointment. Two of them were irritated by this form of
treatment, so that it had to be stopped.

A number of other dermatoses were treated with the
colloidal calomel ointment more or less unsuccessfully.

1806

POLIOMYELITIS-SMITH

Javs. A. Jf. A.
Nov. 11, 1939

There is no benefit from its use in lichen planus, paro-
nychia due to yeast infections, pityriasis rosea, tinea
circinata, lupus erythematosus or lupus vulgaris.

SUMMARY

Colloidal calomel ointment in this study was found
to be a clean, unusually effective agent in impetigo con-
tagiosa and related superficial pyodermas. Seborrheic
eczema behind the ears, which is often quite resistant
to treatment, was favorably influenced by applications
of colloidal calomel ointment. It improved leg ulcers
aggravated or continued by a secondary pyogenic infec-
tion; also some forms of seborrheic eczema and early
cases of psoriasis. In other dermatoses, colloidal calo-
mel ointment either was without benefit or proved to
be irritating.

Clinical Notes, Suggestions and
New Instruments

EIGHT YEARS DEPENDENCE ON A RESPIRATOR

AN UNUSUAL CASE OF POLIOMYELITIS

Scott Lord Smith, M.D., Poughkeepsie, N. Y.

Seven years dependence on a respirator is an experience
sufficiently unusual to warrant chronicle and comment. When
the cause of such dependence is a case of acute anterior polio-
myelitis with resultant massive paralysis involving practically
all voluntary .muscles below the clavicles and all automatic
respiratory muscles with the exception of the right leaf of
the diaphragm, the number and magnitude of the problems
presented are all too evident. In these seven years the
subject of this report spent more than half his time in the
respirator, never acquiring a capacity to sleep and carry on
respiration simultaneously. During this time three types of
problems arose: (1) those immediately connected with his care,
(2) those concerned with the physiologic changes occurring as
a result of the extensive paralysis and (3) those involved in a
study of his respiratory control. The first two of these problems
will be discussed in this paper; the third is now under investi-
gation. In order to show what problems arose in dealing with
the acute illness, the maintenance of body function, the treat-
ment of upper respiratory infection and pneumonia in one who
could not cough, and the preservation of function of the few
unimpaired muscles, a brief summary of the condition of the
boy on admission to the hospital in September 1931 and at the
end of each subsequent year will be given.

B. S., a boy aged 13 years, was admitted to the Medical
Service of Vassar Brothers Hospital on the fifth day of an
acute illness. A diagnosis of poliomyelitis was confirmed by a
high cell count of the spinal fluid, and 60 cc. of immune serum
was given at once intramuscularly. The patient was excep-
tionally well nourished and developed and was not at that time
in immediate respiratory distress, although his extremely labored
breathing was short, shallow, rapid and confined entirely to
the diaphragm. The intercostal muscles did not move at all.
The temperature was 103 F., the pulse rate 110 and the respira-
tory rate 30. The pupils were equal and contracted, reacting
sluggishly to light. There was no paralysis of the ocular or
facial muscles. There was no trouble in swallowing. The
heart was rapid and regular except for an occasionally missed
beat. The sounds were clear and without murmurs. The lungs
were clear and the abdomen was normal except for the exag-
geration of abdominal respiration. There was complete paralysis
of all four extremities, the patient being able to move only the
toes of both feet and to make slight motions with the left hand
and forearm. The cutaneous reflexes were absent.

During the interval between the preparation of this report and its
publication, the patient has completed his eighth year, with dependence on
the respirator, without material changes over the preceding year.

The studies on metabolic changes referred to in the first paragraph
and made in collaboration with Prof. Elizabeth Magers, of the physiology
Department of Vassar College, will shortly be published elsewhere.

Twelve hours after admission, increasing dyspnea and cya-
nosis demanded the use of the respirator and on the second day
catheterization became necessary. As extreme cyanosis occurred
within thirty seconds after the respirator was opened a team
of four persons was required, a doctor to do artificial respi-
ration, another to catheterize, a nurse to change the sheets
and another to rub the back. Even with all four working
simultaneously and at top speed, from three and a half to four
minutes was necessary and the boy approached asphyxiation
and unconsciousness.

For two days the temperature fell. It then rose to 108 F.
and again dropped rapidly, ceasing to be significant. Persistent
muscle twitching of the face, neck and left leg was trouble-
some from the first and continued during four weeks in all
four extremities. This necessitated frequent sedatives. There
was also extreme difficulty in establishing intestinal action, and
for two or three days a paralytic ileus seemed about to occur.
Gradually, however, the combined use of cathartics and enemas
was successful. Poor appetite required feeding by tube. But
after a few months the body became adjusted, the gastro-
intestinal tract resumed its normal functioning, appetite returned
and ability to breathe improved. After seven months ol
paralysis a general upturn in physical condition was observable.
Gradually the use of the auxiliary muscles, semivoluntary in
character, made it possible for the patient to spend more and
more time out of the machine. The only lessening o! the
paralysis, however, was in the wrist and finger of the left
hand, in one finger of the right hand and in the flexor muscle
of the left thigh. Movement was possible in these muscles
only when the boy was in the bath.

In September 1932 the child could remain out of the respirator
for eight or nine hours without undue fatigue. Fluoroscopic
examination showed a right diaphragm with an excursion
estimated at 2 cm. and a negative action of the left diaphragm.
No motion of the intercostal muscles could be detected. The
auxiliary respiratory muscles, especially of the scalenus group
on the right side, seemed to have developed a semiautomatic
action. Outside the respirator he was never able to sleep and
could eat but little without experiencing a sense of fulness.
There had been no changes in the affected muscles. His weight,
which in the spring had been 73 pounds (33 Kg.), had increased
to 92 pounds (42 Kg.). His general condition was good, Ins
spirits were excellent. He enjoyed a daily tub bath, made trips
about the hospital in a wheel chair and played several games
adapted to his capabilities.

The second year was one of ups and downs. Dr. Drinker
felt that it was important for the boy to regain self confidence
and therefore advised that he be forced to discontinue sleeping
in the machine. It was hoped that fatigue would eventua j
induce natural sleep. On one occasion he was kept out of t' c
respirator for two and one half days until complete exhaustion
forced a return to artificial respiration. Later we tried or
several weeks having him remain outside part of every scco
night, but as there were progressive loss of weight, increase
irritability and digestive upsets we abandoned attempts to orce
normal respiration during sleep. During most of this year
lost weight. In March and June there were periods of. cv
and infection of the upper respiratory tract, which were di >c
to relieve and painful. Continuous artificial respiration, asP ir
tion of secretions from the nasopharynx, morphine and amm
nium chloride were found helpful. .

On the afternoon of June 16, 1933, without warning 0 ? •
kind, the slowly built-up ability to breathe with the auN ' , ‘ ,
muscles, especially with the right scalenus group, su “ ,
ceased. Complaining of a lump in the chest, he became su
cyanotic. In the respirator he rapidly regained color ...
comfort. Examination showed that the voluntary auxi
muscles of respiration, the contractions of which with
respiration had been visible a few hours earlier, had cease
work on the right side, where they had been the strong
Two weeks later muscular ability had again been hunt up
for an hour at a time he was able to breathe comfortao J.
a month he could breathe alone for twelve hours. llic . .,
scalenus muscle group developed and soon exceeded ic
ones in strength. This condition has continued. .

In the early part of the third year the lost weight
regained. Thereafter, although there was no change in resp

VOMJME 113
Number 20

TRACHOMA— SPEARMAN AND VANDEVERE

1807

tory function lie did well on his regular routine and was in
good spirits. In a station wagon which carried his wheel chair
he took many rides about the country and often went to the
movies. Being away from the respirator gave him no appre-
hension, and he was able to eat well outside. Hay fever and
eczema, however, caused considerable distress. Increase in alka-
linity of the urine was accompanied by frequency and discom-
fort, which was readily relieved by the administration of
ammonium chloride. Occasional hematuria accompanied by
vesical irritation appeared for the first time.

During the year 1935 he continued to show symptoms of
kidney stone, acute pain in the right lumbar region, hematuria,
nausea and the passage of small ‘‘gravel” by the urethra. In
April he had pneumonia, with consolidation in the left lower
lobe. For nearly two weeks there was irregular fever up to
104 F., pain in the left side of the chest, and choking. Relief
from thick mucus which he could not loosen was obtained by
aspiration with a suction pump, oxygen being given with a
nasal catheter. Gradually he made a complete recovery.

The fifth year was an uneventful one. An x-ray examination
showed the presence of a stone in the right kidney pelvis. Two
months later stones appeared in the left kidney pelvis and low
down in the left ureter. Sex development was average for
his age.

In 1937 the chief changes were psychologic. In general he
lost confidence in himself and was fearful of being at a distance
from the respirator, so that he gave up his frequent trips. He
lost his former belief in his eventual recovery and in the value
of living. He maintained, however, his interest in all athletic
contests, in cross-word puzzles and in cards, checkers and chess.

The seventh year was without new development. The loss of
morale, begun in the previous year, continued and increased.
Through most of 1938 he did not leave the hospital grounds.
There was increasing pain and hematuria from the renal calculi,
which were seen by means of the x-rays to be increasing in
size. For three months approximately 85,000 units of vitamin A
was given daily. As the calculi had not decreased in size at
the end of this period, this therapy was discontinued.

GENERAL PROBLEMS

Later in the fall of 1938, signs of eye strain became apparent.
Glasses with a 3 degree prism base up, in addition to ordinary
correction, raised the field of vision one foot nearer to the plane
of direct vision. This procedure not only had the desired effect
on his vision but caused a more important uplift of his general
morale.

Deformities came on late and insidiously. A tendency to a
lateral curvature of the spine became apparent when he first
began to use a wheel chair in 1932, even though the shoulders
were elevated only a few inches in order to give him an oppor-
tunity to look around. Sand bags and other means of correction
proved ineffectual and uncomfortable and were abandoned. The
resulting curvature has slowly increased in the last two years.
Contractures of both hands appeared considerably later and
became stationary.

Constant twenty-four hour nursing attention was maintained
from the first and we were unable to find any way to dispense
with it or even to combine the care of this boy with that of
others. All changes in position of the body from the shoulders
down had to be made by the nurse, and all parts exposed to
pressure were kept cushioned with rings. As a means of main-
taining a healthy condition of the skin the daily bath was begun
as soon as respiratory function permitted. The old style port-
able typhoid tub served this purpose admirably. In addition
the nurse had to feed him each mouthful; she also turned each
page of the books he read and made the moves he indicated
in playing games. She remained constantly within earshot,
because we were unable to arrange a call system, and speech
for him was possible only during one phase of the respirator
action. Nursing care was exceeded in importance only by
mechanical respiration.

The original respirator has been in service during the entire
seven years, except for a period of two months when the motor
blower exhaust was being replaced by bellows. These are much
quieter and have the additional advantage of being operable by
hand in an emergency. As fuses had blown out several times

when continuous operation was necessary, the manual operation
was reassuring to the patient and his attendants although its
use has never been required.

SUMMARY

At the time this is being written the subject of this report,
a youth nearly 21 years of age and a victim of the 1931 polio-
myelitis epidemic, has been dependent on a respirator, at least
during sleep, for over seven years. He has been through the
vicissitudes of colds, hay fever, eczema and pneumonia. He is
still troubled by renal calculi, a continuously developing spinal
curvature, and occasional mental depression. The nearly com-
plete paralysis has given opportunity to study some of the con-
comitant metabolic changes.

SULFAPYRIDINE IN TRACHOMA

At. P. Spear irAN, M.D., and IV. E. Vaxdevere, JI.D.

Ei. Paso, Texas

To the growing list of diseases in which sulfapyridine may
be found of use we should like to add trachoma. In two
cases, herewith reported, we have observed astonishing improve-
ment in the chronic form of the disease when treated with
sulfapyridine.

REPORT OF CASES

Case 1. — F. F., a white youth aged 15, first seen by us
March 11, 1939, had been under treatment for trachoma else-
where for about one year. Examination showed both corneas
markedly opaque. There were no clear areas on either cornea.
Vision in both eyes was fingers at 1 foot. Pannus was markedly
developed on both corneas. The under surfaces of both upper
lids were covered with follicles. The Wassermann and Kahn
reactions of the blood were negative. ' The patient was hos-
pitalized and massive doses of sulfanilamide were given. During
the period of hospitalization, covering one month, about 1,000
grains (65 Gm.) of sulfanilamide was given. Local treatment
with ophthalmic ointments, copper citrate and quinine bisulfate
was given. At the end of one month the patient was discharged
from the hospital only slightly improved. The patient went
home, where he used only local treatment, consisting of oph-
thalmic ointment quinine bisulfate twice a day. On July 24
he was again seen at our office. No improvement was noted.
At that time we prescribed sulfapyridine, 7 A grains (0.5 Gm.)
every four hours. August 5 we again examined the patient.
The lower half of each cornea was found to be free from
pannus and was completely transparent. The vision was 20/50
in both eyes. The under surfaces of the lids were smooth and
free from irritation. The patient was told to continue the
same dosage of sulfapyridine. August 26 we last saw the
patient. At this time both corneas were almost completely
transparent and all signs of pannus bad disappeared. Vision
was 20/30 in the right eye and 20/40 in the left eye (without
glasses). There have been no toxic reactions to the sulfa-
pyridine.

Case 2. — G. U., a white man aged 49, admitted to our out-
patient service at a local hospital Aug. 11, 1939, bad been treated
for trachoma for about five years. The Wassermann and Kahn
reactions of the blood were negative. Every conceivable anti-
septic had been used in the eyes. Two years before admission
bilateral tarsectomy was done on the upper eyelids. Some
months later a plastic procedure was performed for “entropion.”
Certain of the organic silver preparations bad been abundantly
used as instillations in the eyes, so that there was on admission
a definite argyrosis of the bulbar and palpebral conjunctivas.
Examination on admission showed marked opacity of both
corneas, well developed pannus and deep scarring of the under
surfaces ol the upper lids but no trichiasis. Vision was fingers
at 6 feet in both eyes. August 23 we prescribed sulfapyridine
7Vt grains every four hours. Examination of the eyes August
30 showed both corneas beginning to clear and the pannus
lessening. September 6 the lower half of each cornea was
becoming transparent ; the upper portions were much less opaque,
with tiny, scattered areas of transparency. The pannus had*
nearly disappeared in both eyes. Vision was 20/100 in both
eves.

1808

SEVERE BURNS— McCLURE

Jour. A. .V. A.
Nov. 11, 1939

COMMENT

While realizing that adequate conclusions cannot be drawn
from clinical results obtained in only two cases, we nevertheless
were greatly impressed with the remarkable remissions of
pathologic signs obtained in two cases of chronic trachoma
when sulfapyridine was given. Both cases had proved intracta-
ble to all other methods of treatment. Vision lias improved
greatly in both cases. We plan to continue our present treat-
ment at least until maximum improvement, both subjectively
and objectively, is obtained.

1001 First National Bank Building.

CONTACT DERMATITIS DUE TO MANGO
Samuel J. Zakon, M.D., Chicago

Case 1. — A 29 year old woman presented an acute vesicular
dermatitis of three days’ duration which involved both lips
and a moderately large circumoral area. There was no history
of contact with any of the common substances usually respon-
sible for a dermatitis in this location. She stated that two days
prior to the onset she received a case of mangoes from her
father, who owns a fruit farm in Florida. About twenty-four
hours after eating a mango itching developed about her mouth,
and her lips began to swell.

Examination revealed an erythematovesicular eruption involv-
ing both lips, the chin and both cheeks. The lips were edema-
tous and she had difficulty in opening the mouth. There were
no lesions on the mucous membranes of the mouth. The patient
stated that she felt nauseated after eating the mangoes. Her
past history is irrelevant with the exception that she had had
attacks of urticaria after the ingestion of strawberries.

Patch tests performed on the patient’s back using mango
peel and juice proved that only the peel produced a positive
reaction.

Case 2. — A 19 year old girl presented an acute erythemato-
vesicular eruption of twenty-four hours’ duration on the lips,
nose, face and neck. There were extreme burning and itching.
The patient felt nauseated and complained of a moderate head-
ache. There was no history of contact with any of the materials
usually suspected when an eruption involves this area, such as
cosmetics, mouth washes or tooth pastes. There was a history
of eating a mango twenty-four hours before the onset of the
eruption. Other members of the same family who ate mangoes
were unaffected.

Examination revealed marked edema about the lips and a dull
red erythema studded with discrete vesicles and bullae about
the face. The previous history is essentially irrelevant with
the exception that six months prior to this attack a dermatitis
which was due to dress shields developed in the axillas.

Patch tests with the peel and juice of the fruit produced a
positive reaction to the peel and not the juice.

In both cases the condition cleared up within ten days with
mild local therapy.

COMMENT

The fruit of the mango has recently become popular as a
delicacy in many parts of the United States. According -to
Kirby-Smith, 1 the peel before ripening contains a substance
which affords protection from the attacks of insects. This
substance remains so active in some varieties, even after the
fruit has ripened, as to affect some people eating the fruit with
what is known as “mango poisoning.”

The mango belongs to the species Mangifera indica. Its
home is believed to be India, Burma and Malaya and it is
known as the “apple of the tropics.” The fruit varies from
oval to S shape, weighing from 8 to 38 ounces. It has a
relatively smooth peel with a single large seed and when ripe
is usually greenish yellow.

Mango dermatitis as defined by Kirby-Smith 1 is an irritation
of the skin and mucous membranes produced in susceptible

1 Kirbv-Smilh, J. Lee: Mango Dermatitis, Am. J. Trop. Med. IS:

373-3S4 (July) 193S.

persons by contact with the resin from the peeling or stem
of the fruit or with the sap of the tree. The sites usually
affected are the lips, face and hands. Depending on the sus-
ceptibility of the individual and the amount of exposure, the
lesions vary from mild dermatitis to severe disfiguring edema
and even to prostration.

The mango and the poison ivy both belong to the family Ana-
cardiaceae. The dermatitis caused by eating the mango fruit
may be compared to that of Rhus venenata.

CONCLUSIONS

An acute vesicular or bullous dermatitis and marked edema
about the mouth may be caused by eating mango fruit. With
the increasing use of this fruit in the daily diet, the mango
should be seriously considered as an etiologic factor in acute
dermatitis of the face.

18S North Wabash Avenue.

Special Clinical Article

THE TREATMENT OF THE PATIENT
WITH SEVERE BURNS

CLINICAL LECTURE AT ST. LOUIS SESSION

ROY D. McCLURE, M.D.

DETROIT

In 1937 there were almost 8,000 deaths from fire in
the United States. Forty-five per cent of lethal burns
are in children under 6 years of age, and in Penberthy s
series of 493 cases at the Children’s Hospital in Detroit
it was found that 80 per cent of these should be con-
sidered avoidable. We, as physicians, should take a
prominent part in a program of safety' education directed
toward preventing this needless loss of life.

It is now fifteen years since Davidson 2 began h's
revolutionary work on burns while he was resident stir-,
geon at the Henry' Ford Hospital. This period marked
the inception of a method of treatment which many °
us believe is the best available at the present time, bu
more significant was the sudden arousal of interest in
the subject of burns among physicians throughout this
country and abroad. The number of papers on burns
during the ten year period following his original com-
munication was three times that of the preceding ten
year period. Many variations in the treatment ha\e
been promulgated which, in the hands of their sponsors,
show results comparable with the best that prevail today
These variations should not be allowed to confuse t ic
average physician, who in the aggregate cares for 1
great mass of all burn cases, from meticulous attentio
to the essential principles of treatment, which I s ' a
attempt to outline. .

In view of the careful clinical and experimental w or '
that has been done recently, it is desirable to pause am
take stock of the present available information. Answers
to the following questions should be sought :

1. Are there any new facts concerning the system^
effects of the chemical and tissue changes which i°
severe burns ? . —

From the Department of Surgery of the Henry Ford Hospital- ji.
The author acknowledges the assistance of Dr. L. K.

eparation of this paper. .. ,(eetme’ a!

Read in the Surgical Division of the General Scteultii -
e Ninetieth Annual Session of the American Medical as.

. Louis, 3fay 16, 1939. , ._ ▼ \[»cfciY ac

1. Penberthy, G. C.: Tannic Acid Treatment of Burns, J. -

. So c. 34; 1-4 (Jan.) 1935. • r Tn.yfu. Sut***

2. Davidson, E. C.: Tannic Acid in Treatment of Burur,

•nec. & Obst. 41: 202-221 (Aug.) 1923.

VoujMfc 113
Number 20

SEVERE BURNS—. McCLURE

1809

2. What is the effect on the mortality rate of present
methods of treatment?

3. In the light of our present knowledge, what is the
best therapeutic procedure in burns ?

Research on burns has been largely concentrated on
explaining the so-called toxic phase, which appears after
eighteen to twenty-four hours. Three theories have
arisen :

1. First is the physical, which assumes that there is
local leakage* of fluids and plasma proteins, with result-
ing blood concentration and circulatory failure. This
has been shown by Underhill, 3 Blalock, 4 and Harkins. 5
At the 1937 session of the French Surgical Congress,
where Allen and 1 6 reported the experience with tannic
acid in this country, the trend was markedly toward the
theory of a soluble toxin. All agree on the impor-
tance of loss of plasma protein, but it is probably not
the lethal factor.

At this time I shall mention the possible role of
tissue anoxia in burns. Underhill stated : “Marked
concentration of blood means a failing circulation, an
inefficient oxygen carrier, oxygen starvation of tissues,
fall of temperature, and finally suspension of vital
processes.” This statement is interesting in view of the
recent advances in the knowledge of anoxic lesions pro-
duced by barbiturate poisoning, acute alcoholism, anes-
thetics and other factors, as exemplified by the recent
work of Hartman 7 of our staff.

2. Then there is the bacterial theory of Aldrich. 8 9 At
the Johns Hopkins Hospital he took cultures of a large
series of burns, and at the end of eighteen hours he
found beta hemolytic streptococci in most of them and
invariably found these organisms in the blood and
burned areas in fatal cases. Aldrich remains the chief
proponent of the theory, stating in 1937 : 0 “For let me
add again, where there is no infection, there is no
toxemia.” A recent report from Edinburgh 10 casts con-
siderable doubt on Aldrich’s theory. This report repre-
sents the experience with 200 burns, sixty-five of which
were serious. There were twenty autopsies. Careful
bacteriologic work was done on the burns with aerobic
and anaerobic cultures. Frequently, cultures of repre-
sentative areas showed no growth up to ninety hours.
These authors stated that the evidence was against bac-
terial infection as the cause of the acute toxemia. “Cer-
tainly, there was rarely any evidence that hemolytic
streptococci were flourishing in the burned area and
invading the blood stream. Moreover, hemolytic strepto-
cocci were sometimes grown in pure culture from iso-
lated portions where systemic disturbances were entirely
absent.”

At the Henry Ford Hospital we have been unable
to convince ourselves that bacterial invasion is the sig-
nificant factor in the early acute toxemia. However,

3. Underhill, F. P. : Changes in Blood Concentration with Special
Reference to the Treatment of Extensive Superficial Burns, Ann. Surg.
S<3: 840-S49 (Dec.) 1927.

4. Blalock, Alfred: Experimental Shock: VII. The Importance of
tlie Local Loss of Fluid in the Production of Low Blood Pressure After
Burns, Arch. Surg. 22: 610-616 (April) 1931.

5. Harkins, H. N. : Experimental Burns: I. The Rate of Fluid Shift
and Its Relation to the Onset of Shock in Burns, Arch. Surg. 31: 71-86
(July) 1935.

6. McClure, R. D., and Allen, C. I.: L’emploi de Vacidc tannique
dans 1c traitement des brulures, Compt. rend, du 46° Congres de chirurgie,
1937.

7. Hartman, F. W.: Some Etiological Factors and Lesions in Cerebral
Anoxia, Am. J. Clin. Path. 8: 629-650 (Nov.) 193S.

S. Aldrich, R. II. * The Role of Infection in Burns; Theory and
Treatment with Special Reference to Gentian Violet, New England J.
Med. 20S : 299-309 (Feb. 9) 1933.

9. Aldrich, R. H.: Treatment of Burns with a Compound of Aniline
Djcs, New England J. Med. 217:911-914 (Dec. 2) 1937.

10. Wilson, \Y. C.; MacGregor, A. R., and Stewart, C. P. : The

Clinical Course and Pathology of Burns and Scalds Under Modern

Methods of Treatment, Brit. J. Surg. 23: 826-865 (April) 193S.

we added an antiseptic, hexyl-chloro-resorcinol, to the
tannic acid after the work of Hartman and Schelling 11
showed the efficient bactericidal power of such a combi-
nation.

3. The third theory is that a specific toxin is formed
at the burned area which is absorbed and distributed by
the circulating blood, with the resultant picture, of
toxemia and collapse. This is the oldest theory, and it
came into disrepute when Underhill pointed out the
fallacies of certain previous experimental work l ~ and
produced evidence that there is poor absorption from
burned areas. As has already been stated, the toxic
theory is regaining favor. Mason and his co-workers 13
noted no difference in the absorption of potassium iodide
that was injected subcutaneously into normal tissue or
into burned tissue. Mason, who worked with Davidson
on the question of tissue autolysis, maintains that “death
occurring several days following severe burns is due
mainly to the absorption of protein decomposition prod-
ucts.” Wilson and his collaborators 14 removed the
tissue fluids from edematous burned tissues forty-eight
hours after the burn. They found that this fluid had
acquired toxic properties and was frequently fatal to
healthy animals of the same species. Rosenthal 16 tested
the blood of burned pigs, guinea pigs and human beings
and found a histamine-like substance, which was first
linked with the red cells but was later found in the
serum. It differed in several ways from histamine.

PATHOLOGY

The chief addition to our knowledge of the pathology
of burns since the early article of Bardeen 10 in 1S98
has been the emphasis on the changes in the liver.
Marked necrosis of liver cells has been noted in many
cases of fatal burns. This lesion was especially impres-
sive in two cases recently under treatment. Two men
climbed down into a tank which had been used to store
oxygen and began to worlc with an acetylene torch.
Their clothing suddenly burst into flames. They were
able to climb out of the tank and fellow workers
extinguished the fire. Second and third degree burns
were sustained, which amounted to one half of the
body surface of one man and one fourth of the other.
In spite of intensive treatment, the man with the larger
burn died in profound toxemia on the third day. Post-
mortem examination showed almost total necrosis of
liver tissue, shown by microscopic section in the accom-
panying illustration. The other man showed toxemia
to a less marked degree, but the liver became palpable
and jaundice appeared, the icterus index rising to
130 units. Large amounts of intravenous dextrose were
given to promote regeneration of the liver, with the
result that he recovered without disability.

We agree with Wilson, 10 who stated : “In summary,
we may say that after death from burns a lesion of the
liver cells was found in many cases which was char-
acteristic of this form of injury. Its relation to acute

* - V> V 1 - V " /• u wcior; r-necis oi /\cuis on L,er-

(Dec) I93S SC AntiSCl ' tlCs ’ Proc - Soc. Exper. Biol. & Mcfi. 33:469-471

12. Robertson B„ and Bo.vd G. L.: The Toxemia of Severe Super,
final Bums. J. Lab. & Clm. Med. 9: 1-14 (Oct.) 1923. 1

13 Mason, E. C ; Payton, Pearl, and Shoemaker, H. A.: Comparison

iLXtljLstljT, 193 fi! XOTmal ani! Bu ™ d Tissu «-

1L Wilson, W. C-; Jeffrey, J. S.; Roxbur s h, A. X., and Stewart,
L. Toxin Formation m Burned Tissues, Brit. J. Surg. 24:601*61 1

(Juh) R ]937 thri1 ' S ’ Tox!n of Burns - Ann. Surg. 100:111-117

!SJr rd S’!' .9- 1J.: Review of the Patholoju- of Superficial Burns,
fi on ' r P' ) utton to Our Knowledge of the Pathological Changes in the
KaP'.'Ny Fatal Bums, Johns Hopkins Hosp. Rep. 7:
13/-H9, 1S9S. Since this paper was rcatf, an excellent report on liver
498 [Mav n ) I9i9) hy T ' »• Felt (}. Path. & Ilict. 41 S: 493-

1810

SEVERE BURNS—McCLURE

Jour. A. JI. A.
Nov. 11, 1939

toxemia was so remarkably close as to leave little doubt
that the liver lesion and the acute toxemia were pro-
duced by the same mechanism. The responsible agency
was certainly not bacterial infection, and in our view
the liver lesion furnished the strongest evidence of a
nonbacterial toxin circulating during the first few days
after a burn.” This reservation must, however, be
made : these changes may be due to anoxia.

CHEMICAL PATHOLOGY

It is well known that there are changes in the blood
chemistry in severe burns. The most constant is blood
concentration, as expressed in the hemoglobin determi-
nations and hematocrit readings. However, we have all
seen cases in which the hemoglobin content has been
kept at a normal level or below by intensive adminis-
tration of fluid, and yet we have watched such cases
proceed to death in a state of toxemia.

Based on her own investigations and those of Dr.
Alfred Blalock and Dr. Anne Minot at Vanderbilt Uni-

Section under medium power of liver of burned patient who died on
third day after being burned. Extensive necrosis in center of the liver
lobule, with a zone of intact liver cells in periphery (lower part of
section).

versity School of Medicine, Dr. Katharine Dodd 17 sug-
gests the great importance of replacing promptly the
large amount of circulating protein that is lost in severe
burns. This is done by serum transfusions. The mere
replacement of water and salt as such will only serve
to make matters worse by diluting the concentration of
the protein that remains in the blood vessels. ' If too
great a depletion of plasma volume occurs, the blood
pressure falls precipitately and fatal shock ensues. It
would seem better, therefore, to rely on frequent hemo-
globin or hematocrit determinations and measurement of
serum protein concentration than to use the systolic
blood pressure as a gage of a burned patient’s condition.

Other blood constituents that show variations from
the normal are the chlorides, plasma proteins, carbon
dioxide combining power, nonprotein nitrogen, sodium
and potassium. There is good evidence to indicate that
no one of these factors is a determinant in fatal cases,
although further work must be done to evaluate fully the

behavior of the basic ions. Nevertheless, measures to
restore the blood chemistry to normal should be carried
out in order that the burned patient may be given all
possible assistance during the early critical days.

MORTALITY STATISTICS

In 1935 Allen and 1 18 reported the status of bums
after ten years’ use of Davidson’s method. We called
attention to the fact that the Bureau of Census mor-
tality statistics for the United States registration area
showed a decrease in 1933 from the previous high
figures. In 1928 there were 8,083 deaths from burns
(the highest during the decade) and in 1933 there were
5,232 deaths. I regret to report that in the succeeding
four years there has been no further reduction. 10

The figures in the accompanying table are difficult
to reconcile with the reports of the lowered mortality
rates which come from various institutions. In our
paper Allen and I showed a table which indicated the
reduction in mortality in several centers. To this may
be added the report of Mitchiner. 20 At the St. Thomas
Hospital, London, there was a mortality of 15.5 percent
in the period 1924-1928 when picric acid was used, and
a mortality of 4 per cent in the period 1929-1936 when
the Davidson method was used. The mortality from
scalds was reduced from 7.5 per cent to 1.7 per cent.
At the Children’s Hospital in Toronto Harris 01 noted
a fall in the death rate from 26.6 per cent to 12 per cent,
and Herzfeld, 22 at the Royal Edinburgh Hospital for
Children, had a reduction of 38 per cent to 9 per cent.

In evaluating the Davidson treatment, in addition to
the mortality statistics, one should consider the eco-
nomic factor of great saving in amount of dressings,
shorter stay in the hospital as well as the relief of pain,
and the diminution of scarring and gross deformities.

TREATMENT

In the management of a severe burn, two fundamental
principles must be observed. These are the prevention
or treatment of shock and the carrying out of scrupulous
aseptic technic in the local treatment of the burned
area, which should be regarded as a large open surgica
wound. The advent of the tannic acid treatment o
burns was so revolutionary in character and its immedi-
ate effects so dramatic that attention has been focused on
local applications alone, while the auxiliary treatmen
of shock has too often been neglected. This state o
affairs can be explained by the fact that, except m t ie
larger cities, the opportunity to treat severe burns is
rarely presented to the practitioner. In the Uni cc
States in 1937 alone there were 5,466 deaths noin
burns. If these cases were equally distributed among
the 130,000 practicing physicians, each would have ia
under his care only one fatal case in more than twen }
three years of practice, and if the mortality sliou
placed at 20 per cent, this would mean that, on 1
average, each physician would treat one patient
severe burns every four and one half years. It ,s n
surprising, therefore, that the average physician is n
familiar with all the details of treatment, _F° r \
benefit, the following summary of treatment is inser c^-

18. McClure, R. D., and Allen. C. I.: Davidson Tannic Acid Tro

mcnt of Burns: Ten Year Results, Am. J. Sure. 28:3/0-355 t-'

19. United States Bureau of the Census, Vital Statistics, Special R P°

7:77 (March 20) 1939. , . ,, „ at T. 1!

20. Mitchiner, P. H.: Treatment of Burns and Scalds, Brit. .

27*30 (Jan.) 1938. , . , *

21. Harris, quoted by Martin, . D. D.: Clmical an

Studies of Bums, J. M. A. Georgia 27: 39*46 (Feb.) 19 ' • . jannic

22. Herzfeld, Gertrude: Treatment of Bums and Scams /

Acid, Practitioner 122:106-111 (Feb.) 1929.

17. Personal communication to the author.

Volume 113
Number 20

SEVERE BURNS—. McCLURE

1811

TREATMENT OF BURNS — HENRY FORD
HOSPITAL METHOD

It is important to bear in mind the necessity of treat-
ing the patient as well as the wounds. Treatment
naturally resolves' itself into three phases: supportive
measures, local treatment of the burned areas, and after-
care.

General Supportive Measures . — These are largely
directed toward the control of symptoms.

1. Pain and restlessness are combated by adequate
and repeated sedation.

2. Oxygen therapy may be indicated in certain severe
cases.

3. External heat is applied: hot water bottles and
blankets if the burned area is limited; in extensive
burns, the electrically heated cradle tent and super-
heated room.

4. Restoration of fluid balance is undertaken. The
aim of fluid administration should be to obtain a
twenty-four hour urinary output of 1,500 cc. Fluids
are given by mouth if tolerated, by rectum, interstitially
and intravenously. The continuous intravenous method
is often indicated and may be imperative in cases of
extensive burns involving the extremities. The solu-

Dcaths from Burns, 1933-1937 10

Year Deaths from Burns*

1933 5,232

1934 5,758

1935 5,687

1936 5,971

1937 5,466

* These figures exclude deaths classified as due to conflagration, where
suffocation or cremation may have occurred, and those due to special acci*
dents, such as mine accidents. In 1937 there were 1,688 deaths due to
conflagration and 774 deaths from special accidents, a total of 7,928 deaths
by fire.

tions used are 5 per cent dextrose and physiologic solu-
tion of sodium chloride.

5. Blood plasma transfusions are done. Whole blood
should be used only when blood concentration is nor-
mal, as indicated by repeated hemoglobin or hematocrit
determinations. When hemoglobin values of more than
15.6 Gm. are obtained, plasma transfusions should be
given.

6. Laboratory investigations are made :

(a) Frequent hemoglobin or hematocrit determina-
tions should be made.

( b ) The urine should be analyzed frequently, with
determinations of the specific gravity and albumin
content.

(c) Serum protein determination should be made
immediately on admission.

When facilities are available, the following procedures
should be done :

(d) Chloride estimations should be made at intervals
so that depleted chlorides may be restored by intrave-
nous administration of saline solution.

(e) Blood cultures may be taken.

(f) The nonprotein nitrogen should be determined.

(g) The icterus index should be ascertained as a
means of recognizing toxic hepatitis or liver damage.

Local Treatment. — 1. Remove all clothing under as
sterile conditions as possible and place the patient on
sterile sheets in a warm room.

2. Take all precautions to avoid infection of the
burned area. Treat it just as any other large wound.

All dressings and applications must be done under
aseptic conditions— masks, gloves and gowns must be
worn by doctors and nurses.

3. Debridement should be minimal and should be
limited to opening blisters and cutting away dead skin.

4. Tannic acid in a 5 per cent fresh solution is applied
with an atomizer or power spray. This is a simple and
effective way of tanning the burned area. This solution
is sprayed on at frequent intervals until the burned area
is thoroughly tanned. Ointments containing tannic acid
plus an antiseptic are useful in small burns and for
burns of the face and the perineum. The addition of
antiseptics such as resorcinol or silver nitrate to the
tannic acid with the idea of preventing infection has
been employed with apparent success, but treating the
burned area as a surgical open wound by taking steps
to prevent the introduction of infecting organisms is an
equally, if not more, effective measure.

Ajter-Carc. — 1. Cut away all dead skin and open
collections of fluids under aseptic precautions and then
again spray tannic acid on the bared areas.

2. As the heavy tanned crust forms, watch carefully
for local signs of infection under the crust and liberate
collections of pus. Occasionally the first clue to these
collections is evidence of systemic reaction.

3. Prevent contracture deformities by the early use
of extension apparatus.

4. Employ skin grafting early and freely.

5. Detect and treat secondary anemia early. Blood
transfusion is the best method of doing this in the
late stages.

» COMMENT

We have continued to advocate the use of tannic
acid in the local treatment of the skin. Variations in
the technic have been successful. 13 Other eschar-
forming chemicals, such as gentian violet and silver
nitrate, have given satisfactory results. The advantages
claimed are that the coagulum forms more quickly and
is thinner and more pliable than that produced by tannic
acid. Bettman 34 has had excellent results with a com-
bined tannic acid-silver nitrate treatment. He believes
that the combination is superior to tannic acid alone, and
his experience would tend to bear out this contention.
He attributes the improvement to the increased anti-
septic qualities of the mixture and to the fact that the
coagulum is produced without delay. We have found
that the tannic acid may be conveniently applied to the
medium of a water-soluble jelly to which has been
added an antiseptic of the resorcinol group.

SUMMARY

The original theory that a toxin is formed in the
burned area, from which it is absorbed and carried by
the circulation throughout the body, with the production
of systemic effects has not yet been settled. In spite
of excellent results being obtained in many centers, the
death rate in the United States seems to have reached
a plateau far above that lower level which is possible
with our present knowledge. Disagreements regarding
the proper local treatment should not distract our atten-
tion from the more important problem— the treatment of
a very sick patient who has a threatening toxemia,
alterations in the blood chemistry, a wound very sus-

1935 . ’ A " Th ‘ fra: ' 1 Durns > A ™- Sure. 102 : 429-445 (Sept.)

24. Bettman, A. G.: Rationale of Tannic Acid-Silver Nitrate Treatment
of Bums, J. A. M. A. 108: 1490-1494 (May 1) 1937. ‘

1812

COUNCIL ON PHARMACY AND CHEMISTRY

Jour. A. 51. i
Xor. 1), Wf

ceptible to infection and pathologic changes in organs
remote from the skin. The greatest good can, of course,
come through preventing burns from occurring, and
I believe that the family physician, through his teaching
in the home, can accomplish more than any other agency
in this respect.

Council on Physical Therapy

The Council on Physical Therapy has authorized publication
OF THE FOLLOWING REPORT. HOWARD A. CARTER, SECRETARY.

CLARK DUPLEX INHALATOR
ACCEPTABLE

Manufacturer: Physician’s Oxygen and Supply Company,
Inc., 1390 Eastern Parkway, Brooklyn.

The Clark Duplex Inhalator is designed to supply a mixture
of carbon dioxide and oxygen for resuscitation of victims of
gas poisoning, smoke poisoning, drowning and other conditions
requiring resuscitation. It provides two cylinders with attach-
ments for using the inhalator on two patients simultaneously.
In case the supply from the small cylinders proves insufficient
for longer periods of operation, a larger size tank may be
attached by a third connection. The unit with cylinders weighs
47 pounds out of the case and 62 pounds when weighed with
the case. The outside dimensions of the case are 25 >4 inches
long, 13 inches high and 9J4 inches deep.

One cylinder contains a 7 per cent and the other a 5 per
cent carbon dioxide mixture with oxygen. The change of
administration from 7 per cent to 5 per cent or vice versa
depends simply on the opening and closing of one or the other
cylinder valve. The cylinders are of 16 cubic feet capacity
and deliver upward of 75 liters of gas per minute each. The
firm also supplies cylinders of 110 cubic feet
capacity if desired.

The apparatus was investigated by the
Council. It was found that the cylinder
attachment ports are provided with check
valves which prevent leakage from a cylinder
in use during removal of an empty cylinder
or cause equalization in pressure between two
cylinders if the two are open at the same time.
These valves have been tested and found to
function as intended. Gas from the cylinders
passes through a reducing valve. This valve
is set by the maker to reduce pressure to one
of about 65 pounds per square inch. A gage
reading to 3,000 pounds per square inch is
provided for checking the content of cylinders.
The reducing valve is provided with two safety
devices to prevent the building up of dangerous pressures in
case of failure of its normal mechanism: (1) In the heavy
bronze casing of the reducing valve there is a small frangible
disk which will rupture at a pressure of about 500 pounds per
square inch and (2), should this fail to break at this pressure,
the thin metat bellows, which normally operates the reducing
valve by its collapse and expansion, will rupture and allow the
gas to escape through an aperture plug.

If there should be a continuous free flow of oxygen from
the two cylinders at once, there would result a rapid emptying
of these small portable cylinders. The features peculiar to
this device are largely directed toward effecting oxygen econ-
omy, however. Directly below the reducing valve is a large
rubber bag, called by the makers a "breathing bag." This is
in no sense a rebreathing bag. Inside this bag is a vertical
lever the long arm of which is connected to the middle of the
bag. The short arm operates a valve which admits oxygen
from the low pressure side of the reducing valve to this rubber
bag. When the bag fills to a predetermined volume the move-
ment of the lever closes the valve. Since no great pressure
is required to distend the bag to this extent, the bag virtually
functions as a second sensitive reducing valve and reservoir
from which the patient or patients breathe the gas. From this
point on, the equipment is in duplicate.

Clark Duplex
Inhalator.

There is a. valve delicately balanced against a spiral hair
spring which is opened by the small pressure within the rubber
bag as soon as the pressure within the face mask and breath-
ing tube is reduced slightly below atmospheric pressure by an
inspiratory effort of the patient or by the corresponding part
of the cycle of artificial respiration. The stem of this valve
is geared to an indicating needle, which moves over a dial
and indicates the depth of respiration. These devices were
tested in a laboratory in duplicate and found to operate satis-
factorily. The face masks are provided with inflatable soft
rubber edges for effecting gas-tight contact with the face and
provided with elastic holding bands. The metal connection for
attaching the corrugated rubber breathing tube carries the
exhalation valve. A careful test was made to determine
whether powerful exhalation would force any appreciable
quantity of exhaled air into the rubber bag. It was found
that practically all of the air escaped through the exit valve
at the mouthpiece. When used as described, oxygen is fed into
the mouthpiece only when the valve which actuates the breath-
ing depth indicator is operated by inspiratory efforts. A lever
at the side of the depth-of-breathing indicator case may be
turned up, leaving this valve fully open. Oxygen then flows
freely to the mouthpiece, and the indicator needle remains fully
deflected. Oxygen in excess of that breathed escapes by the
mouthpiece exit valve.

In view of the foregoing report, the Council on Physical
Therapy voted to accept the Clark Duplex Inhalator for inclu-
sion in its list of accepted devices.

Council on Pharmacy and Chemistry

REPORTS OF THE COUNCIL

The Council has authorized publication of the roUOWSG
reports. Paul Nicholas Leech, Secretary-

AMPOULES SODIUM CACODYLATE INTEA-
VENOUS-UPJOHN, 0.45 Gm. (7 grains), 5 cc.,
and AMPOULES SODIUM CACODYLATE
INTRA VENOUS-UPJOHN, 1 Gm.
grains), 10 cc., NOT ACCEPT-
ABLE FOR N. N. R.

The Upjohn Company presented these ampules, of sodium
cacodylate (among others) for consideration as to inclusion i>
New and Nonofficial Remedies. From the names on t 1CSI -
packages it is apparent that they are for intravenous use-
The Council holds that the desired effects of sodium cacod) *
may be achieved by oral administration of the drug or,
exceptional cases, that the intramuscular route may be uesi
able. The Council has on other occasions pronounced sum
dosage forms unacceptable (The Journal, Slay 7, V ->
1654; Dec. 23, 1933, p. 2050). .

The Council was therefore obliged to hold Ampoules 5
Cacodylate Intravenous-Upjohn, 0.45 Gm. (7 grains), 5 cc ':.%/
Ampoules Sodium Cacodylate Intravenous-Upjcdm, 1 Gm. I - -
grains), 10 cc., not acceptable for inclusion in New and ‘ .
official Remedies. This does not apply to Ampoules 0
Cacodylafe-Upjohn for intramuscular use.

DIMENFORMON AND DIMENFORMON B
ZOATE (ROCHE-ORGANON, INC.) N ui

ACCEPTABLE FOR N. N. R- ^

Dimenformon (Estradiol) and Dimenformon Benzoate ( '~ l r ,
ot Benzoate) of Roche-Organon, Inc., are partially syn
-oducts which are claimed to be effective estrogens. . c .
le purpose of this report to criticize the quality ot
rganon estrogenic products, but exception is taken
icthical and undesirable advertising methods used in ti P .
an of these estrogens to the physician. In a recently is
rcular on “Effective Estrogenic Therapy” there arc UsMdaoo
irty or more “indications” for estrogenic therapy v i i , j
rmon and Dimenformon Benzoate “based on a very j
udy of published clinical data augmented by private c

Volume 113
Number 20

COUNCIL ON PHARMACY AND CHEMISTRY

1813

reports.” Among the conditions for which the firm recommends
estrogen therapy based on "very careful study” are leg ulcers,
Buerger’s disease, polyarthritis, certain ocular diseases and other
disorders which have little or no endocrine relationship.

Physicians, even those having no special knowledge of the
endocrines, may readily recognize the lack of scientific evidence
for these therapeutic claims, and a detailed discussion of these
recommendations would therefore be superfluous.

Other disorders, however, which bear some relation to the
endocrine glands are being exploited by Roche-Organon (and
other pharmaceutic houses) in a more subtle manner. For
instance, estrogenic therapy of menstrual disorders has been the
subject of considerable experimental work ever since the estro-
gens have been made available clinically. Except for the con-
ditions of menopause (artificial or spontaneous) little progress
has been made in the effective treatment of such disorders.
Many of the reports on the clinical experimental use of estro-
gens have been unscientific and worthless; others demonstrate
results which raise doubts as to their reliability. Many of the
claims advanced by Roche-Organon appear to be based on such
uncontrolled and unconfirmed reports.

Physicians well realize that the physiology of menstruation
is at present only partially understood. It is true that uterine
bleeding can be induced in the castrate by means of estrogens,
but there are certain features of spontaneous normal men-
struation which are subject to speculation and have not been
satisfactorily explained as yet. It is no wonder, therefore, that
disorders of menstruation are even less well understood. Func-
tional dysmenorrhea, for example, has no established etiologic
factor in most instances, despite the numerous theories concern-
ing the role of the absence of corpus luteum, excess of estrogen,
infantile uterus or neurogenic disorder. There are probably
several types of dysmenorrhea and the outright recommendation
that estrogens are of value in dysmenorrhea, in general, indicates
a lack of understanding of this problem. Many factors, doubt-
less, are involved in the etiology of functional menorrhagia.
The fact that excess bleeding can occur in the presence of a
hyperplastic secretory or a resting endometrium is evidence of
the different types of ovarian function associated with this con-
dition. Similarly, amenorrhea may occur with either resting,
hyperplastic or secretory endometrium, illustrating again the
multiplicity of phases of ovarian activity associated with men-
strual disorders. On the face of the matter, therefore, it is
highly unreasonable to believe that one substance (estrogen) can
alleviate or cure menstrual disorders ranging widely from
amenorrhea to menorrhagia, including dysmenorrhea.

Other conditions for which estrogens have been advocated
after the "careful studies” of Roche-Organon are on an even
less sound basis. Toxemias of pregnancy, mastopathies, pre-
maturity in infants, migraine and pituitary dysfunctions have all
received one or more trials with estrogens. There is a definite
lack of adequate confirmatory evidence in most of these reports.
The rationale for estrogenic therapy here is usually quite flimsy,
based mainly on assumption and imagination. The exercising
of even mild discrimination would at least result in the acknowl-
edgment that estrogenic therapy in these conditions is still mainly
experimental.

The uncritical attitude of this firm is characterized by some
of the statements appearing in its advertising matter. Thus,
estrogens are suggested for the treatment of primary amenor-
rhea "of uncertain origin” and vaginitis of “non-specific” etiology
occurring in children (!) Such a recommendation implies, in
effect, that one is justified in prescribing treatment (estrogenic)
when in doubt.

Matching the boldness of the suggestions for estrogenic
therapy is the advice on the actual treatment of these conditions.
In columns adjoining the recommended indications, the exact
dosage of hypodermic and oral estrogens and any auxiliary
treatment recommended is stated. The presence of printed
figures on dosage gives an air of undisputed authority and
finality to the recommendations. It would be interesting to learn
of the sources from which the data were obtained. Especially
valuable would be the firm’s references on oral therapy since
the reports in the scientific literature are relatively few. Xot
only should the accuracy of the information be challenged, but
the physician should resent the aggressiveness of this firm in
advertising in detail so-called instructions in a field of therapy

which is as controversial and unsettled as the one in question.
Reliable information of this nature may be found by consulting
scientific publications, and the usurpation of their function by
commercially minded institutions should not be condoned.

Too much has already been made of the mysteries of endo-
crinology. It would be safe to say that the so-called mysteries
and complexities are merely reflections of our present lack of
knowledge of glandular physiology and therapy. Such a con-
dition usually results when it is attempted to explain many
phenomena on the basis of few facts. Much of our uncertainty
has arisen from the discrepancies and unreliability of some of
the endocrine literature. The result has been confusion and
misunderstanding. Some of the manufacturers of pharmaceu-
ticals have not been unaware of this state and undoubtedly have
profited much from it. The advertisement “Effective Estrogenic
Therapy” (Roche-Organon) is a clear example of the mere-
tricious appeal to those physicians who are in no position to
evaluate the recently expanded endocrine literature.

The Council voted that Dimenformon and Dimenformon
Benzoate (Roche-Organon, Inc.) be declared unacceptable for
inclusion in New and Nonofficial Remedies because of the exag-
gerated and unwarranted advertising claims with which they are
marketed.

NEW AND NONOFFICIAL REMEDIES

The following additional articles have been accepted as con-
forming TO THE RULES OF THE COUNCIL ON PHARMACY AND CHEMISTRY
of the American Medical Association for admission to New and
Nonofficial Remedies. A copy of the t.ules on which the Council
rases its action will be sent on application.

Paul Nicholas Leech, Secretary.

RACfiPHEDRINE. — Racemic Ephedrine. — d-l-Ephedrine.

— CmHisON. — d-l-7-bydroxy, fi-methylamine phenyl propane.
Actions and Uses . — The same as those of 1-ephedrine.
Dosage . — From 30 to 50 mg.

Racephedrine is a colorless, crystalline substance. The melting point
of the free base is 79 (microscopic heating stage). It is readily soluble
in water, alcohol and ether. Weigh out, accurately, 0.2 Gm. of raceph-
cdrine and transfer to n desiccator over phospiiorus pentoxide for fifteen
hours at room temperature: the loss of moisture is not more than 0.5
per cent. Incinerate 0.1 Gm. of racephcdrine, accurately weighed, and
previously dried to constant weight: no residue remains. Dissolve
approximately 0.5 Gm. of racephedrine in 20 cc. of water: the aqueous
solution does not show optical activity and does not give the U. S. P. XI
chloride or sulfate test.

For further identification sec under racephedrine hydrochloride (The
Journal, April 1, 1939, p. 1257).

Transfer 0.25 Gm. of racephedrine, accurately neighed, and previously
dried over phosphorus pentoxide for five hours at room temperature; to
a beaker. Add 10 cc. of distilled water and titrate with 0.1 normal
sulfuric acid in a slight excess, using methyl red as indicator. Hack-
titrate with 0.1 normal sodium hydroxide. Each cubic centimeter of
0.1 normal sulfuric acid is equivalent to 0.01051 Gm. of anhydrous
racephedrine.

Racephedrine-Gane’s Chemical Works, Inc.— A brand of
racephedrine-N. N. R.

Manufactured by Gane’s Chemical Works, Inc., New York. No U. S.
patent or trademark.

RACEPHEDRINE SULFATE. — Racemic Ephedrine sul-
fate.— C,oH,sON.H=SOi.

Actions and Uses . — The same as those of 1-ephedrinc sulfate.
Dosage . — From 30 to 50 mg.

Racephedrine sulfate is a colorless, crystalline substance. The melting
point is 247 C. (microscopic heating stage). The solubility is fair in
water and alcohol. Dissolve 0.5 Gm. in 25 cc. of distilled water. The
aqueous solution is neutral to litmus aud does not show optical activity.
The U. S. P. XI test for chloride is also negative. Weigh out accu-
rately 0.25 Gm. of racephedrine sulfate and dry to constant weight over
sulfuric acid in a desiccator at room temperature; the loss is not more
than 2 per cent of ( its weight; 0.25 Gm. of racephedrine sulfate has a
negligible ash residue. The assay for anhydrous racephedrine, as
described in racephedrine hydrochloride, is not more than 77.5 per cent
nor less than 75.5 per cent.

Racephedrine Sulfate-Gane’s Chemical Works, Inc.

A brand of racephedrine su!fate-N. N. R.

Manufactured bv Gane's Chemical Works, Inc., New York No U R
patent or trademark. " " *

SRPRARENIN ( Scc ^’ c ' v ai ’d Nonofficial Remedies, 1938,
p. 232).

The following dosage form has been accepted:

'• , *aw»ci contains supraremn bitar-

trate 0.0364 Gm., equivalent to supraremn 0.02 Gm., with iactow 0 0385
Gm., and acetone sodium bisulfite not more than 0.0001 Gm
Prepared by \\ inthrop Chemical Co., Inc., New York, N. Y.

1814

EDITORIALS

Jour, A. M. .A.
.Vov. 11, is;j

THE JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION

535 North

Dearborn

Street - - - Chicago, III.

Cable Address -

- - - "Medic, Chicago”

Subscription price -

- Eight dollars per annum in advance

Please send m promptly notice of change of address, giving
both old and new; always state whether the change is temporary
or permanent. Such notice should mention all journals received
from this office. Important i nformation regarding contributions
will be found on second advertising page following reading matter.

SATURDAY,

NOVEMBER 11 , 1939

THE PLUMMER-VINSON SYNDROME
AND CANCER

The Plummer- Vinson syndrome, which appears to
occur mostly if not exclusively in women, is character-
ized by hypochromic anemia, with or without achlor-
hydria, dysphagia and chronic inflammatory and
atrophic changes in the mouth, pharynx and upper end
of the esophagus. According to the observations of
Ahlbom 1 at Radiumhemmet in Stockholm the syn-
drome brings with it a special liability to cancer in those
structures. As a rule the afflicted women are poorly
developed and poorly nourished ; weakness and anemia
may have existed for years, the first symptoms com-
monly appearing at the ages of from 18 to 20; some-
times anemia, sometimes dysphagia is the more
prominent; in the milder forms the dysphagia may be
missed easily by the clinician. All observers agree that,
while liver preparations are without curative effect,
iron in large doses leads to improvement, even to appar-
ently complete recovery ; only too frequently the anemia
returns and the dysphagia may become more or less
continuous for years. Such patients eat slowly and
swallow only a little at a time ; occasionally only liquids
can be swallowed ; there may be choking spells due to
spasm. In addition to the anemia and dysphagia there
develop, as is true also in some degree in pernicious ane-
mia, chronic inflammatory and atrophic changes in the
lips, the tongue and the buccal and pharyngeal mucous
membranes as well as in the upper part of the esopha-
gus, the entrance to which is narrowed. These mem-
branes become dry and inelastic, the tongue smooth and
glazed, the lips thinned, stiff and cracked at the corners,
the face gradually taking on a characteristic change.
Early loss of teeth is common. Buccal leukoplakia may
develop and the nails may turn spoon shaped (koilo-
nvchia). In about one fourth of the cases the spleen
has been found to be enlarged. No systematic studies

1. Ahlbom. Hugo E. : Anemia. Glossitis and Dysphagia (Plummer-
Vinson *s Syndrome) in Anamnesis of AVomen with Cancer of Oral Cavity,
Xord. med. tidskr. XI: 171 (Jan 31) 1936; Simple Achlorhydric Anemia,
Plummer-Vinson Syndrome, and Carcinoma of Mouth, Pharynx and
Oesophagus in Women, Brit. M. J. 2:331 (Aug. 15) 1936.

appear to have been made of the blood chemistry, the
metabolism or the structural changes in cases of the
syndrome. In a case in which death occurred from
puncture of the esophagus by a filiform bougie, Suz-
man - found hyperkeratinization of the oropharyngeal
mucosa, lymphoid infiltration in the submucosa and
atrophy of the muscular coat — changes currently
regarded as “precancerous.” The real nature and cause
of the Plummer-Vinson syndrome or disease are not
known; all observers agree that it concerns a nutri-
tional deficiency or imbalance in which the lack of iron
plays a part of fundamental importance as indicated by
its curative action, but no deeper studies appear to
have been made into the genesis of the condition. The
limitation of the disease to women suggests that it is
connected in some way with functions, endocrine and
otherwise, peculiar to women.

The occurrence occasionally of cancer in women suf-
fering from the Plummer-Vinson syndrome has been
noted by several observers. 2 On the basis of a study
of the rich clinical material at Radiumhemmet, Ahlbom
has shown that there is a definite relation of the syn-
drome to cancer. The first two instances observed
suggestive of such a relation concerned multiple squa-
mous cell cancer of the cheek in women who had bad
Plummer-Vinson symptoms for years. It soon became
quite clear that a high percentage of the women with
squamous cell cancer of the mouth, pharynx and upper
part of the esophagus had had anemia and dysphagia.
Exact final figures are not yet available, but of ninety-
four eases studied with particular reference to the
Plummer-Vinson syndrome during 1931-1935 the out-
come was positive in fifty-seven instances (60 per cent)-
The relatively greater frequency than elsewhere o
oral and pharyngeal cancer, and especially of P ost
cricoid cancer, in women among the patients at Radium
hetnmet is of course also significant. Ahlbom 1 states
that in Radiumhemmet 90 per cent of the cases of P 05t
cricoid cancer occurred in women and that of these
women 90 per cent reported a record like that of t > e
Plummer-Vinson syndrome. There is every reason to
look forward with special interest to the results
further study. The indications are that in Sweden a
least the Plummer-Vinson syndrome in women isj
highly important predisposing factor to cancer m
mouth, the pharynx and the upper part of the csop 1 ^
gus. How is it elsewhere ? It is noteworthy that t
seems to have been uncovered an apparently preven a
malnutritional condition that greatly favors the cle\c oE
ment of cancer. Early diagnosis of the condition
prompt and effective treatment, curative and prevent!' ,
is needed in order to forestall cancer, the foun ut
for which may be laid long in advance of its appear* .

2. Suzman, M. M. :

Syndrome of Anemia, Glossitis and I q.J,

Arch. Inf. Med. 51.-1 (Jan.) 1933. Kelly. _A. J!.: J' ^L^ilid. " S:

rcn. mi. iucu. «* a - * J , \ T -

4 : 285_(A_ug.) J9J9; 42^221 ( April) 1 92/. ^ s 168, IS 25 ’

. 1

os** "

281, 1913; 35:3*1 (Feb.) 1920. Cameron, J. A. M., tUid.

La ub, R..- Acta oto-larynff. 2C:C68, 1938.

3. Cutler, Max, and Buschke, Franz: Cancer: jgj.

Treatment, Philadelphia, W. B. Saunders Company, W*. 1-

Volume 333
Number 20

EDITORIALS

1815

CRITICAL CREOSOTE CRITERIA

A recent Report of the Council on Pharmacy and
Chemistry of the American Medical Association 1
indicated that creosote and its allied preparations have
received more promotion and widespread application in
the past than is warranted by the available pharma-
cologic evidence. The Council found little published
scientific evidence to substantiate claims of some drug
firms for the value of these compounds in the treat-
ment of various pulmonary conditions. Before reach-
ing a final decision the Council sent a questionnaire to
members of the Association of American Physicians
and the American Pediatric Society. The result of this
survey confirmed the Council’s conclusions and indi-
cated that such drugs are rarely employed by leaders
in the profession and that their rationale is little under-
stood by those who do employ them. The Council
omitted all such preparations from New and Nonofficial
Remedies because they are marketed without satisfac-
tory evidence that they have sufficient therapeutic value
and their use is based entirely on empiricism.

Fellows, 2 who previously reported three studies of a
series now reports a critical study of the effect of
orally administered calcium creosotate on the twenty-
four hour sputum of patients with pulmonary tuber-
culosis. This author indicates that the purpose of his
fourth investigation was to determine whether or not
any modification of twenty-four hour sputum specimens
could be demonstrated during a period of calcium
creosotate administration. To accomplish this the
author measured the volatile phenol content and the
volume of these specimens in a total of fifty-six cases
showing similar degrees of lung change. Approximately
half of these were used as controls to compare with
the patients who received the drug. In spite of the fact
that estimations of the volatile phenols excreted in the
urine of patients who received the highest oral doses
of the drug indicated adequate absorption, significant
change in either the sputum phenols or sputum volumes
was not observed in any of the cases during the period
of calcium creosotate administration. In one group not
more than two 0.26 Cm. tablets three times a day could
be given because of nausea after administration for a
period of one month. In another group the majority
of patients tolerated doses as high as four tablets three
times a day for a period of five months.

The author emphasizes the conclusiveness of his
observations because of the large doses administered to
many of the patients. Significantly an equal number
of patients were unable to tolerate such large doses for
a shorter period, which further emphasizes the useless-

]. Creosote and Guaiacol Compounds Omitted from X. X. R., J. A.
M. A. 110:209 (Jan. 15) 193S.

2. Fellows, E. J. : Studies on Calcium Creosotate; IV. Observations
on Its Use in Pulmonary Tuberculosis. Am. J. M. Sc. 197:683 (May)
1939. (These studies were conducted undeT a grout from the Maltbic
Ui:mical Co., Newark, X. J.)

ness of the employment of such treatment in pulmonary
disorders on the basis that an appreciable phenol con-
centration in the lungs is produced. The author’s failure
to find evidence of excretion of phenols in the sputum
of patients who received calcium creosotate suggested
the necessity of investigating expired air of animals
given the drug. Observations on six rabbits revealed
that phenolic material was not present in their expired
air during a period of eight to eighteen hours after each
animal had been given 0.5 Gm. of water-soluble calcium
creosotate phenols by stomach tube.

The results of the entire study not only invalidate
the reports of other workers who attempted to establish
a rationale for creosote compounds in pulmonary dis-
orders on the basis of change in the expired air during
administration of such drugs but also disprove previous
claims for symptomatic relief because of the increase in
expectoration and appetite or lessening of cough. The
author selected tuberculous patients for the study only
because such cases provide a more constant daily output
of sputum, whereas in most bronchial diseases the daily
variation in volume of sputum is so great that it is
impossible to conduct reliable control studies. The
absence of adequate controls probably explains many of
the statements in the literature concerning the changes
in volume of sputum after creosote. Such statements
appear to be the result of isolated observations on per-
sons who might have shown the same changes without
the drug.

BACTERIA, THE SMALLEST OF
LIVING THINGS

The famous paper of the plant physiologist Ferdinand
Cohn entitled “Bacteria, the Smallest of Living
Things’’ introduced scientific bacteriology; it was first
published in Berlin, Germany, in 1872 and has just been
issued in an English translation in the Bulletin of the
History of Medicine and as a separate reprint. 1 Morris
C. Leikind has added an informative and interesting
preface. The paper was translated in 1881 by Charles S.
Dolley, who, by the way, spent several years as a student
in Europe, at the university in Leipzig and at the
zoological station in Naples. Dolley, while yet a medi-
cal student at the University of Pennsylvania, read
Cohn’s paper in the original German. Recognizing at
once its importance for the entire field of biology and
bacteriology, he published the translation which is the
basis of this new edition.

Cohn’s systematic investigations of the life of the
microbe world began in 1S51. The basis of systematic
bacteriology even today is his classification of plant
micro-organisms named according to their forms : cocci,
bacteria, bacilli, vibrios, spirilla and spirochetes. His
discovery' of spores, that form of bacteria which con-
tinues to live even after life for the bacterium proper

1. Baltimore, Johns Hopkins Tress, 1939.

1816

CURRENT COMMENT

Jovr. A. 31. A.
Nov. 11, 191)

has become impossible, is one of the most important
experimental observations in the field of plant physi-
ology.

Bacteriology cannot be regarded merely as a branch
of medical science. The discovery of the pathogenic
germs, chiefly due to Pasteur and Koch, was important
for the science of pathology and especially for the study
of infectious diseases; but the number of those bacteria
which play a part as agents of diseases and have become
commonly known is relatively insignificant in the total
kingdom of microbes. Where there are fifty or a
hundred bacterial agents of human and animal diseases
there are thousands of different species in the microbe
world. Great biologic importance is due to bacteria
and related fungi, which play a decisive part in the
decomposition of organic matter; i. e. in decay and
putrefaction of dead plant and animal bodies, in fer-
mentation and normal digestion, in the loosening of the
soil, in the aggregation of nitrogen in the roots of
certain plants, in the reduction of sulfur, also an indis-
pensable element for life, and in numerous other bio-
logic processes. Cohn’s classic paper is still important
today because he, “like nobod)’ before or after him,”
as the present editor remarks in his preface, “has so
brilliantly and clearly indicated the position of bacteria
in the general economy of nature.” Cohn describes
the eternal circle of organic life. His essay is just as
well worth reading today as when it was first published
in 1872 ; it is not really antiquated in essentials. Thus
he writes, according to his English translator (page 25
of the new edition) :

The whole arrangement of nature is based on this, that the
body in which life has been extinguished succumbs to disso-
lution in order that its material may become again serviceable
to new life. If the amount of material which can be molded
into living beings is limited on the earth, the same particles
of material must ever be converted from dead into living
bodies in an eternal circle ; if the wandering of the soul be
a myth, the wandering of matter is a scientific fact. If there
were no bacteria, the material embodied in animals and plants
of one generation would after their decease remain bound,
as are the chemical combinations in the rocks ; new life could
not develop, because there would be a lack of body material.
Since bacteria cause the dead body to come to the earth in
rapid putrefaction, they alone cause the springing forth of
new life and therefore make the continuance of living creatures
possible. The wonderful fact that putrefaction is a work per-
formed by bacteria does not stand alone; there is an entire
series of chemical changes which are produced by bacteria
and similar microscopic forms. These processes are usually
designated as fermentation phenomena, and the organisms which
cause the same as fermentation fungi.

Ferdinand Cohn, director of the plant-physiologic insti-
tute at the university of Breslau, aroused special interest
in medical history in still another way. That was his
meeting with Robert Koch. When Cohn published his
paper on “Bacteria, the Smallest of Living Things,” in
1872 Koch was still completely unknown. In 1876,
when Koch demonstrated his discovery of the life cycle
of anthrax bacilli, he was still a simple country doctor
and he presented himself and his work to Cohn. From
the blood of infected animals Koch had been able to
grow these bacilli in pure culture and had been first

to prove experimentally the significance of anthrax
spores. These resistant spores become mature bacilli.
With the pure cultivated germs Koch was able to pro-
duce real anthrax or splenic fever in the bodies of
susceptible animals. That important discovery was the
first of Koch’s great accomplishments in the etiology
of infectious diseases. The memorable demonstration
began on April 30, 1876, and lasted for three days.
“Koch completely convinced his audience of his dis-
covery', and Cohn’s enthusiasm was boundless.”

Ferdinand Cohn tried at once to remove all obstacles
from Koch’s way. He not only published in his own
periodical ( Beitrage zur Biologic der Pflanzcn, 1876)
tiie paper, fundamental for medical bacteriology, but
also did his best to secure for Koch an adequate position
in Berlin. Thus the botanist Ferdinand Cohn prepared
the way for the medical man Robert Koch. The aging
Virchow, then president of the Berlin Medical Society,
met the young investigator and colleague with the
greatest skepticism. This went so far that in 1882 Koch
was not permitted to deliver before the medical society
his lecture on the Etiology of Tuberculosis, a lecture
which later became world famous. Ferdinand Cohn
was free from the malevolent jealousy which has unfor-
tunately played a part in scientific competiton among
important scholars. Cohn’s own work was fundamental
as the basis of scientific bacteriology. The republication
of this classic paper (in the original English translation)
is most commendable.

Current Comment

AMERICAN DOCTORS ON
POSTAGE STAMPS

Last year The Journal 1 called attention to the
disparity between the number of physicians in °‘ ie |
countries who had been honored by special issues o
postage stamps and the number so honored m 1
United States. Now the United States Posto ^
Department announces a famous American series ^
postage stamps which will soon be issued. . AmcM
some thirty Americans to be thus memorialize ar
two physicians, Major Walter Reed of the U. S. t rn .
Medical Corps and Dr. Crawford W. Long of 6e°T'
Although other names might well have been a< e
this brief list, no one will deny that the two sc ec
fully merit this honor. Our Eastern shores an
of our cities were invaded some ninety-five h nlCS
yellow fever before Drs. Reed, Carroll,
and Lazear conducted experiments in Cuba wine i
onstrated that yellow fever is transmitted by 1 ,c ^
of certain species of mosquitoes. Yellow c ' c ’ r ,
been present in the Western hemisphere f° r a
300 years and had caused tens of thousands o c ‘ _
Following this discovery by Walter Reed anc » 5 ‘ .

dates in 1900, yellow fever soon disappeared
North America and has never returned. — -

1. Medical Portraits on Stamps, J. A- M. A- Ills 536 (Au*

20

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1818

MEDICAL NEWS

Jouz. A. M. A.
Nov. 11, 1939

Society News. — Dr. Italo F. Volini, Chicago, discussed
“Sulfapyridine Treatment of Pneumonia” before the Ogle

County Medical Society October 26.- At a meeting of the

LaSalle County Medical Society at Starved Rock October 26
Dr. Lowell D. Snorf, Chicago, spoke on “Functional Disorders
of the Stomach and Intestines.” Dr. Jesshill Love, Louis-

ville, Ky., _ addressed the St. Clair County Medical Society
October 5 in East St. Louis on “X-Ray in Treatment of Skin
Malignancies.”

Chicago

Dr. Kronfeld to Direct Postgraduate Education. — Dr.
Peter Kronfeld, professor of ophthalmology at Peiping Union
Aledical College, Peiping, China, for the past six years, has
been appointed dean of instruction at the Illinois Eye and Ear
Infirmary. This is a new position, in which Dr. Kronfeld will
supervise instruction of interns and residents and will have
charge of short courses to be given at various times at the
infirmary. Dr. Kronfeld, who graduated from the University
of Vienna Faculty of Medicine in 1923, came to Chicago in
1928 as assistant professor of ophthalmology at the University
of Chicago. In 1929 he became associate professor and remained
on the faculty until he went to Peiping in 1933.

Dr. Post Made Dean of Rush Graduate School. — Dr.
Wilber E. Post, clinical professor of medicine at Rush Medical
College and president of the staff of Presbyterian Hospital,
has been appointed dean of Rush Graduate School of Medi-
cine. Organization of the new program of graduate work to
become effective in 1942 (The Journal, October 14, p. 1498)
will now begin under Dr. Post’s direction. Dr. Post was born
in Lowell, Mich.,_ in 1877 and graduated at Rush Medical Col-
lege in 1903, joining the faculty two years later. He has
served as clinical professor of medicine since 1916. He has
also been a member of the board of trustees of the University
of Chicago since 1919, but under the practice of the board his
acceptance of the administrative position required his resigna-
tion as trustee.

IOWA

Dr. Geiling Gives Rockwood Lecture. — Dr. Eugene
M. K. Geiling, professor of pharmacology, Division of Bio-
logical Sciences, University of Chicago, will deliver the third
annual Paul Reed Rockwood lecture at the State University
of Iowa College of Medicine, Iowa City, November IS. His
subject will be “Comparative Anatomy and Pharmacology of
the Pituitary Gland.”

Society News. — Dr. Leo H. LaDage, Davenport, discussed
“Plastic Procedures in General Practice” before the Bremer

County Medical Society in Waverly September 27. At a

meeting of the Cass County Medical Society in Atlantic Sep-
tember 21 Dr, Walter A. Anneberg, Carroll, spoke on “Treat-
ment of Pneumonia with Sulfapyridine.” At a meeting of

the Lee County Medical Society in Keokuk October 20 the
speakers were Drs. John I. Brewer on “Uterine Bleeding”;
Grant H. Laing, “Clinical Importance of Pylorospasm” ; George
W. Hall, “Newer Treatment of Mental and Nervous Diseases,”
and Fremont A. Chandler, “Low Back Pain.” All are from
Chicago.

Postgraduate Courses. — Postgraduate extension courses are
now under way in the first, second, third, fourth and tenth
districts of the state. Participating in these courses as instruc-
tors are ;

Dr. Fred M. Smith, Iowa City, Diagnosis and Treatment of Coronary
Thrombosis.

Dr. Willis M. Fowler, Iowa City, The Anemias.

Dr. John H. Peck, Oakdale, Pulmonary Tuberculosis.

Dr. Nathaniel G. Alcock, Iowa City, Management of Common Urinary
Disorders.

Dr. William F. Mengert, Iowa City, Common Gynecologic Disorders.

Dr. Donald C. Conzett, Dubuque, Minor Surgery.

Dr. Arnold S. Jackson, Madison, Wis., The Acute Abdomen.

Dr. Everett D. Plass, Iowa City, Treatment of Leukorrhea.

Dr. Adolph L. Sahs, Iowa City, Diagnosis and Treatment of Neurosis.

Dr. Daniel L. Sexton, St. Louis, Endocrine Therapy: Its Application
in General Practice.

Dr. Fremont A. Chandler, Chicago, Basic Problems in the Management
of Fractures.

Dr. Roger L. J. Kennedy. Rochester, Minn., Gastrointestinal Dis-
turbances in Infants and Children; Convulsive Attacks in Infants and
Children.

Dr. William D. Paul, Iona City, Hypertension with Complicated Heart
Lesions.

Dr. Lester R. Dragstedt, Chicago, Endocrinology.

Dr. Henry W. F. Woltman, Rochester, Minn., Neuritis.^

Dr. Edwin. B. Winnett, Des Moines, Management of Diabetes.

Dr. Leon S- McGoogan, Omaha. Common Obstetric Abnormalities.

Dr. Lewis M. Overton, Des Moines, Backache.

Dr. Edgar V. Allen. Rochester, Minn., Hypertension.

Dr. Ernest Kellev, Omaha. The More Common Neurologic Conditions.

Dr. Edwin L. Miller. Kansas City, Mo, How Can Wc Reduce the
Mortality Rate of Acute Appendicitis?

KANSAS

Society News. — The Sedgwick County Medical Society nat
addressed in Wichita October 3 by Dr. Paul F. Stookev
Kansas City, Mo., on “Staphylococcic Septicemia” and Octo-
ber 17 by Drs. Albert R. Hatcher, Wellington, and Hervey
R. Hodson, Wichita, on “Problems in the Management oi
Carcinoma of the Breast” and “Peritonitis" respectively. —
At a meeting of the Cowley County Medical Society in
Arkansas City September 28 the speakers were Drs. Janies S.
Hibbard and Vincent L. Scott, Wichita, on “Diagnosis and
Treatment of Intestinal Obstructions” and “Convulsions in

Infancy and Childhood.” The Northwest Kansas Medical

Society was addressed at Norton October 3 by Drs. Daniel
V. Conwell, Halstead, on “Migraine” ; Lloyd 0. E. Pecken-
sehneider, Halstead, “Treatment of Congestive Heart Failure,”
and James L. Jenson, Colby, “Basal Metabolism.”

KENTUCKY

Changes in Health Officers. — Dr. Elmer R. Sclmake,
Newport, has been appointed health officer of that city. —
Dr. George B. Davis, Guilford, Conn., succeeds Dr. Chester
R. Markwood, Glasgow, as health officer of Barren County.

Dr. Reuben M. Coblin, Frankfort, has been appointed

health officer of Franklin County to succeed the late Dr.

Eugen C. Roemele. Dr. James W. Miller, Greensburg, lias

resigned as director of the Green County Medical Society to
enter private practice.

Society News. — Drs. William W. Nicholson and Harry - S.
Andrews addressed the Jefferson County Medical Society,
Louisville, October 2 on “Sulfapyridine in the Treatment of
Pneumonia in Children” and “Acute Pharyngolaryngotracheo-

bronchitis in Children” respectively. Drs. Carl H. Fortune

and David Woolfolk Barrow, Lexington, addressed the_ Bour-
bon County Medical Society, Paris, October 19 on “Pituitary
Functions” and “Surgical Treatment of Varicose Veins” respec-
tively. Drs. Catherine Brummett and Albert W. Cowan,

Middlesboro, addressed the Bell County Medical Society, M'd-
dlesboro, October 13 on “Nutritional Requirements of j' e
Normal Infant” and “The Climacteric and the Use of_ the
Estrogenic Hormone” respectively.

District Meetings.— The sixth and seventh councilor dis-
tricts of the Kentucky State Medical Association held a J°' n
m’eeting in Somerset October 26. A symposium on a proposes
law to require premarital medical examinations was presente
in the afternoon by Dr. Fred W. Caudill, Louisville, an
Nicholas W. Klein, Somerset attorney. Speakers on the scien-
tific program were Drs. Harry S. Andrews, Louisville, o
“Vitamin Deficiency Diseases of Children” ; Arthur B. bar ,
Lexington, “Leukorrhea: Its Differential Diagnosis and ir
ment,” and John Harvey, Lexington, “Sulfapyridine m

Treatment of Pneumonia.” The Third District i

Society met with the Christian County Medical Socie J
Hopkinsville October 17, with the following speakers.

John W. Scott, Lexington, “The Problems of the ’ ’

John M. Coffman, Owensboro, “Recent Advances in Nemw
psychiatry,” and Addie M. Lyon, Hopkinsville, superin e : ,
of the Western State Hospital, on the work of the li 1

MASSACHUSETTS

Annual Meeting on Mental Hygiene.— The Massachusetts
Society for Mental Hygiene will hold its annual coni
the Twentieth Century Club, Boston, November 23. 11 e p

cipal speaker will be Dr. George S, Stevenson, New
medical director of the National Committee for Mental, WS
who will discuss “New Vistas for Mental Hygiene.

Society News. — At a meeting of the Harvard . •
Society October 10 Dr. Mercier Fauteux, Montreal, can

spoke on “A New Surgical Method to Improve the d
Supply to the Heart in Coronary Disease — -im ~

District Medical Society was addressed m Boston Ucw
bv Dr. Charles H. Lawrence, Dr. Joseph T.

Nicholas T. Werthessen on “.Obesity and, Menstrual u
bailee: Endocrine and Endometrial Studies ; Drs. wena .
Overbolt, “Clinical Studies in Primary Malignancy o
Lung”; Siegfried J. Thannhauser, “Xanthomatosis , .3™
Proger, “Observations on Heart Disease and Joseph H ; B
“Secretin Test of Pancreatic Function.”-— A *™,l” prc .
“Pain : Its Significance in Diagnosis and Prognosis .
sented October 10 before the Four County Medical Soc^
comprising the county societies of Berkshire, Fra > y\'.

den and Hampshire, by Drs. Lewis M. Hurxftd, '1™“^
Allen, Joe V. Meigs, Boston, and Foster Kennedy, Ncu

Volume 113
Number 20

MEDICAL NEWS

1819

MICHIGAN

Society News.— Dr. Stanley Milton Goldhamer, Ann Arbor,
discussed “Transfusion and the Blood Bank” before the Wash-
tenaw County Medical Society October 16. The West Side

Medical Society, Detroit, was addressed recently by Dr, John
G. Mateer, among others, on “Evolution of Knowledge Regard-
ing Vitamin IC and Blood Prothrombin in Relation to Hemor-
rhage.” At a meeting of the Wayne County Medical Society,

Detroit, October 16 Dr. Russell L. Haden, Cleveland, spoke

on "Etiology and Diagnosis of Leukemia.” Dr. Harry Bak-

win, New York, discussed “Newer Developments in Vitamins”
before the Calhoun County Medical Society in Battle Creek

October 3. Dr. Manuel E. Lichtenstein, Chicago, addressed

the Van Buren County Medical Society, South Haven, Octo-
ber 10 on “Periappendiceal Phlegmon and Abscess.”

NEW JERSEY

State Society Arranges Medical Care for Needy. — The
Medical Society of New Jersey has issued for the second year
its invitation to any person in the state in need of medical
care to communicate with the executive office in Trenton. All
requests will be referred to the county medical societies of
the counties from which the requests come. The societies will
assign physicians to investigate applications and provide care
in all cases of genuine need.

Dr. Flexner Retires. — Abraham Flexner, LL.D., director
of the Institute for Advanced Study, Princeton, since its estab-
lishment in 1930, has resigned on the advice of his physician.
Dr. Flexner, now 72 years old, has been prominent in educa-
tion for many years. He was associated with the Carnegie
Foundation for the Advancement of Teaching from 1908 to
1925, serving as secretary the last eight years. Early in this
period he made the well known study of medical education
at the invitation of the Council on Medical Education of the
American Medical Association, which led to basic reforms in
the medical schools of the country. The study was published
in 1910. From 1925 to 1928 he was director of the division
of studies and medical education of the General Education
Board. He holds many honorary degrees, among them medical
degrees from the universities of Berlin and Brussels. His
successor at the Institute for Advanced Study will be Frank
Aydelotte, LL.D., president of Swarthmore College, Swarth-
more, Pa., since 1921.

Society News. — Drs. Harry Gold, New York, and Robert
Edward Gross, Boston, addressed the New York Heart Asso-
ciation at a scientific session. November 7 on “Studies on
the Nature of Digitalis Action” and "Experiences with Sur-
gical Treatment of the Patent Ductus Arteriosus” respectively.

Drs. Francis W. Sovak, New York, and Abraham Shul-

man, Paterson, N. J., addressed the Bronx Gynecological and
Obstetrical Society October 23 on “Operative Treatment of
Sterility” and “Pregnancy Following Tubal Implantation”

respectively. Carl R. Moore, Ph.D., Chicago, and Philip

E. Smith, Ph.D., addressed the New York Academy of Medi-
cine at its stated meeting November 2 on “Physiology of the
Testes and Therapeutic Application of Male Sex Hormones”

and “Physiology of the Ovaries” respectively. Dr. James

W. Smith has been elected president of the Alumni Associa-
tion of the New York University College of Medicine; Drs.
Luther B. MacKenzie, vice president, and Phineas Bernstein,
secretary.

NORTH CAROLINA

Annual Symposium at Duke. — The sixth annual sym-
posium conducted by Duke University School of Medicine,
Durham, October 19-21 was on “Diseases of the Lungs and
Thorax.” The visiting speakers included Drs. Edward D.
Churchill, Maxwell Finland and Frederick T. Lord, Boston;
Daniel M. Brumfiel, Saranac Lake, N. Y. ; Chester A. Stewart,
Minneapolis ; Harry A. Bray, Ray Brook, N. Y. ; Cameron
Haight, Ann Arbor, Mich. ; William D. Andrus and Dickin-
son W. Richards Jr., New York; Isaac A. Bigger, Richmond,
Va. ; Charles R. Austrian and William F. Rienhoff Jr., Balti-
more ; Stuart W. Harrington, Rochester, Minn. ; Daniel C.
Elkin, Atlanta, Ga., and Gabriel Tucker, Philadelphia.

Society News. — Dr. Bernard J. Alpers, Philadelphia, gave
two lectures before the Guilford and Forsyth county medical
societies in Greensboro in September as the first of a series
of seminars sponsored by the two societies. His subjects were
"Interpretation of Neurologic Signs in Common Neurologic
Disorders” and “Diagnosis and Treatment of Common Neuro-
logic Disorders." Drs. Joseph T. Sullivan and Thomas R.

Huffines addressed the Buncombe County Medical Society,
Asheville, October 16 on “Traumatic Rupture of Liver and

Diaphragm” and “Urologic Anomalies” respectively. Dr.

Hubert B. Haywood, Raleigh, addressed the Hartnett County
Medical Society, Dunn, recently on “Medicine at the Cross-
roads.”

OHIO

NEW YORK

Hospital News. — A new $100,000 wing was opened at the
Buffalo Columbus Hospital, Buffalo, October 23. The new
unit now forms the central part of the hospital. It contains
three operating rooms, accommodations for twenty private and
ten semiprivate patients, and enlarged outpatient quarters in
the basement. This is the seventh major addition to the
hospital since it was founded in 1908 by Dr. Charles R.
Borzilleri.

Project to Discover Hard-of-Hearing Children. — The
New York State Commission to Study Facilities for the Care
of the Deaf and the Hard of Hearing announces a case-finding
project to discover children under 6 years old who have defec-
tive hearing. The project will be carried out in Columbia
County under the direction of Dr. Marion F. Loew, a member
of the staff of the state department of health and of the com-
mission, in cooperation with the county health commissioner.
Dr. Louis Van Hoesen, Hudson, and with the health depart-
ment’s divisions of maternity, infancy and child hygiene and
communicable diseases.

New York City

Personal. — Dr. Condict W. Cutler Jr. has been elected an
alumni trustee of Columbia University, succeeding Dr. Eugene

H. Pool. Dr. John Francis McGrath has been appointed

director of gynecology and obstetrics at St. Vincent’s Hospital.

Lectures on Venereal Diseases. — The bureau of social
hygiene of the department of health has opened its fall pro-
gram of lectures on venereal disease for physicians and the
public. Sessions for physicians arc being held Saturday morn-
ings from October 14 to November 26. In addition, an eve-
ning meeting was held October 31 and another is scheduled
for December 6. Meetings for the public were announced for
October IS, November 15 and December 20. In cooperation
with this program the section of historical and cultural medi-
cine of the New York Academy of Medicine presented a sym-
posium on syphilis November 8 by Drs. John L. Rice, health
commissioner, Herman Goodman and Theodore Rosenthal.

Personal. — Dr. George Frederick Mocnch, Mount Victory,
has been appointed health officer of Delaware and Delaware
County. Dr. Orlando E. Harvey, superintendent of the Dis-

trict Tuberculosis Hospital, Lima, has resigned, it is reported,
and Dr. Edward W. Laboe, Howell, Mich., has been named

to succeed him. Dr. Maurice Lincoln Fisher, Mansfield, has

been appointed medical director of tuberculosis work in Rich-
land County. A half mill tax levy to provide funds for the
care of indigent tuberculosis patients will become available in
January.

Society News. — Dr. Louis H. Newburgh, Ann Arbor,
Mich., addressed the Mahoning County Medical Society,
Youngstown, October 17 on metabolism. Dr. Jerome Selinger,

New York, will speak November 21 on peptic ulcer. Drs.

Raymond S. Rosedale, Canton, and Walter IC. Stewart, Youngs-
town, addressed the Stark County Medical Society at Canton
September 21 on “Infections of the Neck” and "Progress in

Medical Economics During the Past Year” respectively,

Dr. Camille J. DeLor, Columbus, addressed the Fayette County
Medical Society in Washington Court House recently on
“Bile Salts in the Treatment of Biliary Diseases.”— — Dr.
Lauren N. Lindenbergcr, Troy, addressed the Miami County
Medical Society, Piqua, recently on “Dermatitis Resulting from
Sensitivity to Novocain.” At a meeting of the Marion Acad-

emy of Medicine recently the speaker was Dr. Russel G.

Means, Columbus, on “New Conceptions of Otitis Media.”

Dr. John A. Toomey, Cleveland, addressed the Montgomery
County Medical Society. Dayton, October 20 on “Differential
Diagnosis of Various Forms of Meningeal Irritations.”

utsuatiUMA

Another Medical Supplement.— A twenty-four page medi-
cal section in tabloid form was published September 24 by
The Daily Oklahoman, Oklahoma City, under the supervision
ot the Oklahoma County Medical Association. Articles of a
general medical and health nature carried by-lines, whereas
those dealing with specific diseases and therapeutic methods
earned merely the by-line “By a Member, Oklahoma Countv
Medical Association.”

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Volume 313
Number 20

FOREIGN LETTERS

1821

FOREIGN

League Against Rheumatism Suspends Activities.— The
International League Against Rheumatism announces from its
headquarters in Amsterdam that the condition of war prevents
continuation of its activities. The bureau is to be closed and
all members and officials have been officially discharged from
their rights and duties.

Nobel Prize for 1938 Awarded to Dr. Heymans.—
Dr Corneille Heymans, professor of pharmacology and phar-
macodynamics at the University of Ghent, Belgium, received
the Nobel Prize in physiology and medicine for 1938, awarded
at the same time that the 1939 prize went to Dr. Gerhard
Domagk of Wuppertal, Germany, who was the discoverer of
the curative effects of prontosir (now neoprontosil). Professor
Heymans was born in Ghent and took his medical degree at
the university in 1920. He joined the research staff of the
university after his graduation and became a full professor in
1929. He is also director of the J. F. Heymans Institute of
Pharmacology and Therapeutics, continuing the work of his
father on the influence of the Arctic regions on respiration,
according to an Associated Press dispatch. Dr. Heymans has
visited the United States various times, first under research
fellowships and in 1929 as a delegate to the International
Physiological Congress. In 1934 he delivered the Herter Lec-
tures at New York University and in 1937 the Dunham Lectures
at Harvard Medical School.

Government Services

Medical Mission to China

The U. S. Public Health Service at the invitation of the
Chinese government has sent three officers to Southwestern
China to investigate in cooperation with the Chinese health
service the reported occurrence of a malignant disease near the
Burma border and determine the menace to the United States
incident to its possible spread to Oriental seaports. The offi-
cers are Drs. Louis L. Williams Jr. and Hiram J. Bush and
Bruce Mayne, Dr.P.H. In addition to determining the nature
and extent of the disease or diseases prevalent in the areas
they visit, they will inform the Chinese authorities of the
results of their survey and advise them as to control measures.

Syphilis Clinics on Wheels

“Clinics on wheels” for treatment of syphilis in four southern
areas have recently been provided by the U. S. Public Health
Service with funds made available by the Venereal Disease
Control Act of 1938. Successful use of a "trailer clinic” in
Glynn, Camden and McIntosh counties in Georgia in 1937 led
to the development of the traveling clinics. In a second project
in North Carolina in 1938 a specially constructed bus was
found more satisfactory than a trailer. The new units are
all-steel buses finished in black and silver. The interior is
divided into sections, one for blood testing and 'injection of
neoarsphenamine and the other for physical examination and
administration of bismuth. There are doors on each side of
the body. Two gas sterilizers are part of the equipment and
there is desk space for the physician and nurse. The new
buses will be used in Macon County, Ala. ; Phillips and Lee
counties, Ark.; Scott County, Mo., and Charleston County,

Health Service Engineer Retires
Joseph Augustin LePrince, senior sanitary engineer, U. S.
Public Health Service, retired September 1 at the legal age
limit after twenty-five years of continuous service. Born in
England in 1875, Mr. LePrince graduated in civil engineering
from Columbia University, New York, and in 1901-1902 he was
assistant to Dr. William C. Gorgas, then chief sanitary officer
of Havana, Cuba, during the first organized campaign for the
eradication of yellow fever and malaria. From 1904 to 1914
lie served as health officer of the section taken over by the
United States in connection with the construction of the Panama
Canal. In March 1914 he was transferred from the Isthmian
Canal Commission to the public health service and was attached
to the scientific research division until his retirement. During
his service lie engaged in studies of malaria control and in
control projects, demonstrations and investigations. During
1922 he was temporarily assigned to yellow fever control mea-
sures along the Mexican border. Since March 1935 he had
been consultant in malaria control to the Tennessee Valley
Authoritv. He had been stationed at Memphis, Term., for
several years.

Foreign Letters

LONDON

(From Our Regular Correspondent)

Oct. 16, 1939

The Certification of Deaths During the War
In ordinary conditions of civil life all deaths from violence
have to be reported to the coroner, who holds an inquest. The
uselessness as well as the difficulty of this procedure for the
numerous deaths expected from air raids is evident. Like every
other contingency which may arise from the war, this one has
been provided for. Special arrangements have been made for
the certification of deaths due to war operations. Bodies not
claimed by relatives will be taken to mortuaries, which have
been prepared, and the clerk to the local council will send to
the registrar of deaths a certificate that the death was due to
war operations. In the case of serving soldiers or airmen and
of certain classes of civilians employed with the armed forces,
commanding officers are authorized to issue a certificate. The
ordinary procedure will apply to other deaths. A physician who
attended a person prior to death should issue an ordinary death
certificate and should add the words “war operations” to the
particulars of violence. When no physician has been in atten-
dance before death the relatives may request one to inspect the
body and issue a certificate, and if he is satisfied that death
was due to war operations he may say so. Whether a physician
has been in attendance or not, there will be no necessity (as
there normally is) to report these deaths to the coroner, and no
inquests will be held on them.

Chaoul Therapy in England
In a short distance, low voltage form of roentgen therapy,
introduced by Henri Chaoul, of Berlin (StrahlcMhcrapic 53:202
[June 29] 1935), and called after him, the tube is so constructed
that the anode can be brought within a few centimeters of the
lesion and thus their radiation of the tissues is confined to a
small area. A tube with the anode at one end for introduc-
tion into the vagina in the treatment of carcinoma of the cervix
was previously introduced by Schaefer and Witte (ibid. 44 :
283 [June 15] 1932) but Chaoul is chiefly responsible for the
development of this procedure for the treatment of carcinoma
on the surface of the body. At the Royal Cancer Hospital,
London, Chaoul therapy was first used in England in 1935 and
in the ensuing years the staff has collaborated in giving it a
thorough test. A report on the treatment of 500 cases treated
from July 1935 to August 1938 has been published by Flood,
Smithers and R. Waldron under the title “Short Distance, Low
Voltage X-Ray Therapy (Bril. J. Radiol. 12:426 [July] 1939).
The malignant cases included 100 epitheliomas, 100 carcinomas
of the breast, chiefly cutaneous recurrences, eighty-two rodent
ulcers, seven carcinomas of the rectum, seven malignant mela-
nomas, three carcinomas of the parotid gland and eleven mis-
cellaneous cases. The nonmalignant cases included seventy-nine
warts and papillomas, twenty-four pitch warts, ten keloid scars,
eleven cases of leukoplakia, eleven nevi, thirteen pigmented
moles, nine corns, three cases of lupus, two cases of neuro-
fibromatosis and twenty-five miscellaneous cases.

Encouraging results were obtained in certain cases of epithe-
lioma of the lip, scalp, face, neck, trunk, limbs and mouth,
and they were remarkably good cosmetically. In rodent ulcer
the results were excellent and when the eyelid was affected
the majority of cases could be treated without damage to the
eyeball (always a difficulty), which is protected by a contact
lens with its outer surface covered with lead introduced under
the lids. A recent advance is the adaptation of Chaoul therapy
to carcinoma in other situations than the surface of the body.
Several cases of carcinoma of the urinary bladder have been

1822

FOREIGN LETTERS

Join:. A. M. A
Kov. 11, W!

treated by the introduction of the Chaoul tube through a supra-
pubic cystostomy. One massive dose is given and the wound
is closed. The nonmalignant lesions, such as warts and papil-
lomas, disappear with excellent cosmetic results. Good results
have also been obtained in the treatment of keloid scars, caver-
nous nevi and corns.

The following are the chief advantages of the treatment :

1. It is possible to give a large dose and spare the surrounding
tissues. This results in rapid healing and good cosmetic results.

2. The high dosage — up to 8,000 roentgens a minute — makes
the time of treatment short, usually three or four minutes.
Many patients can be treated during a day and their loss of
time is minimal. It is also possible to administer large doses
under anesthesia when surgical exposure of the lesion is neces-
sary. 3. The method is economical and the running expenses
are negligible. The majority of the cases can be treated in
the outpatient department with a considerable saving to the
hospital.

Danger of Food Contamination by Gas Attacks
The danger of food contamination by gas attacks was dis-
cussed at a conference of the food group of the Society of
Chemical Industry. Dr. A. P. B. Page, of the Entomological
Research Station of the Imperial College, Slough, said that
methods were available for the detection and determination of
all the known war gases. It seemed that many foodstuffs could
be well protected against such gases. It should be possible to
decontaminate most foodstuffs affected by vapors but few
affected by liquids. Contamination was likely to be severe only
on the surface of piles of food; thus big piles would be less
affected than small ones.

Annual Meeting of the British Medical
Association Canceled

The war has had a profound effect on medical arrangements.
Many of the usual fixed events have been countermanded. The
annual meeting of the British Medical Association, which was
due to take place at Birmingham in the summer of 1940, has
been canceled.

PARIS

(From Our Regular Correspondent)

Oct. 4, 1939.

Blood Transfusion During the War
In 1937 Mme. Raba Deutsch de la Meurthe, on the initiative
of Dr. A. Tzanck and with the cooperation of the Administra-
tion of Public Aid of Paris, founded the Centre de transfusions
et de recherches hematologiques. A special building was con-
structed in the St. Anthony Hospital gardens in Paris and
completely furnished. Its purpose is to furnish the necessary
blood for all transfusions needed by physicians connected with
the hospital services of the city, as well as by physicians in
private practice, and to organize well equipped laboratories for
the study of blood. The center began to function at once.
Carefully chosen donors were recruited and permanent files set
up where any physician at any time can quickly find donors
and transfusion specialists. The donors were subjected to the
usual tests. Blood groups were established and the universal
donors kept. A large number of donors were selected and paid.
In 193S more than 8,000 blood transfusions were performed.
Tzanck’s apparatus was used, a syringe with two openings
which permits aspiration of 10 cc. of blood and its immediate
forcing into the veins of the patient. The blood is transmitted
in complete protection from the air, with no need for citration.
With the coming of the war, the center was assigned the task
of organizing the blood service for wounded soldiers. The blood
quantities required could be supplied only by conserved blood.
An appeal, accordingly, was made through the press and radio
to voluntary donors. The response was overwhelming. Those
selected were given the requisite tests and from 200 to 230 Gm.

of venous blood was taken. A simple apparatus permits
oxygenation and citration of the blood; it is poured into
ampules that are promptly sealed and placed in refrigeration.
Ten thousand goodwill donors of the universal type are expected.
This will permit creating a constantly renewable stock of 500
liters of conserved blood, sufficient for all pressing needs, mili-
tary as well as civilian. Blood shipments are made in specially
wrapped packages and can be used two weeks after taking.
Blood changes with age. The power of oxygen fixation and
corpuscle resistance slowly diminishes, about the tenth to the
twelfth day if physiologic solution of sodium chloride is added
to the blood, from the thirteenth to the twenty-first day if
sodium citrate is added, from the twentieth to the thirtieth day
if a citrated dextrose solution is added. The blood groups do
not change, nor do the serologic reactions, but the corpuscles
do change from the fifteenth day on. The center has rejected
the handling of the blood of dead bodies. Dr. Tzanck was
commandeered for war service and has organized a sort of
branch of the Paris center in the provincial city to which he
was assigned. His place in Paris has been taken in the mean-
time by his associate Professor Sureau.

Absinth

Absinth has been known for its digestive and tonic properties.
Galen often mentioned it. However, the word "absinth” today
may mean several things. Absinth as a liqueur comes from
Switzerland. It is an alcoholic beverage of different essences
the majority of which belong to the genus Artemisia; that is,
large and small absinthium, Artemisia rupestris and others. To
these are often added Chinese anise (Illicium verum), hyssop
(Hyssopus officinalis) and anise (Carum pimpinella). Its rec ’P^
has been modified in the course of its expansion in France an
in the basin of the Mediterranean and it now contains chic )
anise, or rather anethol.

To a certain quantity of absinth, 1,000 cc. or more, the con
sumer adds water, which precipitates the essences and cau^s
the solution to become muddy or thick (louche), appearing " ,l
fifteen measures of water and giving absinth the character o
an aperitif. This quality of louche is demanded by the a s ] n
drinker. An attempt was made to regulate the use of a sin •
in 1912, and a law was passed prescribing that it contal ™ on *

1 Gm. of essence per liter and titrate to not more than
cent alcohol and that it contain no thujone or acetone 0 1
Under these conditions it was impossible, with the custon ^ s0
quantities, to obtain the characteristic muddiness unless one
increased the quantities of the liqueur a great deal. J

therefore, called for only a slight decrease in the quantity ^
essences absorbed but a great increase in that of alco o .
the beginning of the World War in 1914 the consump ^
absinth was strictly forbidden. But beginning with " 1 ^
again authorized in continental France on the basis o 1 ^
of 1922, while in Algeria an absinth of 45 per cent a c
with 2 Gm. of essence per liter was permitted. J hlS . a . 5> -

permitted the consumer to achieve the desired mu ^.jer
Fraudulent practices came into use. In southern France p
packages and small bottles of extract under the nanw o 1 ^

were devised. The consumer dissolved them m any ’> j
alcohol. The powerful taste concealed the impurities, jc ^
or amyl alcohols and even the strong flavor of big > a ^
content. Hence, to the harmfulness of toxic essences uas
strong and impure alcohol. _ . . , v ;di

A commission appointed by the minister of agricu u ’ ^
Professor Tanon, chairman, examined the toxicity oi tv:
of anise or rather of anethol, which has replaced it.
eluded that it was not harmful in small doses provide
correctly distilled and contained no thujone. Anethol i» ^
propylanisol, also called iso-estragol and in large c osc5
convulsions. The commission admitted that it the use 0
was to be permitted to continue it would be better

Volume 113
ft umber 20

FOREIGN LETTERS

1823

the regulations of Algeria; that is, to authorize 45 per cent
alcohol, provided it was pure, and 2 Gm. of essences. In the
Academie de medecinc, Professor Vincent had a pledge put to
a vote tending to complete suppression of absinth and similar
beverages. However, the minister of finance will hardly
renounce some six billions annually of revenue from alcohol,
though it is collected at the expense of the national health.

Harmfulness of Mineral Dusts
At its last session, the Academie de medecine honored the
memory of Harvey Cushing, who was one of its members and
whose eulogy will be pronounced at the next meeting. It
heard a fine funeral oration on Albert Brault, its recently deceased
dean. Among the papers read at this session was that of
A. Policard and J. Rollet on the harmfulness of mineral dusts
tested by the corneal biomicroscope. There are, according to
the authors, great differences among mineral dusts. To deter-
mine their harmfulncss, subcutaneous injections of fine suspen-
sions followed by local examinations of the tissues were made.
Recently, intrapleural injections (Sayers) were practiced — an
excellent but slow procedure, since one must wait weeks for the
tissue response. The same is true of intrapleural or intra-
testicular injections. Intravenous injections, the results of which
are quite precise, remain a laboratory approach. Artificial dust
implantation of animals is not practical. Policard and Rollet
conceived the idea of inserting into the thickness of a rabbit’s
cornea, after incision, an extremely small quantity of dry dust.
The next day and the following days the cornea was examined
with the aid of the corneal biomicroscope or the ocular micro-
scope with the Sitllstrand opening. This is a simple test and
allows one to take precise cognizance of the reactions of the
corneal parenchyma to the dust inserted. When finely pulverized
charcoal is used, the least harmful of the dusts, the first reac-
tion is a local edema. This is followed by a grayish infiltration
of a cellular nature having minute punctations and being pro-
ductive of a corneal disturbance around the mineral deposit.
All these symptoms belong as much to the traumatism as to
the irritation caused by the strange body and constitute the
minimal reactions. In extreme cases, on the contrary, the reac-
tion is violent. The edema appears early, is intense and exten-
sive, may last for several weeks and leaves a cicatrice. Between
these two extremes all intermediary degrees are found. The
authors studied the toxicity of a whole series of dusts by this
method and classified them according to their injuriousness.

BERLIN

(From Ottr Regular Correspondent )

Sept. 15, 1939.

Effect on Head Wounds of Transportation by Air

Professor Schaltenbrand, a neurologist, reported in Dcr
Deutsche Militorarst observations on transporting soldiers with
head wounds by air. Rapid conveyance to special clinics should
be done at once. Transportation by air may have serious
consequences, but they do not exceed those incurred during
long transportation by automobile. Schaltenbrand observed that
the increase of atmospheric pressure had no positive effect on
cerebral fluid pressure. Increased cerebral fluid pressure may
result from incipient oxygen deficiency. Whenever it occurs,
several factors are to be considered: (1) augmentation of
cerebral fluid secretion in the plexus due to oxygen deficiency,
(2) elevation of arterial pressure and (3) elevation of venous
pressure. It is of prime importance to know that cerebral fluid
pressure rises notably in healthy persons at greater altitude,
but probably especially so if anemia through loss of blood or
for other reasons is present. The application of these principles
to the transportation by air of those with head wounds makes
the following considerations mandatory: 1. Higher altitudes
i vght to be avoided as much as possible. 2. If higher altitudes

cannot be avoided, oxygen is to be supplied the patient in time
without waiting until the 3,000 meter limit has been reached.
3. Circulation must be stimulated by strophanthin. The possi-
bility that air may penetrate into the cerebral fluid spores and
cause a tendency of the brain to collapse is much greater than
that of oxygen deficiency. Cerebral fluid pressure under con-
ditions of aerial transportation not only varies with low pres-
sure of the outer atmosphere but falls below normal level with
atmospheric high pressure. The rise of cerebral fluid pressure
in external atmospheric low pressure cannot be remedied with
administration of oxygen. This consideration leads to further
necessary precautions. 4. Patients with open brain injuries
should be placed as horizontally as possible. 5. Wide skull
clefts should not be closed before transportation. 6. A roentgen
examination should be made before the flight. 7. If the ventricle
is filled with air, the plane’s ascent and descent should be care-
fully managed and greater fluctuations of altitude be avoided.

Meeting of the Roentgen Society

The main topics for discussion at this year’s meeting of the
Deutsche Rontgen Gcsellschaft were the following: centra!
x-ray institutes, x-ray tests for cardiac function, dosimetry,
short wave therapy, effect of roentgen irradiation on the cells,
sterilization by irradiation and x-ray serial tests. Holfelder’s
paper on the organization of x-ray service in universities and
hospitals was occasioned by a similar paper read before this
year’s congress of German surgeons in which opposition was
voiced against the central x-ray institute and the claim of
surgeons advanced for x-ray divisions subject to their control.
Hotfelder pointed out that it was impossible for clinical special-
ists to be experts also in roentgenology. However, great stress
should be laid on a thorough and many sided preparatory train-
ing of roentgenologists. Centralized institutes do not aim at
monopoly. He admitted that clinicians need their own x-ray
apparatus in their clinics for special occasions but also indicated
that clinicians should limit themselves to the roentgenology of
their special field. Roentgenologists should be trained only in
central x-ray institutes. Representatives had been sent to this
meeting by large clinical societies to discuss this fundamentally
important problem. Schittenhelm, a Munich internist, set forth
that the systematic training in the foundations of roentgenology
must be given in independent special institutes but that the prac-
tical application of the principles acquired should be made in
the x-ray divisions of the clinics and hospitals.

High voltage roentgen therapy, however, should be performed
largely in independent x-ray institutes. Kirschner, a Heidel-
berg surgeon, explained that the diagnosis should be done in
the individual clinics but that on the whole treatments should
be administered in special institutes by roentgenologists. A
forcible separation of x-ray diagnosis from the functions of the
surgical clinics was out of the question. Besides, larger dis-
tances constituted a great disadvantage to the patient, especially
in urgent cases. K, Hoede, a Wurzburg dermatologist, pointed
out that dermatologists had always stood aloof from centraliza-
tion. In liis opinion it was sufficient for a practicing physician
who wishes to give his patients roentgen therapy to possess a
general knowledge of the other fields of roentgenology. On
the other hand, it was not sufficient for a roentgenologist to
possess only a superficial knowledge of cutaneous and venereal
diseases. The specialist, therefore, should be consulted before
and during therapeutic management. He did not doubt that
too many skin diseases were treated in x-ray institutes. Derma-
tologic clinics ought to be included in instruction on roentgen
therapy. Holfcldcr indicated that the desire of roentgenologists
for centralized institutes was not motivated by monopolistic
intentions to encroach on the activities of the clinicians. The
discussions at this meeting may have helped to clarify the
situation, for previously roentgenologists had made larger

1824

FOREIGN LETTERS

Joes. A. JI. A
Nov. 11, i;r,

demands. Tliese discussions bear also on the new medical cur-
riculum requiring students to take a two hour course for one
semester in roentgenology.

M. Burger, a Leipzig clinician, and W. Teschendorf, a Cologne
roentgenologist, presented a joint paper on x-ray examinations
for cardiac functioning. Burger set forth that it was better to
speak of examinations for circulatory functioning. The exami-
nations were based more or less on the observation of strains
on the regulatory mechanism that takes care of an orderly
interplay between circulation and respiration. What is observed
is arbitrarily induced modification of the size, shape and move-
ment of the heart and its large vessels. The size of the heart
is essentially a function of its condition of fulness, a condition
which can be influenced by suction (Muller’s test) or pressure
(Valsalva’s test). X-ray examinations of changes in the size
of the heart can acquire value for functional tests of the circula-
tion only if all the circulatory conditions and the electrocardio-
graphically perceptible disturbances of cardiac action, if present,
are considered.

Reindell, of Freiburg, discussed the effect of sports on the
heart, especially that of winners in competitive games. The
question whether hearts enlarged by athletic exercises are to
be considered as damaged does not receive a uniform answer.
He himself denies it, supported by electrocardiographic and
kymographic investigations. Neither does he accept the view
that the youthful heart inclines more to enlargement than that
of the older sportsman. It may be assumed that the heart of
the sportsman eliminates its residual blood after strain and thus
increases its efficiency.

Rajewski, of Frankfort-on-the-Main, and Schliephake, of
Giessen, discussed short wave therapy. Long wave diathermy,
they said, had disappeared almost altogether. The generally
used wave length of 3 meters did not yet conform to the best
conditions for the "selectivity factor”; 1 meter was more favor-
able. Also the problem of dosage, he said, might soon be
sufficiently clarified. In the biology of high frequency currents
attention should be called to the fact that the presence of
"specific effects” is not sufficiently proved. In fact, much was
still doubtful in this field. The I meter wave seemed to possess
a superior penetration but was accompanied, as Schliephake
pointed out, by certain dangers. Therefore, only specially trained
and experienced physicians should employ it.

A. Hintze, a Berlin roentgenologist at the surgical clinic of
the university, reported on the results of the use of irradiation
on carcinomas. During the years 1912-1925 about 5,000 cancer
patients were treated, about 3,400 with roentgen rays or radium.
A change has set in; more patients are being therapeutically
managed with irradiation or irradiation in combination with
surgery than by surgery alone. The majority of permanent
cures were effected in patients subjected either exclusively to
roentgen therapy or in combination with surgical intervention.

Gauss, of Wurzburg and Pickhan, of Berlin, discussed steril-
ization by means of irradiation. Originally the German laws
on sterilization permitted surgery only. Since February 1936,
roentgen rays and radium are allowed under certain conditions.
A questionnaire addressed to centers possessing legal authority
to sterilize elicited the information that 95 per cent of the
patients were operated on and 5 per cent were treated with
roentgen rays; of the latter, four fifths received roentgen and
one fifth, radium therapy. The results of irradiation, with few
exceptions, were entirely satisfactory. Secondary effects were
relatively few and insignificant compared with those attending
surgery. Impairment of the ability to work, he said, because
of roentgen therapy was not demonstrable.

Value as Evidence of Blood Group Determination

At the request of the reieh’s minister of the interior, the
Robert Koch Institute for Infectious Diseases in Berlin has
rendered an official expert opinion on the value of blood group

determination as legal evidence (The Journal, July 2, 19)?,
p. 72). The report contains the following statements: Th
evidential value of the blood groups 0, A, B and AB a.-..'
of the M, N and MN characteristics of the blood corpuscL
lias recently been challenged in different ways. Tht anr;-
ments advanced against the validity of the blood groups a:;
(1) that qualitative changes (mutations) of the genes can okk
and (2) that the genes may be hindered in their develops::.-:
so that a structure genotypically present may not receive pheno-
typical evolution. These objections are answered in the expert
opinion as foliows : I. In extensive scientifically performed
investigations of heredity and family descent, not a single cast
of mutation of genes has been established. 2. Factors restric-
tive of gene deveiopment are of no significance for practical
purposes. Therefore they offer no scientific basis for limiting
the evidential value of the blood groups. The limitations and
fallibilities of the methods, the report continues, are sufficiently
known to all experts. In all cases in which these metnedi
yield univoeal results, the blood group of the individual "host
sample has been taken is assured. If the results are equivocal,
e. g. defective types or blood samples of the newborn in "tan:
the presence of isobodies cannot be verified, the blood group
is not reliably determinable. For that reason, experts mud
always clearly indicate whether univocal results have been

obtained or not.

This judgment of the Robert Koch Institute was based (in
a questionnaire addressed to experts. All of them agree, on
the basis of thousands of observations, that the hereditary
transmission of blood group characteristics of A and B xA
those of the red corpuscles M and N can be safely relied on.
If performed according to the regular method, the procedure
for the blood groups O, A, B and AB and for the character
istics of the red blood corpuscles M and N can fulfil a"
required conditions. There is no other hereditary character
istic in human beings the hereditary evolution of which ->
been so fully reexamined and confirmed. The alleged muta : 1 1
of the blood group of an individual and the deviations rcn
the acknowledged laws of heredity formerly asserted "O'
found to be due to errors of procedure or involved illeg ! t ,n ’ 3
offspring. , .

Only two exceptions exist to the validity of the observa ^
just formulated and to the conclusions to be deduce
them: I. The possibility of a feeble erythrocytic c!,aracier ’ we
N (Ns). Only two cases have been observed in the her
in which the N trait showed too feeble an evolution to pe
immediate verification. The Robert Koch Institute as ^
fore taken the position that the conclusions derive
accepted and correctly performed procedures possess a P ^
bility bordering on certainty if the negation of patcrn o! ^
founded on the absence of N, whereas paternity can .,
denied in the presence of a feeble N(N?)- This pro a ^ ^
exceedingly great because blood samples with f ee ® g n tent.
nowadays be definitely recognized as possessive of a i ^ ^
because of the precautions provided. Consequently ^ ^
cases mentioned cannot constitute an argument aga ^
reliability of the M and N determinations. 2. 11 c ;
groups of A (Ai/A;) and AB (AiB/A?B). A h’S .;eP 3 -
probability attaches to the conclusions derived {torn . ^
tions based on correctly performed procedures o t ie
nate blood groups just mentioned. However, statistics
on a large scale is not yet available to permit a

statement. , i • If pa !c: '

The opinion is summarized in the following vi or s Jfr .
nity can at all be excluded on the basis oi blow gro
ination, all other combinations admit of conclusions
absolute certainty, provided the blood group c _ tr
have been made in a scientifically unobjectionable man

Volume 113
Number 20

MARRIA.GES

1825

ITALY

(from Our Regular Correspondent)

Sept. 22, 1939.

Leishmaniasis in Italy

Dr. Pulle, of Riccione, in a lecture before the Societa Medico-
Chirurgica della Romagna, discussed the clinical forms of leish-
maniasis. The insect which transmits leishmaniasis is unknown.
Probably various insects which fly during the day may trans-
mit the disease. Rodents are highly receptive but they do not
directly transmit the disease.

Professors Monti and Poggi reported on a large focus • of
cutaneous leishmaniasis which developed at Forli and was
observed by the speakers. In a municipality of the province,
sixty cases were found. The twenty patients who had local
injections of from 0.05 to 0.1 cc. of atabrine, according to
Flarer's technic, recovered. The technic of administration is
simple. The leishmaniotic nodules regress in ten or twenty
days. The speakers showed photographs, microscopic prepara-
tions and photomicrographs. They presented four patients who
had had the atabrine treatment.

Professor Bartolotti discussed cutaneous leishmaniasis. The
speaker found, by microscopic and bacteriologic studies, that
the changes in the epidermis due to Leishmania are similar to
those in the epithelial cells due to Microbacterium leprae. The
reticulo-endothelial cells are phagocytic for leishmania.

Professor Gentili reported three cases of visceral leishmani-
asis in children. Two patients were natives of the province
of Toscana and the other came from the region of Calabria.
Leishmania was identified in one in the bone marrow which
was taken by sternal puncture. In the other the parasite was
identified in material taken from puncture of the spleen. The
Auricchio-Chieffi reaction gave positive results in all three
cases. The speakers found that the euglobulin fraction of the
blood proteins was increased. They believe that the positive
results of the Auricchio-Chieffi test are associated with the
increase of the protein fraction.

Vascularization of Human Testicle

Professor Balice recently lectured to the Accadetnia delle
Scienze Medichc e Chirurgiche, of Naples, on primary tuber-
culosis of the epididymis and testicle. The speaker recently
carried on an x-ray study of the vascularization of the human
testicle after having injected a thorium preparation into the
spermatic artery. The roentgenograms show that the vascular
supply of the testicle is provided by the spermatic artery and
its branches, which bifurcate through the testicular parenchyma.
The roentgenograms of the epididymis and the body of High-
more show a uniform dark shadow from the blood vessels. It
cannot be determined whether the blood vessels originate only
in the spermatic artery or in both the artery and blood vessels at
the body of Highmore. Blood vessels of decreasing caliber from
the body of Highmore to the free surface of the parenchyma can
occasionally be seen in the roentgenograms. Probably they origi-
nate in central blood vessels. The speaker believes that tubercle
bacilli come simultaneously to the epididymis and testicle
through the blood. Early in the development of tuberculosis
the disease is more acute in the epididymis, than in the testicle
because of the different blood supply of either structure.
Tuberculous orchiepididymitis develops in most cases from the
hematogenic route. However, in a few cases tuberculosis may
be propagated by a process of continuity from the prostate and
seminal vesicles to the epididymis and to the testicle. When
this is the case, the primary seat of tuberculous granuloma is
intracaualicular. The treatment is conservative, by roentgen
irradiation. When the lesion is in the epididymis and the
testicle is not involved by tuberculosis, an epididymcctomy is
indicated, after which the results of roentgen treatment arc
satisfactory.

Personal

Prof. Galeno Ceccarelli, professor of clinical surgery at the
University of Perugia, was transferred to the same position
at the University of Padua. Professor Ceccarelli graduated in
1913, after which he was appointed to the chair of surgical
pathology at the University of Bari. He has published articles
on pathologic histology of primary cancer of the epidermal
structure of the gallbladder, pedunculated tumors of the liver
and malignant tumors of the testicle. He was awarded a prize
by the Concorso Nazionale Zanetti for his method of perform-
ing cutaneous transplantations in man. He studied the influ-
ence of the endocrine system in the regeneration of the skin
and bones and also conducted clinical and experimental work
on heterotopic ossification. He has written more than seventy
articles on surgery, especially on torsion of the gallbladder and
the painful symptoms of stagnation of the gallbladder.

Clinical Courses in Hospitals
New clinical courses in the hospitals of Rome were recently
opened. The courses form a part of the university curriculum
for physicians. The aim is to give new physicians special
practice in clinical diagnosis and treatment of patients. Special
attention is given to improvement in making diagnoses, deter-
mining proper indications and doses of drugs and other thera-
peutic procedures.

Marriages

William Spears Randall Jr., New Orleans, to Miss
Hattie Louise Stapleton of El Paso, Texas, in San Antonio,
recently.

Richard H. Arimizu, Hilo, Hawaii, to Miss Millicent
Hume of Alliance, Ohio, in Honolulu, August 30.

Courtland Prentice Gray Jr., Monroe, La., to Miss Betty
Eastland Ormond of Forest, Miss., September 9.

Anna Maxwell, North Reading, Mass., to Mr. Jerome A.
Morris of Moncton, N. B., Canada, October 3.

Joseph Boisliniere Grindon Jr., St. Louis, to Miss Mary
Ann Murray of Carlyle, 111., September 27.

Warner Lee Wells, Raleigh, N. C., to Miss Rebecca Ann
Atzrodt of Clarksburg, W. Va., October 7.

Michael J. Stiee, Mount Carmel, Pa., to Miss Margaret
Mary Graham of Shenandoah, Pa., July 15.

William Ernest Coleman Jr., Birmingham, Ala., to Miss
Betty Brown of Eastaboga, September 30.

Isaac Emerson Harris Jr. to Miss Mary Elizabeth Teer,
both of Durham, N. C., in September.

Edwin C. Galsterer, Saginaw, Mich., to Miss Alma Foer-
ster of Holyoke, Mass., September 25.

Lewis E. Abram, Fitzgerald, Ga., to Miss Doris Friedman
of Madison, in Athens, September 10.

Earl E. Houck Jr., Du Bois, Pa., to Miss Katherine Marie
Ulrich of Peoria, 111., September 16.

James Morris Higginbotham to Miss Sue Dobbins, both
of Chattanooga, Tenn., September 6.

Lemuel Photo James Jr., James, Ga., to Miss Ila Ellene
Walker in Atlanta, September 20.

Benzion C. Baron, Wakefield, Mich., to Miss Marion A.
Carter of Crystal Falls, October 8.

Henry H. Merrell, Yorkvillc, 111., to Mrs. Frank Lincoln
Johnson of Chicago, September 9.

David Hale Clement, Boston, to Miss Constance Chambers
of Litchfield, Conn., October 7.

John D. Fitzgerald, Roxboro, N. C., to Miss Betty Offer-
man at Durham, September 5.

Raymond James Kay, Wayne, Pa., to Miss Eva P. Wel-
land of Gulph Mills, recently.

Leon E. Pollock, Spokane, Wash., to Miss Jean Berry of
Portland, Ore., August 13.

Rees Morgan, Roanoke, Ya., to Miss Dorothv Hazelwood at
Richmond, September 30.

Ralph L. High to Miss Jeanne Price, both of Chicago,
September 1.

1826

DEATHS

Joes. A. M. A
Nov. 11, 15:3

Deaths

William Battle Malone $ Memphis, Tenn,; Memphis
(Tenn.) Hospital Medical College, 1899; formerly professor of
surgery and clinical surgery at the University of Tennessee
College of Medicine; past president of the Tennessee State
Medical Association, Memphis and Shelby County Medical
Society and the American Association of Railway Surgeons;
member of the Southern Surgical Association; fellow of the
American College of Surgeons; served during the World War;
on the staffs of the Methodist Hospital and St. Joseph Hospital;
aged 64 ; died, September 4, of acute hemorrhagic encephalitis.

Bernard Portis © Chicago; Rush Medical College, Chicago,
1921, died suddenly of heart disease November 1, aged 42.
Dr. Portis was assistant professor of surgery in the University
of Illinois College of Medicine and associate attending surgeon
in Michael Reese Hospital. Previous to the heart disease,
which proved to be fatal, he had suffered an attack of toxic
encephalopathy. Dr. Portis is survived by two brothers who are
physicians — Drs. Milton and Sidney A. Portis.

Max Halle, New York; Friedrich-Wilhelms-Universitat
Medizinische Fakultat, Berlin, Prussia, Germany, 189S; member
of the Medical Society of the State of New York and of the
American Academy of Ophthalmology and Otolaryngology; on
the staffs of the Broad Street Hospital and the New York
Polyclinic Medical School and Hospital; aged 66; was killed,
September 5, near New Castle, Del., in an automobile accident.

Newton J. Coker, Canton, Ga. ; University of Georgia
Medical Department, Augusta, 1893 ; member of the Medical
Association of Georgia; past president of the Cherokee County
Medical Society; for many years chairman of the city and
county board of education; served during the World War;
founder of a hospital bearing his name ; aged 71 ; died, Sep-
tember 11, of coronary occlusion.

Robert Logan Jones, Nashville, Tenn.; Vanderbilt Uni-
versity School of Medicine, Nashville, 1898; member of the
Tennessee State Medical Association; past president of the
Nashville Academy of Medicine and of the Davidson County
Medical Society ; served during the World War ; city bacteri-
ologist; on the staff of the Protestant Hospital; aged 68; died,
September IS.

Donald Wallace Porter © New Haven, Conn.; Harvard
Medical School, Boston, 1912; clinical professor of pediatrics
at Yale University School of Medicine ; member of the Ameri-
can Academy of Pediatrics and the New England Pediatric
Society; served during the World War; on the staff of the
New Haven Hospital ; aged S3 ; died, September 8, of coronary
occlusion.

Cornelius D. Mulder, Spring Lake, Mich. ; University of
Michigan Homeopathic Medical School, Ann Arbor, 1903 ;
member of the Michigan State Medical Society; for many
years member of the school board ; on the staff of the Hackley
Hospital, Muskegon, and the Elizabeth Hatton Memorial Hos-
pital, Grand Haven; aged 05; died, September 6, of metastatic
carcinoma.

Walter E. Ward, Owosso, Mich. ; University of Michigan
Department of Medicine and Surgery, Ann Arbor, 1883; mem-
ber of the Michigan State Medical Society ; past president and
secretary of the Shiawassee County Medical Society ; health
officer; aged 78; on the staff of the Memorial Hospital, where
he died, September 10, of cerebral hemorrhage.

Harry Clay Smith, Missoula, Mont. ; Bellevue Hospital
Medical College, New York, 1894; member of the Medical
Association of Montana ; fellow of the American College of
Surgeons; on the staffs of the Northern Pacific Beneficial
Association Hospital and St. Patrick Hospital ; aged 67 ; died,
September 13, of heart disease.

Benjamin Hook Ritter, McCdVsvillc, Pa.; Western
Reserve University Medical Department, Cleveland, 1886;
member of the Medical Society of the State of Pennsylvania;
for many years on the staff of the Lewiston (Pa.) Hos-
pital; past president of the Juniata County Medical Society;
aged SO; died, August 27.

John Alexander Macgregor 8? London, Out., Canada;
Western University Faculty of Medicine, London, 1892; an
Associate Fellow of the American Medical Association; pro-
fessor emeritus of medicine at his alma mater; fellow of the
American College of Physicians; aged 67; died. September 20,
c.f cerebral hemorrhage.

Rees Bynon Rees, Bakersfield, Calif.; University of Man-
land School of Medicine, Baltimore, 1900; Harvard Medical
School, Boston, 1901 ; member of the California Medical Asso-
ciation ; owner of a hospital bearing his name ; aged 71 ; did
August 19, of coronary embolus, adenoma of the prostate and
diabetes mellitus.

James Francis Rice,- Watertown, N. Y.; Columbia Uni.
versity College of Physicians and Surgeons, New York. 1902;
fellow of the American College of Physicians ; past president d
the Buffalo Academy of Medicine ; on the staffs of the Hoik
of the Good Samaritan and the Mercy Hospital; aged C6; did
August 3.

George Wallace Jarman, Princess Anne, Md.; Bellevue
Hospital Medical College, New York, 188S; fellow oi the
American College of Surgeons ; director of the Peninsular
General Hospital and member of the hospital executive staff ;
aged 77; died, September 19, of acute myocarditis.

Maurice Isaac Stein ® Harrisburg, Pa.; University oi
Maryland School of Medicine, Baltimore, 1909; past president
of the Harrisburg Academy of Medicine; served during the
World War; served on the staff of the Harrisburg Hospital
in various capacities; aged 52; died, August 15.

Arthur Henry Harms, Knoxville, 111. ; Rush Medical Col-
lege, Chicago, 1904 ; member of the Illinois State Medical
Society; member of the board of education; aged 58; secretary
of the staff of the Galesburg (111.) Cottage Hospital, where lit
died, September 21, of coronary thrombosis.

William Bryan Summerall, Atlanta, Ga. ; Tulane Uni-
versity of Louisiana School of Medicine, New Orleans, 18%,
veteran of the Spanish- American and World wars ; formed!
medical superintendent of the Grady Memorial Hospital; as f
74; died, September 5, of heart disease.

Leroy Alson Luce ® Boston; Tufts .College Mcdicd
School, Boston, 1906; member of the American Psychiatric
Association and the New England Society of Psychiatry ; aRt
59 ; died, September 27, in the West Suburban Hospital,
Park, 111., of carcinoma of the lungs.

Lehnoir Alfred McComb ® Tulsa, Okla.; Baylor U™
versity College of Medicine, Dallas, Texas, 191S; fellow o
American College of Surgeons; on the staff of the Mo .
side Hospital and St. John’s Hospital; aged 45; died, Sep
1, of a self-inflicted bullet wound. . .

John Davis Duckett, Houston, Texas; University,,

ll-ff rfnl-

Nashville (Tenn.) Medical Department, 1898; Vanderbil .
versity School of Medicine, Nashville, 1899; member
State Medical Association of Texas; aged 73; died, M'S
of congestive heart disease. , . , •

Max William Vieweg, Wheeling, W. Va. ; Umvcrsil
Maryland School of Medicine, Baltimore, 191/; . ( | ;t

West Virginia State Medical Association; served du Nji;
World War; on the staff of the Ohio Valley General
aged 55 ; died, August 13. . T . . . , (r , lic0 .

Charles Paxton Stackhouse @ Sandpoint, -Idaho , ‘ ( j, ?

Chirurgical College of Philadelphia, 1898; served d o
World War; past president and secretary of the Bonn 6
Medical Society; on the staff of the Graham Hosp ,

68; died, August 8. n( ]er,

Fred Wells Granger ® Surgeon Lieutenant Comm. {rf ._
U. S. Navy, Houston, Texas; Yale University School oi - ^
cine. New Haven Conn., 1918; entered the Navy in
48; died, August 22, in the Methodist Hospital of suppo-

of urine. Medical

Richard Stephenson, West Lebanon, Ind.; Barnes - ,^1

College, St. Louis, 1898; member of the Indiana htatc : .
Association; formerly county health commissioner,
died, September 1, at Rochester, Minn., of coronary

Burton Roy Miller, Tiffin, Ohio; Ohio Mediat nn.^.^.
Columbus, 1897 ; member of the Ohio State Medical 1 , co unt;'

----- • War; formerly^^

veteran of the Spanish-Amcrican
coroner ; aged 74 ; died, September 16, of

on l,L '

: hri

Fred Harrison Schleich, Chicago; Chicago
1926; member of the Illinois State Rlcclical b ° c , (cirl i
staff of the Illinois Masonic Hospital; aged 5°: 1
16, of cerebral hemorrhage, arteriosclerosis and »>P

Leon Brinkmann, Philadelphia; Un i versj ty 0 * c a '' BVi t'K
Department of Medicine. Philadelphia, 188/ ; form tl)
staffs of the Jewish Hospital, Mount Sinai Hospua
St. Agnes Hospital; aged 72; died, August -3. ^

Beatrice Alma Reed Chatigny, Taunton, Ma-'S-,
College Medical School, Boston, 1913; formerly 0
oi the Taunton State Hospital and the North-imp
State Hospital; aged 48; died, August IS.

Volume 113
Number 20

DEATHS

1827

John Sebring, Bcllcfonte, Pa. ; Jefferson Medical College
of Philadelphia, 1896; member of the Medical Society of the
State of Pennsylvania; on the staff of the Centre County Hos-
pital; aged 6S ; died, August 11.

Philip Richard Flanagan, Chatham, N. Y. ; College of
Physicians and Surgeons, Medical Department of Columbia
College, New York, 1889; aged 73; veteran of the Spanish-
American War; died, August 4.

John Frank Kilroy, Detroit; Detroit Homeopathic College,
1911; member of the Michigan State Medical Society; city
physician; aged 59; died, September 9, in the Alexander Blain
Hospital of pneumonia.

Siegfried F. Bauer ® New York; Juiius-Maximilians-
Universitat Medizinische Fakultiit, Wurzburg, Bavaria, Ger-
many, 1902 ; aged 60 ; died, August 30, in Los Angeles, of septic
infarction of the lung.

Theodore H. Thordarson, Minneota, Minn. ; College of
Physicians and Surgeons of Chicago, School of Medicine of
the University of Illinois, 1897; formerly health officer; aged
74; died, August 2.

Winston W. Barnard, Headland, Ala. ; Memphis (Tenn.)
Hospital Medical College, 1894; aged 79; died, August 22, in
the Moody Hospital, Dothan, of a carbuncle on the neck and
chronic myocarditis.

Robert Andrew Jacobsen ® Exira, Iowa; State Uni-
versity of Iowa College of Homeopathic Medicine, Iowa City,
1894; aged 60; died, September 6, in South Haven, Minn., of
myocarditis.

Joseph Jarvis, Riverside, Calif. ; Bellevue Hospital Medical
College, New York, 1866; Victoria University Medical Depart-
ment, Coburg, Ont., Canada, 1867 ; aged 96 ; died, August 25,
of senility.

John Herbert Callen, Oakland, Calif. ; Homeopathic Medi-
cal College of Missouri, St. Louis, 1890; aged 70; died,
August 3, of strangulated inguinal hernia and tuberculosis of
the lungs.

Edward von Adelung, Oakland, Calif. ; University of Cali-
fornia Medical Department, San Francisco, 1892 ; aged 72 ; died,
August 25, of cerebellopontile angle tumor and cerebral arterio-
sclerosis.

Charles Frederick Mains, Boston; Plarvard Medical
School, Boston, 1S96; member of the Massachusetts Medical
Society ; served during the World War ; aged 67 ; died, August
17.

Charles Rudderow Hutcheson ® Camden, N. J. ; Hahne-
mann Medical College and Hospital of Philadelphia, 1920;
aged 43; died, September 22, of a self-inflicted bullet wound.

William Diamond Sweet, Toronto, Ont., Canada; Uni-
versity of Toronto Faculty of Medicine, 1931; aged 33; on
the staff of the Western Hospital, where he died, August 14.

Frank Dunster White © Milford, Mass. ; University of
Vermont College of Medicine, Burlington, 1897 ; formerly on
the staff of the Milford Hospital; aged 64; died, August 28.

Robert F. Peak, Louisville, Ky. ; University of Louisville
(ICy.) Medical Department, 1880 ; also a lawyer ; aged 80 ; died,
August 16, of hypertrophy of the prostate and heart disease.

Howard D. Manchester, Peoria, 111.; Hahnemann Medical
College and Hospital, Chicago, 1884; aged 79; died, September
4, in the Methodist Hospital of coronary arteriosclerosis.

William Fraser Bryans, Toronto, Ont., Canada; University
of Toronto Faculty of Medicine, 1890; for many years member
of the board of education; aged 7S; died, September 28.

Charles Thomas McLean, Hallsville, 111.; University of
Missouri School of Medicine, Columbia, 1879 ; aged 83 ; died,
September 10, in the Mennonite Hospital, Bloomington.

Ellie H. Putman, Cuero, Texas; University of Tennessee
Medical Department, Nashville, Tenn., 1892; health officer;
aged 73; died, August 24, in the Lutheran Hospital.

Leslie Lamb, Lorimor, Iowa; Keokuk (Iowa) Medical
College, 1896 ; member of the Iowa State Medical Society ;
aged 69; died, August 5, in Van Nuys, Calif.

John Joseph Mulvanity, Nashua, N. H. ; Tufts College
Medical School, Boston, 1913 ; member of the New Hampshire
Medical Society; aged 57; died, August 13.

David Salinger, Chicago ; University of Maryland School
of Medicine, Baltimore, 1894; aged 80; died, September 17, of
cerebral hemorrhage and arteriosclerosis.

Thomas Raymond Dorris, Nanticoke, Pa.; Jefferson
Medical College of Philadelphia, 1925 ; on the staff of the
Mercy Hospital; aged 40; died, August 5.

Samuel J. Litz @ Chicago; Chicago College of Medicine
and Surgery, 1916; for many years member of the board of
education; aged 56; died, September 10.

Winfield Benjamin Trickey, Pittsfield, Maine; Medical
School of Maine, Portland, 1913; member of the Maine Medical
Association; aged 57; died, August 17.

Charles Chester Cottrell ® Scotia, Calif. ; Cooper Medical
College, San Francisco, 1907 ; chief surgeon to the Scotia Hos-
pital ; aged 56 ; died, August 14.

Albert Lincoln Spanogle, Altoona, Pa.; University of
Michigan Department of Medicine and Surgerj', Ann Arbor,
1882; aged 78; died, August 10.

Randall Schuyler, Long Beach, Miss.; University of
Michigan Department of Medicine and Surgery, Ann Arbor,
1S77 ; aged 80 ; died in August.

Adam Emory Kauffman, Chicago; Rush Medical College,
Chicago, 1885; aged 82; died, September 3, in the Presbyterian
Hospital of coronary sclerosis.

Ernest Max Sasville, Collinsville, 111. ; Northwestern Uni-
versity Medical School, Chicago, 1902; aged 76; died, August
27, of chronic myocarditis.

Charles Reuben Buck, Columbus, Ohio; Pulte Medical
College, Cincinnati, 1902; aged 62; died, September 1, of a
self-inflicted bullet wound.

A. R. Lydy, Willard, Ohio; Hahnemann Medical College
and Hospital, Chicago, 1S83; aged 86 ; died, September 1, of
cerebral hemorrhage.

Berton Mell Bishop, Archer, Fla.; College of Physicians
and Surgeons, Baltimore, 1890; aged 70; died, August 22, of
organic heart disease.

Lynn Noah Daniel Kunkel, Pittsburg, Calif.; Univer-
sity of California Medical School, San Francisco, 1932; aged
36; died, July 26.

George Thompson Pool, Vader, Wash.; Barnes Medical
College, St. Louis, 1893 ; aged 74 ; died, August 26, in a hos-
pital at Olympia.

Clarke Eugene Hinman, Syracuse, N. Y. ; New York
Homeopathic Medical College and Hospital, 1895; aged 80;
died, August 27.

Arthur Wellington Ligon, Oxford, Ala.; Vanderbilt Uni-
versity School of Medicine, Nashville, Tenn., 1884; aged 80;
died, August 18.

William J. Casteel, Blairsville, Ga. ; Tennessee Medical
College, Knoxville, 189S ; aged 75 ; died, August 26, of an over-
dose of amytal.

James W. Clark, Columbus, Ga. ; North Carolina Medical
College, Davidson, 1906; aged 56; died, August 24, of cerebral
hemorrhage.

Julius Schneyer, Philadelphia; Jefferson Medical College
of Philadelphia, 1909; aged 64; died, August 8 , of coronary
thrombosis.

Buchanan Burr, Yarmouthport, Mass.; Harvard Medical
School, Boston, 1879; aged 83; died, August 11, of coronary
thrombosis.

Henley Abraham Stark, Cleveland; Cornel! University
Medical College, New York, 1937; aged 26; was drowned,
August 12.

Abner William Shultz, Lebanon, Pa. ; Jefferson Medical
College of Philadelphia, 1870; formerly coroner; aged 93; died,
August 19.

Jessie Boggs Stoner, Berlin, Pa.; Woman’s Medical Col-
lege, Chicago, 1889; aged 74; died, August 28, of diabetes
mcllitus.

Vincent D. Krout, Mechanicsburg, Ohio; Medical College
of Ohio, Cincinnati, 1897; aged 70; died in August of angina
pectoris.

Frank E. Shepardson, Painesville, Ohio; Indiana Eclectic
Medical College, Indianapolis, 1889; aged 77; died, August 22.

Milton Armstrong Griffith, Lintlaw, Sask., Canada; Mani-
toba Medical College, Winnipeg, 1904; died, August 9.

Peyton H Calloway Beckley, W. Va.; Leonard Medical
School, Raleigh, N. C, 1901; aged 69; died, Avgust 1 .

Henry LeHardy Chattanooga, Tenn.; Savannah (Ga.)
Medical College, IS/a; aged 86 ; died, August 15.

Edward Linwood Emrich, Los Angeles; Rush Medical
College, Chicago, 1892; aged 69; died, August 8 .

! ,I°r£- ay uJ enW ^ k L Wa " ai - ljL; Rush Medical Col-
lege, Chicago, 1904 ; aged 08 ; died, August 29,

1828

BUREAU OF INVESTIGATION

S ora. A. M. .V
Nov. 11, 193)

Bureau of Investigation

PEPPLES PEP-YOU-UP
The William Everrette Fraud

William Everrette carried on a piece of mail-order quackery
from Philadelphia that has been declared a fraud and debarred
from the mails. Everrette used such trade names as “Peppies
Co.,” “Peppies Pep-You-Up Co.” and "W. E. M. E. Medicine
Co.” Everrette called himself “Doctor” and claimed to have
studied “naturopathy” and to have been licensed by the state
of New Jersey to practice “naturopathy.” The Post Office
fraud order, however, brought out that there had been accepted
as evidence in this case a letter from the New Jersey Board of
Medical Examiners stating that any one who intends to prac-
tice naturopathy in New Jersey must secure a license from that
board to practice medicine and surgery and that William Ever-
rette was not licensed to practice any branch of medicine and
surgery in New Jersey.

Tlte character of the Everrette fraud is shown in two of his
advertisements : SEXUAL VIGOR

For Men and Women

Try Peppies Pep-You-Up, non-injurious; no drugs or dope. The
result is pep, power, energy and endurance. Bring back lost
pleasures.

And another :

WEAK MEN AND WOMEN TOO
Do you suffer from lost PEP, weakness, piles, kidney, indigestion,
nervousness, rheumatic pains, getting up nights. Say good-bye to
these conditions. Buy a bottle of W. E. M. E. Herb Tonic.

. . . $1.00 per bottle. Cash with order.

These advertisements, according to the evidence in the case,
were placed in “various newspapers.”

On July 11, 1938, Hon. W. E. Kelly, Acting Solicitor for the
Post Office Department, after a hearing in Washington at which
Everrette and his attorney appeared, recommended in a memo-
randum to the Postmaster General that this fraud be debarred
from the mails. The information in this article is based on the
facts given in the Solicitor’s memorandum and, in part, on
material in the files of the Bureau of Investigation of the Ameri-
can Medical Association.

The “treatment” — whether for piles or for lack of “pep” —
consisted of a liquid and some tablets. The liquid, according to
government chemists, was a solution of epsom salt in water
flavored with peppermint, together with some laxative drugs.
Yet Everrette claimed in his advertisements that his stuff con-
tained “no drugs.” The tablets when analyzed were reported
to consist essentially of plant tissue including a bitter and a
laxative. Both the tablets and the liquid were reported to con-
tain damiana, which the Council on Pharmacy and Chemistry
has described in the “Epitome of the U. S. P. and N. F.”
(A. M. A. Press) as an “ingredient of nostrums for sexual
debility in the male; mildly irritant, but otherwise probably
inert.”

The government charged that the claims made by Everrette
that bis “patent medicines” would enable sufferers from “kidney
trouble,” indigestion, piles, sexual weakness, and so on to “say
goodbye to these conditions” were false and fraudulent. Even
the physician whom Everrette got to testify in his behalf prac-
tically admitted the same thing.

The Post Office Department is not the only government agency
that looked into this fraud. As long ago as March 1937 the
Federal Trade Commission issued a complaint against Ever-
rette, trading as W. E. & M. E. Medicine Co. The charge
was not that the business was a fraud but that the claims made
by Everrette were “exaggerated and misleading” and that such
claims would cause “diversion of trade from competitors.” The
Commission’s complaint allowed Everrette twenty days in which
to file answers to the charge. Four months later (July 1937)
the Commission reported that a hearing on the charge would
be held in Philadelphia on July 30, 1937. Time passed! Ten
months later (May 193S) the Commission declared that a hear-
ing on the same case would be held in Washington, D. C., on
May 27. 1938. More time passed! Four months later still
(September 193S) the Commission again reported that a hearing
on the same charges would be held in Washington on Sept. 2S,
193S — more than two months after the Post Office Department
had put this piece of mail-order quackery out of business ! The

case was not finally settled until September 1939, when the
Commission definitely ordered Everrette to cease representing
that his “Herb Tonic” purifies the blood, relieves all acute pains,
stimulates the sexual organs or system, or does some oi the
other things claimed for it.

The Post Office Department acted with less circumlocution
in Everrette’s case. It notified him of .the charges on April 28,
1938, and on July 14, 1938, his fraud was debarred from the
mails.

MISBRANDED “PATENT MEDICINES"

Abstracts of Notices of Judgment Issued by the Food
and Drug Administration of the United States
Department of Agriculture
['Editorial Note. — The abstracts that follow are given in
the briefest possible form: (1) the name of the product; (2)
the name of the manufacturer, shipper or consigner; (3) the
composition ; (4) the type of nostrum ; (5) the reason for
the charge of misbranding, and (6) the date of issuance of the
Notice of Judgment — which is considerably later than the date
of the seizure of the product and somewhat later than the con-
clusion of the case by the Food and Drug Administration.]

Go-Gon 7-11. — Helm Co., Benton Harbor, Mich. Composition: Liquid,
essentially small amounts of boric acid, zinc sulfate, a calcium compound,
phosphates, glycerin and water; tablets, chiefly small proportions of
ferrous sulfate and volatile oils (including santal, wintergreen and cubeb)
with copaiba, and chalk coating. Fraudulently represented as effective
in preventing and curing gonorrhea, discharges from urethra and bladder,
and urinary complaints in general. — [iV. J. 29444; February 1939.]
Minnequa Water. — Minnequa Springs, Canton, Pa. Composition: A
lightly mineralized water of the bicarbonate type. Fraudulently repre-
sented as an effective treatment for impaired tissues, acid djspepsia, con-
stipation, gallstones, gravel, gout, diabetes, skin eruptions, rheumatism,
neuritis, obesity, etc . — [ N . /. 29262; December 1938 .]

Ranoll’s (Dr.) Indian Black Tablets. — Suter Chemical Co-, Altoona.
Pa. Composition: Essentially methenamine, saltpeter, oil of juniper and
plant drugs including buchu, bearberry, podophyllum and an emodm-
bearing drug. Fraudulently represented to be effective for kidney and
bladder disorders, etc. — [JV. J. 29431; February 1939.3

Ranoll’s (Dr.) Indian Herb Tablets. — Suter Chemical Co., Altoona, Fa-
Composition: Essentially aloe, podophyllum, gentian and red pepP cr -
Fraudulently represented as an effective remedy for stomach, blood an
liver disorders, sick headache, etc. — [N. J. 29431; February jPjP.J
Sanettes (Mentholated Kerchiefs). — San-Nap-Pak Mfg. Co.,
wright, Mass. Composition: Tissue paper impregnated with nl . ’

Claims that it was “Useful during . . . hay fever and sinus ,rrl

tions” and “Aids in clearing congested air passage” were declared
lent. — [A r . J . 29258; December 1938.3

Saxon Blackberry Cordial Compound. — Saxon Co., Duquesne, Fa-*
Cleveland, Ohio, and Royal Mfg. Co., Duquesne. Composition: L*
tially water, sugar, glycerin and alcohol, with small amounts of S V . 8
acid and plant extracts, including ginger. Fraudulently represente
remedy “For Diarrhea, Summer Complaint, Cholera Morbus, t
Colic and similar complaints.” — [N. J. 29270; December 1938 . J
Shapley’s Liniment. — Shapley Drug Co., Inc., Decatur, 111. Composition*
Essentially common salt with small proportions of ammonia and amm
salts, and extracts of plant drugs, with camphor and water. . prauai ^
represented as effective in rheumatism, neuralgia, neuritis, croup,

[A r . J. 29433; February 1939.3

Shapley’s Stimulating Pills. — Shapley Drug ^ Co., Inc., Decatur,
Composition: Essentially plant drug extracts including a , reP fC-
with baking soda and dextrose, and colored green. Fraudulent }
sented to stimulate the kidneys and bladder and to help backac ' clfavarf
matic pains, uric acid, gout, scanty urine, etc. — [A r . J. 29413,

1939.3

Shapley’s Unguentum Camphoratum. — Shapley Drug Co.,

III. Composition: Essentially a small amount of °f nrtrolatflff

camphor, menthol and possibly eucalyptol, in a base chief!} o F ^
and a small amount of paraffin. Fraudulently represented as _
for catarrh, hay fever, earache, influenza, neuralgia, tonsil
[A r . J. 29433; February 1939.3

Trox Tablets. — Oxol Laboratories. Denver. Composition. incltai-
charcoal, starch, magnesium carbonate, extracts of plant m cCt i ve ne««
ing snponins, and a small amount of oxyquinolinc sultate. ~ j jlj.
b 1 nrnct.-itic and vencrc.u _

as a treatment for urinary
orders was fraudulently represented

Ward’s Anti-Pain Remedy. — Dr. Ward’s Medical Co., Winona,

1

Mine.

infections, cystitis, prostatic and i

•presented.— [A*. J. 29259; December 19-1

cdy. — Dr. Ward’s Medical Co.. 'Y'".?”’ frrcf-
Composition: Essentially a small amount of volatile oils (inciu J J dulerdf
green, sassafras and mustard), with alcohol and '' atcr * . reurafeu
represented as an effective treatment of lame back, rheumaus - ,
and lumbago.— [A r . J. 29450; February 1939.3 ^

Ward’s Cough Syrup. — Dr. Ward’s Medical Co., Yri non ?’ tartf

position: Essentially alcohol, ammonium chloride, chlorotor r r3U im-
material, with a small amount of plant extracts and aroma * «
lently represented as effective in treating “certain disorder. * . cr; v: 3 J

of the bronchial tubes and lungs, coughs, spasmodic cf ‘
coughs, sore throat, pleuritic Coughs, whooping cougn. « fc t?c*-

hoarseness, and kindred ills affecting the lungs and branc .
chitis, pleurisy, throat disorders and croup.’ — I*>* •'* '

1939.3

Volume 113
Number 20

CORRESPONDENCE

1829

Correspondence

STANDARDIZATION OF BLOOD
PRESSURE READINGS

To the Editor : — Tiic report of the Committees for the stand-
ardization of Blood Pressure Readings appointed by the Ameri-
can Heart Association and by the Cardiac Society of Great
Britain and Ireland recently appeared in The Journal (July 22,
p. 294). The recommendations embodied in the report are
excellent except for those of the American committee relative
to diastolic pressure readings. The committees agree that “with
continued deflation of the cuff, the point at which the sounds
suddenly become dull and muffled should be known as the
diastolic pressure.” However, the American committee recom-
mends that “if there is a difference between that point and the
level at which the sounds completely disappear . . . the
latter reading should be regarded also as the diastolic pressure.”
The British committee, on the other hand, “believes that except
in aortic regurgitation it is nearly always possible to decide
the point at which the change conies and this is the only reading
that should be recorded.”

From the physiologic point of view there is much to sub-
stantiate tbe British and little to support the American opinion
in this matter. Ordinarily, of course, the difference between
the diastolic readings obtained by using the sudden muffling of
the sounds and the disappearance of the sounds is not more
than from S to 10 mm. of mercury. However, in an occasional
individual the sounds persist even to the 0 level and thus in
the report the American committee recommends the recording
of a blood pressure of 140/70-0. A diastolic pressure of 0 is
possible only theoretically with a completely rigid vascular tree.

Recent studies have shown that there is reasonably close
agreement between diastolic readings obtained in man by direct
methods and by the indirect method of employing the appear-
ance of the muffled sounds ( Ztschr . f. d. gcs. Expcr. Med.
79:509, 1931; The Journal, Sept. 12, 1930, p. 853).

The diastolic pressure is considered to be the minimum pres-
sure in an artery at the end of ventricular diastole. Only con-
fusion can result from assigning two values to a single pressure
level. In our courses in physiology for medical students we
have for years discouraged the use of the disappearance of all
sounds as a criterion for the diastolic pressure level and will
continue to do so.

George E. Wakerlin, M.D., Pu.D., Chicago.

Professor of Physiology and Head of the
Department of Physiology, University of
Illinois College of Medicine.

BIOGRAPHY OF DR. HARVEY CUSHING

To the Editor: — Mrs. Cushing has requested me to prepare a
biography of her husband, and I should be most grateful to any
one who wishes to make letters, anecdotes or other memorabilia
available.

Copies of all letters, no matter how brief, are desired, and if
dates are omitted it is hoped that, when possible, these may be
supplied (c. g., from the postmark). If original letters or
other documents are submitted, they will be copied and returned
promptly.

A new medical library building is being erected at Yale
University School of Medicine to receive Dr. Cushingls library
and collections, including his letters, diaries and manuscripts.
Any of his friends who wish, now or later, to present corre-
spondence, photographs or other memorabilia for permanent
preservation among the Cushing papers will receive the appre-
ciative thanks of the university.

John F. Fulton, M.D.,

333 Cedar Street, New Haven, Conn.

Yale University School of Medicine.

SILK IN SURGERY

To the Editor : — Your editorial in the October 7 issue of The
Journal “The Rennaissance of Silk in Surgery” is apropos,
as silk for suturing has been relegated into desuetude for too
long a time. Some fifteen or eighteen years ago, in line with
the current fashion, I began to employ clips in the closure of
mastoid wounds. The results were not always satisfactory
because of secondary infections. I decided that too much ten-
sion by tbe clips on the edges of the wound was responsible
for necrosis of the tissue with the resulting difficulties ; although
these were not productive of actual mal results as to et'entual
union, the healing was delayed. Then I turned to catgut —
plain or chromicized — with practically the same difficulties.
For the past six years I have used silk in place of clips or
catgut and, making sure that not too great tension on the
sutures is exerted, I have not been bothered with any secondary
necrosis and secondary infection. Your editorial remarks are
directed particularly toward silk as opposed to catgut, but I
would extend that opposition to include metal clips.

Philip Frank, M.D., Schenectady, N. Y.

ILLEGITIMACY IN THE UNITED STATES

To the Editor : — May I express to you my deep appreciation
of the editorial on illegitimacy in tbe United States, which
appeared in The Journal September 30, page 1329.

We in New Jersey are engaged in the administration of a
law which became operative Jan. 1, 1939, for a better control
of the adoption situation, especially in relation to good social
practice.

Previous to Jan. 1, 1939, adoption practice was most infor-
mal, easily commercialized and with no guaranty whatever
that the child, the child’s mother and the adopting parents were
protected in any way.

No longer may individuals place children for adoption with-
out subsequent review, on order of tbe court, of all the factors
involved; this department and incorporated social agencies,
qualified to serve children, are the instrumentalities to be used
by the court in the necessary investigations which shall insure
to the three parties concerned that their best interests are
protected.

In addition, provision is made to protect the confidential
nature of such transactions. We believe that we shall have
informative material available in regard to this whole matter
which may be useful in the future handling of tbe problem.

Ellen C. Potter, M.D., Trenton, N. J.

Director of Medicine, Department
of Institutions and Agencies.

DIFFICULTIES IN EVALUATING AN
INSULIN PREPARATION

To the Editor : — The efficiency of a new insulin preparation
is determined by its effect on the sugar metabolism of a diabetic
patient who is receiving suitable quantities of food. Judgment
is rendered difficult by unexplained variations in sugar excretion,
though every effort lias been made to control insulin dosage,
diet, physical and mental activities and tbe like. It is probable
that this annoying irregularity is occasioned by unknown limit-
ing factors that are necessary for insulin activity. The profes-
sion is distressingly ignorant of this phase of carbohydrate
metabolism, and it is to be hoped that further work by bio-
chemists and physiologists will elucidate this question.

Another disturbing factor, more amenable to correction, is
the lack of agreement among writers as to what constitutes
acceptable regulation of tbe diabetic patient. A committee of
men especially interested in diabetes might undertake to dispose
of this problem. T _

Louis Bauman, M.D., New York.

1830

QUERIES AND MINOR NOTES

Jour. A. M. A
Xor. II, U!)

Queries and Minor Notes

The answers here published have been prepared by competent
AUTHORITIES. TlIEV DO NOT, HOWEVER, REPRESENT THE OPINIONS OF
ANY OFFICIAL BODIES UNLESS SPECIFICALLY STATED IN THE REPLY.

Anonymous communications and queries on postal cards will not

BE NOTICED. EVERY LETTER MUST CONTAIN THE WRITER’S NAME AND
ADDRESS, BUT THESE WILL BE OMITTED ON REQUEST.

CANCER OF LUNGS

To the Editor : — The condition of my father, who is 62 years old, was
diagnosed bronchial carcinoma of the squamous cell type (primary) in
December 1938. Diagnosis was made by biopsy. Prior to that time
he had a nonproductive cough for five months, some loss of weight and
slight general debility. In January 1939 roentgen treatment was started
over the upper right part of the chest, the site of the lesion. Each day
he received 200 roentgens over the anterior and posterior portions of the
chest. A total of 8,000 roentgens was given. Coughing was much
less and generally he felt better as well as gaining several pounds.
Seven months after conclusion of the first roentgen treatment, coughing
became more pronounced and general debility more marked. An x-ray
examination of the chest revealed an atelectatic area in the lower part
of the right lung, involving most of the middle lobe and a small amount
of the lower lobe. This of course was thought to be due to extension
rather than possible damage by farmer roentgen treatment. Treatment
was started over the new area, 200 roentgens anteriorly and posteriorly
daily, a dose of 8,000 roentgens being contemplated. All treatment
has been given at 200 kilovolts. There has been no reduction of the
cough since treatment has been started and some nausea has been
experienced. Will you please advise me what other treatment might
help. Do you consider the roentgen treatment adequate? If not, please
advise me as to the dosage and amount. I would also appreciate your
comment on the expectancy of life. M.D. Texas.

Answer. — The events described in this case are fairly typical
of the results usually obtained in the roentgen treatment of
cancer of the lungs. The treatment resulted in some degree
of palliation, followed by recurrence. The second course
therapy was less efficacious. This holds true for a second
irradiation not only of cancer of the lungs but of other lesions
as well. In all probability further roentgen or radium treat-
ment would not be of value.

The prognosis of cancer of the lungs is somewhat as follows :
One third of the patients die within three months, one third
within six months and the other third within twelve to eigh-
teen months.

INGESTION OF POTASSIUM PERMANGANATE

To the Editor : — Please give me what information you can on the ingestion
of potassium permanganate. My inquiry is instigated by the discovery
that a considerable number of men have been using potassium perman-
ganate over a period of time going back several years in the self treat-
ment of acute coryza and boils. For both conditions they claim that the
material taken as a one-tenth molecular solution, one teaspoonful three
times a day in a glass of water, is unusually efficacious. I shall appreciate
any information you can give me on this subject.

H. H. Gay, M.D., Midland, Mich.

Answer. — Whatever action potassium permanganate has is
due largely to its ability as an oxidizing agent, provided it is
present in adequate quantities. Solutions of potassium perman-
ganate have been used for destruction of morphine or strychnine,
provided the poison is still in the stomach ; but it should not
be employed to the exclusion of gastric lavage. One thousand
cc. (1 quart) of a 1 : 2,000 solution is used to wash the stomach,
and it must be evacuated after a few minutes. It usually is of
little value when the stomach contains much organic matter,
but morphine and physostigmine are decomposed readily even
in the presence of organic matter. In snake bite permanganate
may be used to wash the incised wound and also to inject imme-
diately around it, but little or none of the permanganate diffuses
through the tissue, and it has no effect on any poison that has
been absorbed. Potassium permanganate is a deodorant, germi-
cide, irritant and astringent. It is used on mucous membranes,
especially of the urethra, in dilutions of from I : 5,000 to 1 : 1,000.
It has been used to disinfect the hands in surgery. The hand
is dipped into the disinfectant solution until it is mahogany
brown and then dipped into a warm saturated solution of oxalic
acid and rinsed in sterile water. Solution of 1 : 500 is applied
externally for excessive sweating of the feet (Useful Drugs).
There are no indications other than those already given for the
ora! administration of the product. It is difficult to believe that
it would be of any use for treatment in coryza or cutaneous
abscesses. Potassium permanganate naturally reacts to the
contents of the stomach, forming manganese compounds such as
manganese oxide and possibly manganese chloride. Of late
years it has been pointed out particularly that manganese as a
metal is a dangerous substance, especially when ft enters the

body in the form of dust by inhalation. When a workroom or
mine contains as much as 2 mg. of manganese dioxide per cubic
foot of air, severe poisoning may arise after long exposure.
Lately there has conic into prominence in some European coin-
tries a form of pneumonia attributed to manganese. This arises
solely in towns or cities harboring manganese industries. How-
ever, persons not employed in the manganese industries appar-
ently readily acquire the disease, owing to manganese du>t>
discharged into the general atmosphere. Low quantities ti
manganese have produced this form of pneumonia in experi-
mental animals. While there is no proof that the oral intake
of manganese will induce this condition, it seems likely that this
substance will in the future be regarded as more dangcrom
than heretofore. Manganese pneumonia is well described in the
“Proceedings and Papers of the Eighth International Congress
for Industrial Medicine and Occupational Diseases” held in
Frankfort on the Main Sept. 26-30, 1938 (Leipzig, Georg
Thicmc, 1939) through three contributions, as follows:

1. Bcolmclitungcn iiber Mangatimicumonicn, by Dr. D. EUtailt, 0-h,
2 : 101 - 1 .

2. Die Manganpneumonie, by Prof. Dr, II. E. Biittner, Gorlin. 2: 10”

3. Expcrimcntciles zur Tlioaiassclilackenstaub und M a n tran pne umoaie,
by Prof. Dr. Iv. \V. Jottcn und Dozcnt Dr. II. Itcploli, Miinsicr, 2:
102S.

SANOCRYSIN AND DREYER'S ANTIGEN IN
TUBERCULOSIS

To the Editor : — Please give the merits and demerits of treatment of tutu-
culosis by sanocrysin and Dreyer's defatted antigen. M.D., Arizona.

Answer.- — Since Mollgaard published the results of his study
of sanocrysin and claimed its specifically curative effect in
tuberculosis, the drug has been tried on patients by imu.'
investigators. There is no uniform opinion as to its place as
a therapeutic agent. The predominant opinion in this country
is that the drug is of little use. . , ,

Investigation has shown that the action of sanocrysin is out
to stimulation of the natural defenses of the body and is not
bactericidal, as proposed by Mollgaard. The cases most favor-
ably affected are the acute or subacute types. Because it
difficult to determine the type that will react unfavorably, t
treatment must be started with small doses and be merw-
according to the patient’s tolerance. It has been found t
patients with fibroid lesions arc not benefited by the or S-
Bronchopneumonic lesions pursuing an acutely progress
course are harmed by sanocrysin. . , „

Various disturbing reactions have been observed in a s
proportion of cases during the treatment which ! ntlic:l
sanocrysin is not a safe remedy. The complications c
tered are chiefly those of heavy metal poisoning. . '
and hiccup difficult to control may occur soon after tne j
tion. Persistent high fever, gastric derangement, f* iar L m ;„.
cutaneous eruptions have been frequently observed, t
uria, hematuria and symptoms of shock and collapse na A
noted. There is strong evidence that sanocrysin ■
unfavorably the trend of the disease and that it exer
ful systemic effects because of its toxicity. _ , < u

Dreyer in 1923 announced a diaplyte vaccine pro , , T
treating killed tubercle bacilli with solution of wr (3 j
and acetone. His work was based on slight C -'P . B?
evidence. It has been shown to be capable ot
tissue reactions which resulted in active timcrc 5 |,nrt
with caseation. Any supposed benefits were lnnite
period of time.

EPISCLERITIS PERIODICA FUGAX ^

0 the Editor:— Tor many years a patient has had episcleritis [tn! .:l

She has had numerous treatments, including opening or „ jlliijt

of the teeth, appendectomy, hysterectomy, tuberculin J | (m ||jrirff,
elimination diets, autogenous vaccines from thc n , ' tion , inclod-'l
gynergen and protein shock therapy and mony d c feri«i" 4W ’

x-ray examinations of thc chest and gastrointcstma ceflt

of the basal metabolic rate, sugar tolerance tests and cf / cc ( e« *■*
has ever been discovered, nor has there been any lover |ion ,r

disease. Now thc patient is desperate. Have you ony^s Lm ;,i<r } -

Answer. — The best description of ^'sclcritis

to be found in thc second volume of Dukc-lv dev"'-- -

1 Ophthalmology of 1938. There is considers i I ,| 1C j'j'.iT

i the discussion of thc etiology of the comm 10 ' G

includes with thc following sentence : 1 I> e ° n !> u3 ||y r,u'- :

due is systemic treatment, for local treatment s

tliout effect.” The one phase of etiology 1 3P p3re r ;‘- r
tuberculous allergy, winch tyu ^

lphasized is that of a tuberculous allergy, ‘ r ,'ub tree-"

i cause in many cases. Long continued cours •' C3!C <.

■ desensitization have proved to he curative m -

Volume 113
Number 20

QUERIES AND MINOR NOTES

1831

PNEUMOPERITONEUM FOR TUBERCULOUS ADHESIONS

To the Editor : — Will you kindly toll me the status of air inflation treatment
done repeatedly in the hope of releasing abdominal adhesions from an old
tuberculous peritonitis? How and when should it be done? Is there any
proof of relief of obstructive symptoms?

Elizabeth Ford Love, M.D., Moorcstown, N. J.

Answer.— The introduction of air into the peritoneal cavity,
known as pneumoperitoneum, has been used for approximately
a third of a century. It was originally employed primarily in
the treatment of tuberculous peritonitis, since there was a belief
that this condition was frequently brought under control by
allowing air to enter the peritoneal cavity during laparotomy.
It has also been used rather extensively in the treatment of
intestinal tuberculosis.

Pneumoperitoneum is frequently instituted in an attempt to
elevate and partially immobilize the diaphragm, the thought
being to bring about partial rest of the diseased lung, as is
believed to occur during pregnancy. It is also used in various
diagnostic procedures. Probably pneumoperitoneum is valuable
in the prevention of adhesions while tuberculous peritonitis is
being brought under control, but it is extremely doubtful
whether it is of any value in releasing abdominal adhesions
from an old tuberculous peritonitis. The only possibility would
be that it might change the position of abdominal organs, par-
ticularly parts of the intestine, to relieve the obstructive symp-
toms partially. If such symptoms are severe, however, one
should not rely on pneumoperitoneum but should resort to sur-
gical methods.’ There is one danger that should he kept in mind
constantly when one attempts to introduce air into the peritoneal
cavity, and it is particularly great if adhesions are present; it
is the introduction of the air into a blood vessel. Patients have
died almost instantly from air embolism while pneumoperitoneum
was being attempted. To determine just when the needle is in
free peritoneal space is more difficult than in the case of the
pleural space, on account of the high negative pressure in the
latter. When pneumoperitoneum is to be instituted, an ordinary
artificial pneumothorax needle or instrument may be introduced
approximately an inch to the right or left and one-half inch
below the umbilicus. This area usually avoids the penetration
of large blood vessels in tiie abdominal wall. When one is
certain that the needle is in the peritoneal space, air may be
introduced by the ordinary artificial pneumothorax equipment.
Usually from 300 to 500 cc. suffices for each treatment. Per-
cussion over the liver while the treatment is being instituted
will usually result in a change from a flat to a somewhat
resonant note if the air is reaching the peritoneal cavity.

GASTRIC CARCINOMA

To the Cditor : — Of all gastric carcinomas, how many occur above the
pyloric area? What is the usual type that occurs in the upper section
of the stomach? Is there an accepted "classic symptomatology" of upper
gastric carcinoma? What percentage of surgical cures has been reported?

M.D., Indiana.

Answer. — The incidence of gastric carcinoma above the
antrum has been found to be about 50 per cent in many large
series of surgically resected and postmortem specimens. When
the lesser curvature is included, the figure rises to about 75
per cent. Some authors, among them Konjetzny, believe that
many carcinomas of the lesser curvature arc often carcinomas
of the antrum with secondary extension along the lesser curva-
ture. Konjetzny (Der Magenkrebs, Stuttgart, Ferdinand Enke,
1938, p. 158) in a series of resected specimens found only 18
per cent of the carcinomas to have arisen above the antrum.

Gastric carcinoma rarely causes characteristic early symp-
toms. Those above the antrum are no exception. Symptoms
are often insignificant even when the lesion has progressed
beyond the resectable stage. This is especially true ol car-
cinoma of the fundus. On the other hand, carcinoma of the
cardia ma> give relatively early symptoms of esophageal
obstruction, but because of its surgical inacessibility the earlier
diagnosis leaves the poor prognosis unaltered. Later symp-
toms are usually not characteristic of the region of the stom-
ach involved.

A variety of pathologic types of gastric carcinoma occur
above the antrum and will be discussed together with surgical
cures.

Surgical cures reported amount to from 1 to 5 per cent of
all gastric carcinoma seen in large clinics. This figure, how-
ever, is misleading in an individual case, because in cases in
which the lesion can he resected Balfour ( Surg Gyiicc. &
Obst. 51:312 [Feb., No. 2A] 1932) reports 20 per cent to be
ten year cures. Carcinomas above the antrum include those
with the best and also those with the poorest prospect of
surgical cure. As a group, carcinomas of the body and greater

curvature (from 10 to 15 per cent of all gastric carcinomas)
offer the best hope for surgical cure. The borders are usually
sharply demarcated, metastases are relatively late, and they
are surgically accessible. Malignant linitis plastica or car-
cinoma fibrosum, found in less than 2 per cent of Marines and
Geschickter’s series of 541 cases (Am. J. Cancer 27:740 [Aug.J
1936), is seldom cured. At operation it is difficult to differen-
tiate involved from uninvolved - areas, and even when a wide
resection is done considerable carcinomatous tissue remains
behind. Carcinoma of the cardia and fundus have poor pros-
pects for surgical cure. Those of the lesser curvature are
intermediate in the possibility of a cure, depending on the
proximity to the cardia on one hand and the involvement of
neighboring structures on the other. Carcinoma in this loca-
tion metastasizes and invades adjacent organs relatively early.

PROBABLE ACUTE ULCUS VULVAE

To the Editor : — Thirteen months ago small blisters began to develop on the
vuivo of a girl aged 9 years. These lesions appeared at intervals of
from seven to fourteen days and required from three to ten days to heal.

I first saw the child four months ago. At that time the mucous mem-
brane of the vulva appeared thin, and there were two or three tiny
cracks near the clitoris. On the right labium mojus there was a blister
1.5 by 1 cm. This was filled with a serosanguincous fluid. The mucous
membrane over the blister broke after a few hours, leaving a shallow
denuded area. This gave the child no discomfort, except on voiding,
when the urine caused considerable burning and pain. The Wossermann
reaction was negative; examination of the stool was negative for para-
sites. The child's weight was 77 pounds (35 kg.), which is 10 pounds
(4.5 kg.) above the average for her age and height. The vaginal smear
is negative for gonorrhea, for Trichomonas vaginalis and for monilio.
Examination of the urine was negative for sugar on the first three
examinations. On several occasions since, however, a trace of sugar has
been found. This can be controlled by moderate limitation of carbo-
hydrates. Treatment has been unsuccessful. She was given estrogenic
substance as a suppository and Hos hod local treatments with gentian
violet, silver nitrate ond silver picrate to no avail, i would appreciate
any suggestions as to diagnosis and treatment. M.D., Alabama,

Answer .— 1 The blisters in this case may represent retention
cysts of the sweat or sebaceous glands about the vulva, or they
may be herpes genitalis. The latter has a tendency to recur
and is usually located on the labia minora. Trauma such as
from masturbation must be ruled out, particularly because of
the presence of the tiny cracks near the clitoris. The most likely
diagnosis, however, is ulcus vulvae acutum, first described by
Lipschtitz in 1913. The blisters in the present case may repre-'
sent a prodromal stage of this disease. Wien and Perlstein
(The Journal, Feb. 6, 1932, p. 461), who reported one of the
first American cases, point out that the disease is characterized
by the presence of ulcers which appear suddenly in the mucous
membrane of the vulva or adjacent region in which Bacillus
crassus is constantly found. This organism is apparently identi-
cal with Doderlein’s vaginal bacillus. The lesions involute
spontaneously after varying lengths of time with slight or no
scar formation, depending on the depth of ulceration.

In the case reported by Wien and Perlstein, the lesions
occurred in definite cycles directly related to the physical con-
dition of the patient. Fatigue, nervous exhaustion and mild
infections of the upper respiratory tract predisposed to the
occurrence of the lesions.

The treatment is usually simple. The lesions heal quickly
when treated with mild antiseptic washes or compresses. The
persistent application of aluminum acetate packs to the vulva
daily for a month will usually give permanent relief. Attention
should also be paid to the patient’s general physical condition,
her diet, her periods of rest and her environment.

ARGYLL ROBERTSON PUPIL

To the Editor : — Is it possible to dilate a true syphilitic Argyll Robertson
pupil adequately with a cycloplegic? Will the pupil return to normal
after the patient has been cured by antisyphilitic treatment. If so, why?

Robert Emmet Jameson, M.O., Davenport, Iowa.

Answer. — In the article by Merritt and Moore (The Argyll
Robertson Pupil : An Anatomic-Physiologic Explanation of the
Phenomenon, with a Survey of Its Occurrence in Neurosyphilis
Arch. Neurol. & Psychiat. 30:o57 [Aug.J 1933) is quoted the
original description by Argyll Robertson of the pupillary phe-
nomenon which bears his name. In the quotation appears this
statement : “Strong solutions of atropine only induced a medium
dilatation of the pupil.” The imperfect dilatation of the Argyll
Robertson pupil in response to installations with cycloplegics is
characteristic of paralysis in the sympathetic innervation of the
eye.

i nere arc scattered reports of the return to normal of true
Argyll Robertson pupils after artificial fever therapy in syphilis

1S32

QUERIES AND MINOR NOTES

Jout. A. M. A
Nov. I], I5j)

of the central nervous system but, so far as is known, not after
other forms of antisyphilitic treatment. Why the Argyll Robert-
son pupil should return to normal under such circumstances or
indeed under any other circumstances is not known, since the
exact mechanism of its production is also unknown.

SUSPECTED CERVICAL CARCINOMA AND BIOPSY

To the Editor: — What are the dangers in taking a biopsy with a cautery
or knife in a case of tumor of the cervix which is probably malignant?
My situation up here is such that with present facilities I am not able
to do a microscopic section and all specimens are sent to the States.
In a case of cancer would this tend to spread it, and if so is the danger
great enough to warrant sending the patient out or doing a total
hysterectomy rather than taking a biopsy and waiting a month? What
would be the best way to make a biopsy to prevent spread? Would a
loop on a diathermy be better than a cautery and how much better is
that than a knife? Is it true that after cautery the lymph flow is to
the wound and that after the knife it is away from the wound? What is
the danger of dilating the cervical canal in the presence of a possible
malignant growth in order to see it better?

David Hoehn, M.D., Fairbanks, Alaska.

Answer. — There is no definite evidence that there is danger
in performing a biopsy on a carcinoma of the cervix with a
sharp scalpel or cautery, provided the procedure is executed
carefully. The danger of spreading the disease after biopsy in
relation to the time interval between biopsy and therapy is a
controversial question. On the whole, experience indicates that
it is best to execute the therapeutic procedure as soon after the
biopsy' as possible. In mentioning the question of hysterectomy
it is assumed that there are no facilities for irradiation available.
As to the choice of waiting a month or performing a hysterec-
tomy, a decision must naturally be made in each individual case.
This would depend on the clinical examinations. In doubtful
cases, waiting is certainly preferable. A diathermy loop is an
excellent way of performing biopsy for suspected carcinoma of
the cervix. A knife is perfectly satisfactory if the procedure
is executed carefully. There is no acceptable evidence that
after the use of cautery the lymph flow is to the wound and
that after the use of the knife it is away from the wound. Care-
ful dilation of the cervical canal may be performed in cases of
suspected carcinoma of the cervix without danger.

PULMONARY ACTINOMYCOSIS

To the Editor:— At present we have in our children's pavilion a 5 year old
white boy who has pulmonary actinomycosis, proved by culture of pus
obtained by aspiration. Could you give us any information as to the
value of sulfanilamide or sulfapyridine or of iodides with or without
thymol? What about surgical treatment; e. g., drainage or lobectomy
or pneumonectomy? Any information or references would be appreciated.

Samuel A. Jaffe, M. D., New Haven, Conn.

Answer.-— There is no undisputed evidence to show the
specific beneficial effect of any of the drugs mentioned. The
use of iodine salts is, of course, traditional. A few patients
have been treated with thymol (Myers, H. B. : The Journal,
May 29, 1937, p. 1S75J and two with sulfanilamide (Miller,
E. M., and Fell, E. H., ibid., Feb. 25, 1939, p. 731. Hall,
W. E. B., ibid., May 27, p. 2190), all with apparently good
results, but conclusions drawn from such limited experiences
can be only suggestive. Surgical removal of infected material,
when possible, and the curettage and evacuation of dead tissue
in the visceral forms have also given good results (Wangen-
steen, O. H. : Ann. Surg. 104:752 [Oct.] 1936). Drainage,
lobectomy and pneumonectomy would therefore seem to be
worth trying, provided the infection is localized. General symp-
tomatic treatment such as that practiced for the treatment of
tuberculosis is of great importance.

CALCANEAL SPURS

To the Editor: — Can you give me ony information concerning the i n/eefion

method with sodium morrhuate for calcaneal spurs? M.D., Arizona.

Answer. — Many substances have been used as injection
material to give relief from painful heels. Some of these
patients have calcaneal spurs, others have not. An important
consideration is the relationship of calcaneal bursitis to painful
heels. Many of the patients who complain of painful heels have
calcaneal bursitis. There is no doubt that the injection has
relieved many patients; in some cases it has made them worse.
One must realize that any injection in and around the peri-
osteum of a bone is apt to cause considerable pain. Many of
the patients who have been relieved by injection therapy have
been relieved by the interfiltration of the spur bearing area, in
which area there may be a bursa.

Reference :

I.cwin. rfcilip: C.-.!cnncu! Spur'. Arch. Surg. 12:117 (Jan.) I92G.

DANGERS OF MERCURIC OXYCYANIDE

To the Editor: — Is there any danger of absorption of mercuric oxvcnif''
through the skin? I use it in the strength of 1:1,000 ond frequtRltj
pick up instruments without having my rubber gloves on. Is there ru
danger from the vapor that arises from this solution? H D |Jcl|J

Answer. — Mercuric oxycyanide is described in New an!
Nonofficial Remedies as “a basic-mercuric salt of hvdrocvanic
acid, containing from 51.7 to 56.0 per cent of mercuric ejanids
[Hg(CN)u] and from 44.3 to 48.0 per cent of mercuric oxide
(HgO).” It is generally used in strengths of from 1 :500 to
as high as 1 : 10,000. If taken internally, the product is natur-
ally toxic. . The substance has been used as an antiseptic and
in the treatment of syphilis more frequently in the past Ilian
in the present.' Severe acute intoxications have been reported
following its use in irrigating sinuses and hollow viscera. In
general, it appears that the prospects of cutaneous absorption
of mercuric oxycyanide are no greater than for many other
mercury compounds widely used for disinfectant purposes. The
small quantities of vapors that may arise from a solution ci
mercuric oxycyanide seem to be without significance.

INTERSTITIAL KERATITIS AND TRAUMA

To the Editor: — A patient had a foreign body embedded in the « rfl ”
for three days. The foreign body was removed and a small urea -
keratitis developed about the site of the foreign body. Within o lev (op
an interstitial keratitis developed and the patient was found lo have of
plus Wassermann reaction. Is it not probable thot the foreign bout
excited a latent interstitial keratitis? Cannot an irritating, substance
cause a flare-up of a latent interstitial keratitis in a syphilitic potient.

M.D., New Vort.

Answer. — This question raises one of the most interesting
and unanswerable medicolegal problems. It is a well know u
fact that a comparatively minor trauma may be the. exciting
factor of a typical syphilitic interstitial keratitis and it is cquall)
well known that the majority of cases of interstitial kcratit 1 !
develop without the history of any preceding trauma. Tln>
question is discussed at length, with bibliography and citauo
of cases, in “Injuries of the Eye” by H. V. Wiirdemann, sccon
edition, published by C. V. Mosby Company in 1932, page ■
According to various authors, anywhere from 3 to 20 per cen
of all cases are precipitated by trauma, which may be of su
minor nature as merely the instillation of irritating drops,
since practically all cases of interstitial keratitis are bm
and the supposedly exciting trauma is usually monocular, •
importance of injury as an etiologic factor must be <«
Furthermore, there is no evidence that the disease woul
have developed without the trauma.

PRESCRIPTION MIXTURES ,

To the Editor: — Would there be any objection to the mixture o c ■ ^
sodium thiocyanate with aromatic fluidextroct of casc °'° s S.m ,.;i
of elixir of sodium thiocyanate with elixir of phenobarbitol.
a mixture be stable? C. L. Attaway, M.D., Villa P! flt,c '

Answer. — The elixir of sodium thiocyanate and the .
fluidextract of cascara sagrada will form a homogcncot
ture which will not precipitate and which is stable. 1 IC ' j
is true of the mixture of the elixir of sodium tluocjana
the elixir of phcnobarbital. . , . t | ltr e

A possible objection to the first mixture would be t - 0|1 j
is a combination of a sedative and a laxative in fixed P r ^ , ,

In cases in which the sodiurrf thiocyanate might presu ^
used three times a day, the administration of. cascara - o
might frequently be objectionable. This objection j ( j. ;
apply to the second mixture if small enough, amoun. ^
elixir of phcnobarbital are used so that the mixture is
depressing.

ASTIGMATIC DIAL IN REFRACTIONS ^ (Sf

J the Editor: — Whot is the opinion among ophthalmologists nil «

use and accuracy of the Robinson-Cohcn slide in routine r Qtjj

a subjective test and under a cycloplcgic? MJJf

Answer. — The Robinson-Cohcn slide is a re
itigmatic dial that is used by a number of opM- ;J .

requires the use of the projection type of visual t - . b on , r.
itus and changing of the slide when it is used- . ,
ic most desirable methods of using the astigmau ((J
the hands of a careful worker, is a. useful a™ 1 j. c

Tractive equipment. Many rcfractionists will noi •
iccssary time to make it useful. It is to be me ,
conjunction with other means of testing.

Volume 113
Number 20

EXAMINATION AND LICENSURE

1833

Medical Examinations and Licensure

COMING EXAMINATIONS

NATIONAL BOARD OF MEDICAL EXAMINERS
SPECIAL BOARDS

Examinations of the National Board of Medical Examiners and Special
Boards were published in The Journal, Nov. 4, page 1757.

STATE AND TERRITORIAL BOARDS
Alabama: Montgomery, June 18-20. Sec., Dr. J. N. Baker, 519
Dexter Ave., Montgomery.

Arizona: Basic Science. Tucson, Dec. 19. Sec., Dr. Robert L.
Nugent, University of Arizona, Tucson.

California: Oral examination (required when reciprocity application
is based on a state certificate or license issued ten or more years before
filing application in California), San Francisco, Nov. 15. Sec., Dr.
Charles B. Pinkham, 420 State Office Bldg,, Sacramento.

Connecticut: Medical (Regular). Examination. Hartford, Nov.
14-15. Endorsement. Hartford, Nov. 28. Sec., Dr. Thomas P % Murdock,
147 \V. Main St., Meriden. Medical (Homeopathic). Derby, Nov. 14-15.
Sec., Dr. Joseph H. Evans, 1488 Chapel St., New Haven.

Delaware: E-rowinafioit. Dover, July 9-11. Reciprocity. Dover, July
16. Sec., Medical Council of Delaware, Dr. Joseph S. McDaniel, 229 S.
State St., Dover.

Florida; Jacksonville, Nov. 13-14. Sec., Dr. William M. Rowlett,
Box 786, Tampa.

Indiana: Indianapolis, June 18-20. See., Board of Medical Registra-
tion and Examination, Dr. J. W. Bowers, 301 State House, Indianapolis.

Iowa: Basic .Science. Des Moines, Jan. 9. Medical. Des Moines,
Dec. 4-6. Dir., Division of Licensure and Registration, Mr. H. W. Grefe,
State Department of Health, Capitol Bldg., Des Moines.

Kansas: Topeka, Dec. 12-13. Sec., Board of Medical Registration
and Examination, Dr. J. F. Hassig, 905 N. 7th St., Kansas City.

Kentucky: Louisville, Dec. 5-7. Sec., State Board of Health, Dr.
A. T. McCormack, 620 S. Third St., Louisville.

Maine: Portland, Nov. 14-15. Sec., Board of Registration of Medi-
cine, Dr. Adam P. Leighton, 192 State St., Portland.

Maryland; Regular. Baltimore, Dec. 12-15. Sec,, Dr. John T.
O'Mara, 1215 Cathedral St., Baltimore. Homeopathic. Baltimore, Dec.
12-13. Sec., Dr. John A. Evans, 612 W. 40th St., Baltimore.

Massachusetts: Boston, Nov. 14-16. Sec., Board of Registration in
Medicine, Dr. Stephen Ruslimore, 413-F State House, Boston.

Mississippi: Reciprocity. Jackson, December. Asst. Sec., State

Board of Health, Dr. R. N. Whitfield, Jackson.

Nebraska: Lincoln, Nov. 24-25. Dir., Bureau of Examining Boards,
Mrs. Clark Perkins, 1009 State Capitol Bldg., Lincoln.

New Hampshire: Concord, March 14-15. Sec., Dr. T. P. Burroughs,
State House, Concord.

New York: Albany, Buffalo, New York, Syracuse, Jan. 29-Feb. 1.
Chief, Bureau of Professional Examinations, Mr. Herbert J. Hamilton,
315 Education Bldg., Albany.

North Carolina; Reciprocity and Endorsement. Raleigh, Dec. 11.
Sec., Dr. W. D. James, Hamlet.

North Dakota: Grand Forks, Jan. 2-5. Sec., Dr. G. M. Williamson,
4*A S. Third St., Grand Forks.

Ohio: Columbus, Dec. 5-7. Sec., Dr. H. M. Platter, 21 W. Broad
St., Columbus.

Oklahoma: Oklahoma City, Dec, 13. Sec., Dr. James D. Osborn Jr.,
Frederick.

Oregon: Basic Science. Portland, Feb. 24. Sec., State Board of
Higher Education, Mr. Charles D. Byrne, University of Oregon, Eugene.

Pennsylvania: Philadelphia, January. Dir., Bureau of Professional
Licensing, Dr. James A. Newpher, Department of Public Instruction,
358 Education Bldg., Harrisburg.

South Carolina: Columbia, Nov. 14. Sec., Dr. A. Earle Boozer,
505 Saluda Ave., Columbia.

South Dakota; Pierre, Jan. 16-17. Dir., Medical Licensure, Dr.
G. J. Van Heuvelen, State Board of Health, Pierre.

Texas: Austin, Nov. 20-22. Sec., Dr. T. J. Crowe, 918-19-20 Mercan-
tile Bldg., Dallas.

Vermont: Burlington, Feb. 13-15, Sec., Board of Medical Registra-
tion, Dr. W. Scott Nay, Underhill.

Virginia: Richmond, Dec. 13. Sec., Dr. J. W. Preston, 30^
Franklin Road, Roanoke.

Wisconsin: Baric Science. Milwaukee, Dec. 2. Sec., Professor
Robert N. Bauer, 3414 W. Wisconsin Ave., Milwaukee. Medical. Madi-
son, Jan. 9-11. Sec., Dr. E. C. Murphy, 314 E. Grand Ave., Eau Claire.

Iowa Reciprocity and Endorsement Report
Air. H. \V. Grefe, director, Division of Licensure and Regis-
tration, reports forty-six physicians licensed by reciprocity and
three physicians licensed by endorsement from January 20
through September 21. The following schools were represented :

School licensed by reciprocity

College of Medical Evangelists (1930)

Loyola University School of Medicine. (1930)

Northwestern University Medical School (193S)

(1939) Illinois

Rush Medical College (1937)

Minnesota

University of Illinois College of Medicine (1932)

Indiana University School of Medicine ...(1930)

University of Kansas School of Medicine. . (1930), (1935,2)
University of Louisville School of Medicine. . (1935). (1936)
v 0936) Nebraska

University of Michigan Medical School (1930)

University of Minnesota Medical School (1933), (1937),

J193S) Minnesota.

Washington University School of Medicine.... .(1935)

Reciprocity

with

California

Illinois

Wisconsin,

Illinois

Missouri

Indiana

Kansas

Kentucky,

Michigan

Missouri

St. Louis University School of Medicine........ (1914) Oklahoma,

(1926) Missouri, (1934) Kansas
Creighton University School of Medicine. .... (1921), (1925),

(1934), (1935), (1938) Nebraska, (1933) South Dakota

University of Nebraska College of Medicine .(1918),

(1931), (1936), (1937, 2) Nebraska _

University of Cincinnati College of Medicine (1935) Uhio

Jefferson Medical College of ~ ■' ' ■ ■■■ \cw Jersey

University of Pennsylvania Sc‘ ... ’ Minnesota

University of Pittsburgh Schoc ■ 1 ■ Minnesota

Meharry Medical College Tennessee

University of Tennessee College of Medicine. ........ (1931)\\ . \ irgima,

(1935) Tennessee . .

Marquette University School of Medicine (1923)

University of Wisconsin Medical School . (1937)

University of Manitoba Faculty of Medicine (1932)

Friedrich- Wilhelms-Universitat Medizinische Fakul-

tat, Berlin (1934)

Universitat Rostock Medizinische Fakultat (1934)

Year Endorsement

School licensed by endorsement Grad of

College of Medical Evangelists (1937)N. B. M. Ex.

Yale University School of Medicine. (1935)N. B. M. Ex.

McGill University Faculty of Medicine (1931)N. B. M. Ex.

Wisconsin

Wisconsin

Minnesota

New York
Colorado

Ohio Reciprocity and Endorsement Report
Dr. H. M. Platter, secretary, Ohio State Medical Board,
reports forty-six physicians licensed by reciprocity and two
physicians licensed by endorsement, July 18, 1939. The follow-
ing schools were represented :

School ^ LICENSED BY RECIPROCITY

George Washington University School of Medicine. ... (1908)

Howard University College of Medicine (1937)

Emory University School of Medicine (1935), (1937)

Northwestern University Medical School... (1936)

Rush Medical College (1925)

The School of Medicine of the Division of Biological

Sciences (1935)

Indiana University School of Medicine (1938)

State University of Iowa College of Medicine (1935)

University of Kansas School of Medicine (1936)

University of Louisville School of Medicine (1938, 3)

Johns Hopkins Univ. School of Med. (1919), (1934), (1938)

Harvard Medical School (1929) W. Virginia, (1934)

University of Michigan Med. School. . (1921), (1929),

(1933), (1934), (1935) Michigan

Wayne University College of Medicine (1939)

St. Louis Univ, School of Medicine (1932), (1936), (1937)
University of Nebraska College of Medicine. (1932), (1938,2)

University of Buffalo School of Medicine (1934)

University of Rochester School of Medicine ..(1938)

Eclectic Medical College, Cincinnati (1918)

Hahnemann Med. College and Hospital of Philadelphia (1938)

University of Pennsylvania School of Medicine (1937)

Tennessee Medical College .(1900)

University of Tennessee College of Medicine (1925)

Vanderbilt Univ. School of Med. (1935) Connecticut (1938)

Marquette University School of Medicine (1938)

Karl-Franzens-Universitat Medizinische Fakultat, Graz (1932)

Medizinische Fakultat der Universitat Wien .(1926)

Johann Wolfgang Goethe-Universitat Medizinische Fak-
ultat, Frankfurt-am-Main (1923)

Ludwig-Maximilians-Universitat Medizinische Fakultat,

Mtinchen (1916)

Regia University degJi Studi di Roma. Facolta di
Medicina e Chirurgia (1935) Maryland,

Reciprocity

with

Illinois

Tennessee

Georgia

Indiana

Illinois

Michigan
Indiana
Iowa
Kansas
Kentucky
Maryland
N. Carolina

Michigan
Missouri
Nebraska
New York
New York
Kentucky
Maryland
New York
Kentucky
Tennessee
Tennessee
Wisconsin
New York
Louisiana

Maryland

New York

New York

School licensed by endorsement

Rush Medical College

University of Edinburgh Faculty of Medicine

Year Endorsement
Grad. of
(I926)N. B. M. Ex.
(1937)N. B. M. Ex.

Michigan Indorsement Report
Dr. J. Earl McIntyre, secretary, Michigan State Board of
Registration in Medicine, reports sixty-nine physicians licensed
by indorsement from January 3 through July 28, 1939. The
following schools were represented:

School LICENSED BY IN DORSE MONT Grad

University of Arkansas School of Medicine (1938,2)

College of Medical Evangelists (1931), (1936)

(1934) Colorado

University of Colorado School of Medicine (1938, 2)

Howard University College of Medicine (1936)

Bennett College of Eclectic Medicine and Surgery. .. (1911)
* 1 ~ ~ * * of Medicine (1919), (1926), (1933)

'31) Ohio

Medical School (1935)

, . ,’38) Illinois

Rush Medical College.... (1933), (1935,2)

The School of Medicine of the Division of Biological

Sciences , .(1936)

University of Illinois College c r - — '* >

Indiana University School of * ,

State Univ. of Iowa College of ‘ 1 ,

University of Kansas School ot Medicine (1933)

. University of Louisville School of Medicine (1934), (1938,2)

Tulane University School of Medicine (19381

Johns Hopkins University School of Medicine! !!!(1936)

University of Maryland School of Medicine and Col-
lege of Physicians and Surgeons (1935)

Year Indorsement

of

Arkansas

California,

Colorado

Tennessee

Illinois

Illinois,

Kansas,

Illinois

Illinois
Illinois
Indiana
_ Iowa
__ Kansas
Kentucky
Louisiana
Maryland

Maryland

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Volume 113
Number 20

BOOK NOTICES

1835

rotic invalidism, alcohol addiction, antisocial behavior and
psychoses. He regards these as somewhat more successful
though highly unsatisfactory solutions of personality conflicts.
Next he considers focal suicide, under which lie classifies self
mutilations, malingering, addiction to surgery, purposive acci-
dents, impotence and frigidity. Proceeding farther along the
same line he analyzes organic suicide, in which he presents
evidence, admittedly incomplete and fragmentary, in support of
his conception that the psychologic factor in organic disease is
far greater than is commonly recognized. In this connection
the author presents a discussion of the totality concept in
medicine and a brief consideration of the lesser evil as a more
or less unsatisfactory compromise between the will to live and
tlie wish to die. In diagrammatic form this is represented
as the span from the uterus to the grave blocked by a black
obstruction marked "external reality.” In health this obstruc-
tion is completely avoided by a long elliptic detour labeled
“normal excursion of life,” composed largely of self-preservative
impulses with a small component of seif-destructive impulses.
A shorter course skirting closer to the barrier but still avoid-
ing it is labeled “neuroses” and is more heavily tinctured with
self-destructive impulses. A still shorter curve colliding directly
with “external reality" is labeled “psychoses" and lias a heavy
preponderance of self-destructive impulses. The shortest course
of all, composed entirely of self-destructive impulses, is labeled
“suicide” and represents almost a direct line from the uterus
to the grave. An exactly similar diagram is presented in which
the life curves are labeled respectively “health,” “hysterical
lesions,” “structural lesions” and “fatal processes.” The first
diagram is representative of psychiatric categories, the second
of medical categories.

The book is an intensely interesting and logical exposition
of a theory. The theory is, of course, predicated on the accep-
tance of psychoanalysis, to which the author is so completely
committed that he regards its rejection as an example of
stupidity, stubbornness or neuroticism. The book is one that
no doctor, in view of the increasing interest in psychosomatic
medicine, can afford to ignore. It appears to be published for
lay readers, but despite its interesting style and its wealth of
illustrative cases from medical literature, newspapers and news
magazines it will make difficult reading for one who has not
previously gained a conception of the workings of the human
mind and a reasonable familiarity with the theory of psychosis.

Sulnhonamide Treatment of Experimental Tuberculosis in Guinea Pigs.
By Konrad Birklmug, M.Sc., M.D. A Lecture Delivered at the Chr.
Michelsen Institute’s Annual Meeting, March 14, 1939. Faper. Pp. 59,
with 7 illustrations. Bergen : A. S. John Griegs Boktrykkerl, 1939.

No medical institute worthy of the name exists which has
not been intrigued by the possibilities of research with the
drug sulfanilamide or its derivatives. In fact, not since the
epoch-making discovery of Ehrlich has a new chemotherapeutic
agent received such universal scientific recognition as sulfanil-
amide. Dr. Konrad Birkhaug in his lecture delivered at the
annual meeting of the Christian Michelsen Institute, Bergen
(March 14, 1939), reviews much of the work which has already
been covered in the enormous medical archives of the past
three years. In his lecture he reviews the chemistry of the
various compounds. He states: “Happily, this cumbersome
chemical name has been abbreviated by the Council on Phar-
macy and Chemistry of the American Medical Association to
sulfanilamide.” In his lecture he pays particular attention to the
work on sulfanilamide as outlined by Marshall, Emerson and
Cutting and discusses thoroughly the dosage and chemothera-
peutic range of the product. He also reviews rather extensively
the treatment of experimental tuberculosis with sulfanilamide
and concludes that prolonged sulfanilamide treatment in vivo
failed to exert any attenuating action on the virulence, tubercu-
linogenesis, growth, cultural or tinctorial characteristics of the
tubercle bacillus. He also reports that in the case of prontosil
soluble there was some inhibitory action probably due to bac-
teriostatic effect which renders the virulent tubercle bacillus
temporarily impotent but that the huge dose of prontosil soluble
required to bring about this indirect effect makes it obvious that
this form of sulfanilamide therapy falls short of representing
the ultimate goal in the chemotherapy of clinical tuberculosis.

Relation of Trauma to New Growths: Medico-Legal Aspects. By R. J.
Behan, M.D., Br. Moth, F.A.C.S., Surgeon. St. Joseph’s Hospital end
Dispensary, Pittsburgh. Cloth. Price, $5. Pp. 425. Baltimore : Wil-
liams & Wilkins Company, 1939.

The author has accomplished a comprehensive review of a
subject which is greatly in need of clarification. His approach
to the problem is orderly. Following introductory references
to historical aspects of the relation of trauma to cancer, the first
chapters cover general phases of the subject, notable among
which are those in reference to a classification of trauma and to
the single trauma and aggravation controversies, This division
of the book is concluded by an excellent presentation of the
postulates which must be given consideration in determining the
causative relationships between a malignant growth and previous
injury. The remainder of the volume represents individual
reviews of cancer in relation to occupation, medicolegal proof
that trauma is the etiologic factor in a particular instance, and
malignant disease following trauma involving various anatomic
structures and systems, all of which are well developed. The
work as a whole constitutes an excellent source of reference for
the expert medical witness. Because of the extension of interest
in the field of industrial disease and the relation of trauma to
various pathologic states, this book should prove timely.

Handbuch der Viruskrankheiten mit besanderer BerOcksichtigung ihrer
experimented!! Erforschung. Untcr Mitarbelt von IC. Boiler et al. Her-
ausgegeben von Prof. Dr. E. Glldemeister, Vizepriisldent des Instltuts
Robert Koch, Berlin, Prof. Dr. E. Hansen, Abtellungsleiter am Institut
Robert Koch, und Prof. Dr. 0. Waldmann, Dlrektor der Staatl. For-
schungsanstaiten, Insel Riems bet Grclfswald. In zwei Biinden. Band II.
Paper. Price, 44 marks. Fp. 7G8, with 105 illustrations. Jena : Gustav
Fischer, 1939.

This book was written by the authors with the collaboration
of thirty other investigators. The chapters are divided under
seven headings: virus diseases with specific localization, virus
diseases of cold blooded animals, virus diseases of insects, virus
diseases of plants, viruses and tumors, diseases with virus-like
agents and diseases of questionable virus etiology. Many chap-
ters are concerned with animal diseases caused hy viruses. The
virus diseases with specific localizations are subdivided into
three groups: (a) diseases of the respiratory tract, comprising
nine chapters, one devoted to psittacosis, one to influenza, one to
the common cold and the others to animal diseases, (b) diseases
of the nervous system, comprising thirteen chapters treating such
diseases as poliomyelitis, encephalitis and rabies, ( c ) diseases of
other organs, treated in six chapters and including such diseases
as venereal lymphogranuloma, moliuscum contagiosum, and epi-
demic parotitis. Under the heading of diseases witli virus-like
agents are eight chapters in which such diseases as typhus fever
and trachoma are discussed. A chapter on bacteriophage is also
included under this heading. The second volume, like the first,
is beautifully illustrated and the chapters are each followed by
excellent bibliographies. This volume can be heartily recom-
mended to research workers interested in virus diseases and also
as a reference work to the physician interested in these diseases.

The Complete Guide to Bust Culture. By A. F. Niemoeller, A.B., M.A.,
B.S. With a foreword by Edward Podolsky, M.D. Cloth. Price, $3.50.
Pp. 100, with illustrations. New Tork: Harvest House, 1939.

The reader who chooses this hook because of its title is likely
to be disappointed. Starting with the first chapter, which
serves as the introduction to the subject, and continuing for 160
pages to the twenty-fourth chapter, which discusses diseases of
the breast, one hopes in vain for some effective method that will
develop the bust and will not be just a makeshift or an appliance
that gives the illusion of a well developed bust. The chapters
on physiology and anatomy arc well written in simple language
and give excellent information to the reader. In the chapters on
exercise the author warns the reader at the beginning not to
expect exercises to “do the impossible.” He states that exercise
will “do what it can as surely and dependably as any method in
existence.” The exercises he advocates are simple exercises
that aim to bring about a better posture and are well known to
most persons. The influence that diet has on the bust is told
in the first paragraph of the chapter and the patient is warned
that the breasts, react the same as does any other part of the
body in that it is not possible to feed a particular portion and
ignore the rest He warns against freak diets, sudden loss of
weight in the obese and the too rapid gain of weight for the

1836

BOOK NOTICES

very thin woman. The author neatly sums up the effects of
creams and lotions on the bust by saying that the claim that
such products can either “enlarge or reduce the breasts is
utterly ridiculous.” Of most value to the reader will be the
chapters on brassieres. The author discusses adequately the
function of a brassiere and describes the type that can be
employed for the various types of busts. The final two chapters
should have been omitted, as advice about actual treatment for
various disease conditions of the breast is outlined. The warn-
ing that the physician needs to be consulted occurs only when
potent drugs may be found to be necessary. Such advice as
“liquids are restricted" and “cathartics administered,” as well
as “cautious massage” and “the breast pump should be
employed,” should not be left to the discretion of the patient.
The discriminating reader will find some good information in
this volume but must discount some parts as not being useful
information for her.

Health and Unemployment: Some Studies of Their Relationships. By
Leonard C. Marsh, Director of Social Research, McGill University, Mon-
treal. In collaboration with A. Grant Fleming, Professor of Public Health
and Preventive Medicine, McGill University, Montreal, and C. F. Blacklcr.
Published for McGill University. Cloth. Price, $3. Pp. 243, with 30
illustrations. New York: Oxford University Press, 1938.

The relationship of health to unemployment has been devel-
oped in the United States to a political issue. The authors
realize, as they point out in their preface, that one question
which must be considered side by side with the provision of
medical care is that of nutrition. They say that, even if tiie
network of medical nursing and hospital services is radically
widened from its present coverage through health insurance,
the doctor is still limited in his work by the physique and
environment of his patients. The authors are convinced appar-
ently that a national system of health insurance is fundamental
to every other type of medical problem, and they have appar-
ently accepted the statements by Falk as the basis for their
conclusions.

Man Against Microbe. By Joseph W. Bigger, Sc.D., M.D., F.R.C.P.I.,
Professor of Bacteriology and Preventive Medicine, Trinity College, Uni-
versity of Dublin. Cloth. Price, $2.50. Pp. 304, with 17 Illustrations.
New York : Macmillan Company, 1939.

There are good microbes and bad ones. The bad ones are
those which bring about disease in human beings and animals.
The good ones are those which participate in agriculture and
industry. In this simple and well written book the author first
discusses the nature of bacteria, next bacteria as a cause of
disease, and finally control of food supplies, clean air and
other sanitary problems. His book includes also brief sketches
of the great contributors to bacteriologic science. It is a
useful book, particularly for boys and girls of college age who
have a special interest in this subject.

Health Officers' Manual: General Information Regarding the Admin-
istrative and Technical Problems of the Health Officer. By J. C. Geiger,
M.D., Dr. P.H., Sc.D., Director, Department of Public Health, City and
County of San Francisco, California. Cloth. Price, $1.50. Pp. 148,
with 12 illustrations. Philadelphia & London: W. B. Saunders Com-
pany, 1030.

From his wide experience in public health, Dr. Geiger has
prepared the manual dealing briefly with general principles of
public health and organization. All details of controversial sub-
jects are omitted. Dr. Geiger’s knowledge and organizing
ability show clearly in the type of book which he has prepared.

The introductory material concerning organization should be
a helpful guide to the health officer in the establishment of basic
services. Under records and statistics are included birth and
death registration, collection of material for statistical study ,
graphic presentation and the explanation of procedures generally
used in morbidity and mortality records. Under medical services
are included programs on child hygiene, public health nursing,
dental hygiene, mental hygiene and nutrition. The communicable
diseases are classified according to control measures applied.

It is advocated that medical services rendered by the health
department include an emergency service, hospitalization facilities
and homes for children, the aged and incapacitated persons.
The inspection and control services consider procedures in food
inspection and control, housing inspection, industrial hygiene,
camp sites and laboratories. The manual is well written, is
easily read and should serve as a useful guide to health officers
in the administration of a balanced public health program. While

Jour. A. II. A.
Nov. 11, 1939

primarily intended for those actively engaged in public health
activities, this manual could be read with interest by the average
lay person and would give him, in not too complicated form
a sufficiently comprehensive idea of modern trends in public
health. 1

n ICRIUOUK ior students ot Ptmitii

Education. By James Huff McCurdy, A.M., M.D., M.P.E Research
worker (Herbert L. Pratt Research Fellowship), 1935—, and Leonard A.
Larson, B A B.P.E., M.Ed., Professor of Health and Physical Education
in Springfield College (Corporate Title, International Young Men’s Chris-
tian Association College), Springfield, Massachusetts, 1933—. Third
edition. Cloth. Price, $3.75. Pp. 349, with 3 illustrations. Philadel-
phia: Lea & Febiger, 1939.

The first edition of this book was published some years ago.
The authors have made considerable revision and added a sec-
tion on exercise for people over 40 and another on exercise
for women. They have availed themselves of a large amount
of research recently published and also of the personal advice
of many of the leaders in the field of physiology of exercise.
Each of the chapters is supplied with an adequate bibliog-
raphy. The book is of the utmost importance as a guide to
all of those who work in association with modern athletics.

Discovery of the Elements. By Mary Elvira Weeks, Associate Professor
of Chemistry at the University of Kansas, Lawrence, ICaDsas. Fourth
edition. Cloth. Price, $3.50. Pp. 470, with Illustrations collected by
F. B. Dalns, Professor of Chemistry at the University of Kansas. Easton,
Pa. : Journnl of Chemical Education, 1939.

The history of chemistry has been told in many ways. Here
in brief form is the history of the discovery of each of the
elementary substances with profuse illustrations and with brief
biographical sketches of many of the noted chemists who con-
tributed to the advancement of chemical science. The book is
completed with a chronologic table and contains also a good
index.

Nursing Through the Years. By Corlnne Johnson Kern. Cloth. Price,
$2.50. Pp. 340. New York: E. P. Dutton & Cp„ Inc., 1939.

The author of this book has written two previous volumes,
entitled “I Go Nursing” and “I Was a Probationer.” She is
apparently much impressed with her life as a nurse, and she
fills her book of reminiscences with innumerable anecdotes from
the time she began nursing in 1900 to the present period, when
she lives in the mountains and even here finds opportunity for
her skill and her work. She writes with some facility ; her
book should be interesting to the great public, which is D'st
beginning to find out the trials and tribulations of all those
who work in the medical field.

Nobel Prize Winners. Charts, Indexes, Sketches. Compiled by Flota
Kaplan. Boards. Price, $1.53. Pp. 00, with 2 Illustrations. Chicago,
Illinois: The Author, 1939,

In 1938 there was printed in Sweden a book on “Tbc Nobel
Prizes and Their Founder Alfred Nobel,” by Fritz Hcnricks-
son (The Journal, Aug. 19, 1939, p. 711). Now there becomes
available a pamphlet entitled "Nobel Prize Winners,” compi k
by Flora Kaplan and dedicated to Jane Addams. This includes
also a brief sketch of Alfred Nobel, a copy of his will, a
complete table of Nobel prize winners from 1901 to 1938 with
reclassification by nationality and with brief biograp l,c
sketches of Nobel prize winners in each of the various cate-
gories. There are also special analyses of Nobel prize winners
by nationality, sex, race and religion. Both these panip > cls
are exceedingly useful sources of reference on this most mler-
esting topic.

Treatment In General Practice: The Management of Some Malor Meffi-
al Disorders. Volumes I and II. First American edition. C '

7.50 per set. Pp. 259, with 6 Illustrations; 430, with 8 must
lostcra : Little, Brown & Company, 1939.

The articles contained in these books were written as a
erics published by the British Medical Journal with a view i
ringing general practitioners up to date on mcdica rca
'he books were published in Great Britain during .
published in 1938. They are introduced to the Ammo
ledical profession by Dr. Reginald Fttz The _ articles arc

lccinct and practical but, obviously, not who ) P . ' ' *
idicated by the fact that sulfapyridmc is not even men
i the discussion of the treatment of pneumonia. He

Volume 113
Number 20

BUREAU OF LEGAL MEDICINE AND LEGISLATION

1837

also references to medicinal products which are chiefly British
and which are hardly known by their British names in this
country. For instance, in one place readers are told to pur-
chase their rubber mattresses from the Dunlop Rubber Com-
pany in England and other material useful in allergy from
another British company. Throughout, indeed, all of the refer-
ences are to British agencies. Thus the book is not nearly
as useful as it would have been if it had been revised for
American readers with new American work in mind. Never-
theless any general practitioner will find here innumerable
practical hints of value in the daily practice of medicine.

Beniamin Franklin Calls on the President. By John de Meyer. Cloth.
Price, $1.25. Pp. 90. New York: Ives Washburn. Inc., 1039.

In this little satire the author has conceived that Benjamin
Franklin rose from his grave on the 149th anniversary of his
death and went to visit the President. It is the kind of humor
that appeared in the book called “A Connecticut Yankee in
King Arthur's Court.” Benjamin Franklin comes in contact
with the modern motor car, the shower bath, modern credit
and debt, and the New Deal. It is interesting to find what
the author thinks Benjamin Franklin would have said about
spending oneself back into prosperity.

Hospital Dietetics as a Career. The Institute for Research. Research
No, 41. Paper. Price, $1. No pactnatlon, with 3 illustrations. Chicago,
Illinois : Institute for Research, 1939.

This twenty-four page illustrated booklet is designed to present
adequately the calling of hospital dietetics as a career. It is
readable and complete. It should be helpful to every person
interested in becoming a dietitian.

Bureau of Legal Medicine
and Legislation

MEDICOLEGAL ABSTRACTS

Medical Practice Acts: Revocation of License for
Allegedly Prescribing Narcotics to Satisfy Addiction.—
The Colorado state board of medical examiners revoked the
appellant’s license to practice medicine on the basis of a
charge that he was guilty of grossly negligent or ignorant
malpractice and of immoral, unprofessional or dishonorable
conduct. The district court of the city and county of Denver
affirmed the revocation order and the physician prosecuted a
writ of error in the Supreme Court of Colorado.

In brief, the physician was charged with writing various
prescriptions of morphine for several named persons purport-
edly for the treatment of specified diseases when in fact the
morphine was prescribed to satisfy narcotic addiction. The
evidence showed that the morphine was prescribed in the quan-
tities and to the persons named in the charge but, said the
Supreme Court, there was no evidence in the record that the
persons named were not suffering from the particular diseases
specified on the prescriptions. The medical practice act author-
izes the board to revoke a license to practice medicine if the
physician has been convicted of a felony or of a crime involv-
ing moral turpitude or is “guilty of grossly negligent or ignor-
ant malpractice” or of “immoral, unprofessional or dishonorable
conduct." A conviction in a United States court on a charge
of selling morphine to a habitual user thereof for other than
medicinal purposes, the court said, is a conviction of a crime
involving moral turpitude and warrants revocation of the physi-
cian’s license. IV hit e v. Board of Medical Examiners, 70 Colo.
50, 197 P. 564. The physician in the present case, however,
had not been so convicted. The board apparently proceeded
on the assumption that it was sufficient if it found from evi-
dence before it that there was a violation of the federal nar-
cotic laws by the physician and reasoned that if a conviction
of such violation in a court of competent jurisdiction carries
with it the inference of moral turpitude as a matter of law,
a finding by the board of such a violation has a similar effect.
Such an assumption, the court said, was erroneous. The

board in a proceeding of this kind, until a conviction is shown,
has no concern with the provisions of the Harrison Narcotic
Act nor with the regulations promulgated thereunder. The
board is not vested with jurisdiction to try alleged offenders
for a violation of the act and may not make its own finding
of such violation and predicate thereon either malpractice or
immoral, unprofessional or dishonorable conduct. Acts that
are inhibited by the Harrison Narcotic Act may be considered
by the board where there has been no conviction, but such
acts must be proved by competent evidence to constitute mal-
practice or immoral, unprofessional or dishonorable conduct,
without regard to the violation of any law that inhibits them.

Treatment that is proper by correct medical standards does
not constitute malpractice even though some law is violated.
Malpractice consists of a failure to exercise that degree of
care and skill in diagnosis or treatment which may reasonably
be expected from one licensed and holding himself out as a
physician, under the circumstances of the particular case. In
the present case there was no expert testimony tending to
prove a failure properly to diagnose or to treat the disease
of the various persons with respect to whom malpractice was
charged. It was not enough that the board may be composed
of experts who applied their knowledge of diagnosis and treat-
ment to the case. The medical practice act provides for a
review by the district court in revocation proceedings and on
such review the court may determine whether the board
regularly pursued its authority or abused its discretion. Such
determination can be made only on the evidence appearing in
the recofd. Obviously the reviewing court cannot be left to
speculate on what was in the minds of the individual board
members.

Neither the regulations promulgated by the Commissioner
of Narcotics, the Colorado narcotic act nor the Harrison Nar-
cotic Act purport to limit the purpose for which or quantity
of any drug that may be prescribed in good faith by a physi-
cian in treating a patient in the practice of his profession, and
there was no evidence that the morphine prescribed by the
physician in this case was not prescribed in good faith. The
amounts prescribed and the frequency of prescriptions might
be such that in and of itself it would indicate to one skilled
in their proper use that a physician could not possess ordinary
skill and in good faith so frequently prescribe such quantities.
Such matters, however, being only within the knowledge of
experts, must be shown by the testimony of experts appearing
in the record. There was no such testimony in the present
case.

It was charged that several of the prescriptions issued by
the physician were not given in good faith but for the satis-
faction of the patient’s addiction, contrary to the federal nar-
cotic laws. If that is true, the court said, there is a forum
in which the guilt or innocence of the offender may be deter-
mined. If convicted in such forum, the physician’s license may
be revoked. But, until such conviction, the propriety of pre-
scribing for such a purpose is to be determined not* by the
board asking and answering the question as to whether some
statute or regulation issued pursuant thereto has been violated
but by asking and answering the question as to whether, aside
from any law or regulation, the diagnosis and treatment was
such as a physician possessed of ordinary skill in the exercise
of ordinary care in applying his skill with the object of pro-
moting the patient’s physical well being might make and
prescribe.

The finding of the board was further to the effect that all
the acts charged against the physician constituted not only
malpractice but also immoral, unprofessional and dishonorable
conduct. It appeared, the court observed, that the physician
kept full records and had never failed or refused to make
them available to officers entrusted with enforcing the narcotic
laws. No member of the medical profession testified that the
acts were outside the limits within which skilled and honor-
able men exercising ordinary care might operate in the prac-
tice of their profession. No recognized canons of ethics were
shown by the evidence to have been violated, even if that
were a matter for the board’s consideration. In Sapcro v
State Board, 9 0 Colo. 56S, 11 P. (2d) 555, it was held that
a mere violation of canons of ethics not amounting to a breach

1838

SOCIETY PROCEEDINGS

of legal duty does not constitute a sufficient ground for the
revocation of a license. Since in the present case all the acts
relied on as constituting immoral, unprofessional or dishonor-
able conduct related to patients of the physician and to his
manner of treatment, in the absence of evidence showing what
a physician of reasonable and ordinary skill, applying it with
ordinary care in the diagnosis and treatment of the patient
involved, would have done, or should have done, the record
furnished no factual standard for the board's conclusion and
no standard for the court to determine whether the acts charged
amounted to a breach of the legal duty which the physician
owed to his patient and to society in the practice of his
profession.

The judgment upholding the revocation order was therefore
reversed and the tidal court was directed to refer the matter
back to the board of medical examiners for such further pro-
ceedings, if any, as it might deem advisable. — McKay v. State
Board of Medical Examiners (Colo.), 86 P. (2d) 232.

Accident Insurance: Death Due to Hypersusceptibility
to Novocaine Not Death by “Accidental Means.”— Pre-
paratory to the performance of a tonsillectomy on the insured,
novocaine (procaine hydrochloride) was administered hypodermi-
cally, infiltrating the tissue about her tonsils. Before “the usual
amount” had been injected, her pulse weakened, she became pale,
her body began to show a bluish cast, her breath became irreg-
ular and she died within a few minutes. Death was attributed
to the patient’s “hypersusceptibility” or "hypersensitivity” to
novocaine. The plaintiff, as the beneficiary under insurance
policies on the life of the deceased, sued two insurance com-
panies on the policies. Those policies provided certain benefits
in case of death due to bodily injuries caused solely by external,
violent and accidental means. From a judgment in favor of the
plaintiff, the insurance companies appealed to the Supreme Court
of Appeals of West Virginia.

The principal question involved was whether or not death
resulted from "accidental means.” The plaintiff contended that
if the use of novocaine resulted in something unforeseen and
unexpected, the death resulted through accidental means even
though the novocaine was injected intentionally and with the
consent of the insured. The court admitted that the means
• employed by the physician produced unusual and unexpected
results but refused to hold that the means by which they were
produced were accidental. The physician did exactly what he
intended to do and the patient invited it and therefore consented.
The court thought that it could not be said that under such
circumstances the means employed were accidental, even though
the result was not one which was contemplated or expected and
was due to an unknown and rare hypersusceptibility. The
"means” employed were intentional, not accidental. In the
opinion of the court the death did not come within the provisions
of the policies sued on.

The judgments in favor of the plaintiff were reversed and new
trials ordered. — Otcy v. John Hancock Mat. Life Ins. Co.; Same
v. Educators Beneficial Ass’n (W. Va.), 199 S. E. 596.

Cosmetology: Services as “Professional Services” —
Negligence as “Malpractice.” — The defendant insurance com-
pany agreed to indemnify Ilerzberg’s, Inc., a department store,
against claims arising out of accidental bodily injuries occur-
ring within the store. The policy, however, contained an
endorsement which excepted the insurer from liability for—

bodily injuries, illness, or death resulting therefrom, suffered . . .

in consequence of an error or alleged error or mistake in administering,
applying or dispensing drugs, chemicals, mixtures or the like; or in the
making or compounding of prescriptions; or in consequence of professional
services or treatments or the omission thereof , or malpractice on the part
of flitv physician, surgeon, nurse, druggist, assistant, attendant or any
person connected mth the Assured iu the operation of the business covered
by this policy.

A customer underwent a procedure in one of the departments
of the store designed to remove superfluous hair, which pro-
cedure was administered by a so-called cosmetician, using an
electrical apparatus called a "Tricho” machine. The customer
was injured and subsequently sued the store, recovering judg-
ment. The insurer refused apparently to pay either the judg-
ment or the cost of defending the suit, and the store sued it

Jouit. A. M. A.
Nov. I], 1939

on the policy, recovering judgment in the district court of the
United States for the district -of Nebraska. The insurance
company then appealed to the circuit court of appeals, eighth
circuit.

The trial court, said the circuit court of appeals, apparently
considered that the endorsement excepting the insurer from
liability was confined to instances in which injury was “suffered
in consequence of professional treatments administered by anv
physician, surgeon, nurse, druggist, or by any assistant, atten-
dant or helper to any such physician, surgeon, nurse or druggist.”
Such a construction of the endorsement is too narrow. The
endorsement provided, among other things, that the insurance
company should not be liable for bodily injuries suffered by any
person in consequence of professional services or treatments or
malpractice, on the part of any attendant, person or persons
connected xvitli the assured in the operation of the business
covered by the policy. The treatment of the customer’s face
for the removal of superfluous hair was a professional treatment
administered in a department of the store by persons connected
with the assured in the operation of its business. The depart-
ment was held out to the public as qualified to administer treat-
ments of the nature employed in beauty shops generally. The
operator of the shop and her assistant were educated in schools
devoted to instruction in the “art” of cosmetology.

It is significant in this connection that Nebraska has under-
taken to regulate the practice of cosmetology by enacting a
statute requiring certain educational and moral qualifications
of persons licensed to practice cosmetology and authorizing the
revocation of such licenses for the commission of malpractice and
unprofessional conduct. The term “profession” in the past has
been so generally associated with theology, medicine and law
that the construction adopted by the trial court may be readily
understood, but the term has long ceased to be restricted
exclusively to those so-called learned professions. The term is
defined in the New Century Dictionary, 1927, as follows:

Formerly theology, law and medicine were specially known as the pro-
fessions; but as the application of science and learning are extended to
other departments of affairs, other vocations also receive the name.

In the Oxford English Dictionary, 1926-1932, a “profession
is defined as

. . . the occupation which one professes to he skilled in and to

follow [which involves a] vocation in which a professed knowledge o
some department of learning or science is used in his application to me
affairs of others, or in the practice of an art founded upon it.

The fact, continued the court, that physicians, surgeons, nurses
and druggists are specifically mentioned in the endorsement does
not limit its application to such professions and vocations. T ,c
obvious error involved in the professional application of t ic
Tricho apparatus, whether due to negligence, or ignorance,
amounted to malpractice under the terms of this endorsemen-
Consequently, the insurance company is not liable under
policy.

The judgment below in favor of the department store ^
reversed. — Ocean Accident & Guarantee Corporation, Inc.,

H ersberg’s, Inc., 100 F. (2d) 171.

Society Proceedings

COMING MEETINGS

merican Academy of Pediatrics. Cincinnati, November

Clifford G. Grulee, 636 Church Street, Evanston. II'-. S “7%,, j[.

merican Society of Anesthetists, Los Angeles, Dec. 14. ‘ ■

Wood, 745 Fifth Ave., New York, Secretary. _ pr.

merican Society of Tropical Medicine, Memphis, Tenn., Not. -
E Harold Hinman, Wilson Dam, Ala., Secretary- .. p-.

adiological Society of North America Atlanta, Ga., occ. urr .

Donald S. Childs, 607 Medical Arts Bldg., Syracuse, N = deIp y,.
ociety for the Study of Asthma and Allied Condition, U
Dec 9. Dr. W. C. Spain, 116 East 53d St.. [,r.

Dciety of American Bacteriologists. New Haven, Cean.. » Madi-on.
I. L. Baldwin, Agricultural Hall, University of Wiscon.i
Wis., Secretary. Mr. C. >•

V E . A.,u

Al- «•

Stcrcury '

Volume 113
Number 20

CURRENT MEDICAL LITERATURE

1839

Current Medical Literature

AMERICAN

The Association library lends periodicals to members of the Association
and to individual subscribers in continental United States and Canada
for a period of three days. Three journals may be borrowed at a time.
Periodicals are available from 1929 to date. Requests for issues of
earlier date cannot be filled. Requests should he accompanied by
stamps to cover postage (6 cents if one and 18 cents if three periodicals
are requested). Periodicals published by the American Medical Asso-
ciation are not available for lending but may be supplied on purchase
order. Reprints as a rule arc the property of authors and can be
obtained for permanent possession only from them.

Titles marked with an asterisk (*) are abstracted below.

Alabama State Medical Assn. Journal, Montgomery

9: 69-104 (Sept.) 1939

Reducing Pneumonia Death Rate. G. S. Bryan, Amory, Miss.— p. 69.
•New Technic for Blood Sedimentation Test. C. Brooks, New Orleans.
— p. 72.

Sulfapyridinc: Its Use in Pneumococcic Infections. H. Kennedy and
J. S. Smith, Birmingham. — p. 73. 4

Acute Purulent Pericarditis: Report of Case. J. O. Finney and J. O.
Morgan, Gadsden. — p. 81.

New Technic for Blood Sedimentation Test.— Brooks
outlines a blood sedimentation test which he believes is not
difficult or complex in its performance and therefore its use
should not be restricted. The method consists of filling a pipet
with blood directly from the vein and setting the tube imme-
diately in the vertical position in a holder. The graduated limb
of the pipet is filled with anticoagulant, all of which is blown
out except the thin film adherent to the inside of the tube. The
graduated limb is then filled by inserting the needle into a vein
and permitting the blood to flow into the tube by its own pres-
sure. As soon as the tube is filled just beyond the 100 mm.
mark, the cock is closed, cutting off the lumen exactly at the
100 mm. mark; the column of blood held in the tube is thus
exactly 100 mm. long. The needle is quickly removed and the
tube is immediately put in the vertical position in a holder.
The sedimentation is observed for an hour or longer and the
results are recorded on a chart. The method is simple, auto-
matic, direct and precise. Its employment should encourage a
wider use of the blood sedimentation test.

American Journal of Public Health, New York

29 : 983-1082 (Sept.) 1939

Developments in the New York State Tuberculosis Program. R. E.
Plunkett, Albany, N. Y.— p. 983.

Occurrence, Pathologic Aspects and Treatment of Fluoride Waters.

M. S. Nichols, Madison, Wis. — p. 991.

•Morbidity and Mortality from Scarlet Fever in the Negro. P. B.
Comely, Washington. — p. 999.

Control of Syphilis in a Southern Rural Area: Preliminary Report.

L. E. Burney, Brunswick, Ga. — p. 1006.

Public Health Nursing Program of the Future. G. C. Ruhland, Wash-
ington, D. C. — p. 1015.

Morbidity and Mortality Statistics as Health Information. H. Wil-
liams, Baltimore. — p. 1019.

The School Nurse as a Health Educator. Gertrude E. Cromwell, Des
Moines, Iowa. — p. 1022.

Industry’s Challenge to the Nurse. LaYona Babb, St. Joseph, Mo. —
p. 1025.

Newer Concepts and Procedures of Maternal Care. Maude M. Gerdes,
Washington, D. C. — p. 1029.

Epidemiology of Syphilis in New York City. T. Rosenthal and J.
Weinstein, New York. — p. 1034.

Scarlet Fever in Negroes. — Comely discusses the supposed
differences in the mortality and morbidity rate from scarlet fever
in the white and Negro populations in the South, which has led
to the belief that this disease is not common in the Negro and
that therefore he is highly resistant to it. This resistance has
been attributed to his resistant ectoderm and to a longer racial
experience. These two explanations do not seem to hold true
when the author's data are considered, which show that although
there arc great differences in the South there is little inequality
in the northern cities in the mortality and morbidity rates from
scarlet fever in the two races. If the Negro was highly resis-
tant to this disease, even though his mortality and morbidity in
the North and South might not be similar, the disparity between
the two races would be just as great in the North as in the
South. This the author states lias not been shown in his data.
Secondly, the idea of racial susceptibility must be discarded when

the results of Dick test surveys of several investigators have
shown that there is no significant difference between reactions
of white and Negro children to this test. The recorded low
mortality and morbidity from scarlet fever in Negroes in the
South may be explained on (1) the occurrence of mild and sub-
clinical cases which are not recognized and not reported and
(2) most of all on the poor reporting of typical cases and deaths
in the rural areas of the South, in which almost 70 per cent of
the southern Negroes are to be found. That mild and atypical
cases of scarlet fever must occur widely in the South draws
support from the results of Dick test surveys made in certain
tropical countries, which have shown the higher prevalence of
negative Dick tests and the earlier appearance of this immunity
in children in the tropics. No differences were found between
Negroes and white persons. Mayer and Davison have similarly
shown that, although in North Carolina the number of cases
reported was less than half that in New York City, the rate of
susceptibility was much lower than that found in various other
comparable groups in the United States. Thus, it must be
assumed that there is a wide prevalence of mild and atypical
cases in the South.

American Review of Tuberculosis, New York

40 : 243-362 (Sept.) 1939

Extrapleural Pneumonolysis with Paraffin Filling: Late Results. R. 33.
Mclndoe, Howell, Mich.; J. D. Steele Jr., Milwaukee, and J. Alex-
ander, Ann Arbor, Mich. — p. 243.

•Collapse Therapy of Tuberculosis: Seen from the Point of View of
Control of Disease in Community. A. J. Hruby, Chicago. — p. 255.
Management of Pleural Effusions Complicating Artificial Pneumothorax.

T. De Cecio and B. P. Potter, Jersey City, N. J. — p. 272.
Transmediastinal Hernia: Mediastinal Movements During Respiration
in Bilateral Pneumothorax. M. Finkelstein, Denver. — p. 281.
Precursors of Forlanini and Murphy. L. R. Davidson, Staten Island,
N. Y.; M. Fuhrman and V. J. Rella, New York. — p. 292.

Tuberculin Survey of School Children: Method of Case Finding of
Adult Type Pulmonary Tuberculosis. E. S. James, Vancouver, B. C.
— p. 306.

Growth and Metabolism of Tubercle Bacilli: Role of Source and Propor-
tion of Nitrogen in Medium. R, R. Henley and P. W. LeDuc, Wash-
ington, D. C. — p. 313.

Intracutaneous Tuberculosis in Rabbits: Effect of Previous Injury on
Lesions of Primary and Secondary Type. W. H. Feldman and F. C.
Mann, Rochester, Minn. — p. 336.

Error in Counting Bacilli in Sputum. W. N, Berg, New York. — p. 351.

Collapse Therapy of Tuberculosis. — Hruby reviews the
history of the institution of collapse therapy for tuberculosis
and its value in the control of the disease in a community, in
particular Chicago. Over the six and a half years since the
procedure has been carried out in the Municipal Tuberculosis
Sanitarium he states that the results in 7,341 cases have been
twice as good in the cases so treated as in the controls. Undue
attention must not be paid to the mortality tables as an index
to the value of collapse. To be fully effective, collapse as a
measure of community control of tuberculosis should have wide-
spread and efficient application. Wherever possible the unified
plan should prevail, intramural collapse, extramural collapse,
reciprocity of function, interchange of patients as between the
sanatorium and the field. For the fullest measure of community
control this combination is necessary. The field clinic, expan-
sile, inexpensive, elastic in its applicability to the need, should
take up the treatment immediately after the patient is dismissed
from the sanatorium. The much discussed question of the initial
treatment outside the Municipal Tuberculosis Sanitarium does
not seem to make a great difference, 70.6 per cent of the patients
who received their initial treatment in the clinic are living as
against 78.1 per cent for the patients who received their first
injection in the Municipal Tuberculosis Sanitarium. The figures
embracing 3,090 treated cases explode the belief still current in
some quarters that the induction of collapse is purely an institu-
tional prerogative. Owing to its possibilities in the direction of
community control, collapse in the Negro deserves more energetic
consideration. At present the results for Negroes, while not as
good as those for white persons, are considered satisfactory. A
gap in the mortality of six to one is reduced to a gap of three
to two. The officers and medical personnel of the Municipal
Tuberculosis Sanitarium engaged in the study are convinced that
collapse, in its dual capacity as public health instrument and
medium ot cure, symbolizes a union of ends and aims, offering
the patient his best chance and the community its best protection.

1840

CURRENT MEDICAL LITERATURE

Jour. A. M. A.
Nov. 11 , 1919

Archives of Surgery, Chicago

39 : 513-690 (Oct.) 1939

Pr ™.f y C*«*>ona of Male Urethra. H. A. R. Kreutzmann and B.
'-oil oft, San Francisco. — p. 513.

Pancreaticogastrostomy: Experimental Transplantation of Pancreas

into Mornach. E. C. Person Jr. and F. Glenn, New York. — p. 530.

Traumatic Subcutaneous Rupture of Normal Spleen. L. T. Wright and
A. Prigot, Neiv York.— p. 551.

Correlation of Pathologic and Clinical Observations in Chronic Lymphoid
Appendicitis. C. B. Fausset, New York. — p. 577.

Capillary Permeability and Inflammation in Narcotized Rabbits. R. 0.
Cressman and R. H. Rigdon, Nashville, Tenn.— p. 586.

*Joint Cartilage Under Infraphysiologic, Ultraphysiologic and Euphysio-
logic Demands. E. Freund. Los Angeles.— p, 596.

Thyroid Gland: Clinical Pathologic Stndv, with Special Reference to
True Tumor: Analysis of 216 Cases. E. J. Delli Bovi, New York.
— p. 624.

Aseptic Necrosis of Femoral Head Following Traumatic Dislocation:
Report of Two Cases. S. Kleinberg, New York. — p. 637.

Tumors of Small Intestine. S. Cohn, J. A. Landy and M. Richter,
New York. — p. 647.

disregarded. Associated Jesions may mask the signs and symp-
toms associated with a ruptured spleen. The treatment of
rupture of the spleen is surgical, that is splenectomy. Pre-
operative enemas are forbidden. The mortality (thirteen of the
thirty patients died, a gross mortality of 43.3 per cent, and
seven died without operation, giving an operative mortality 0 !

per cent) for subcutaneous rupture of the normal spleen
is discussed. This mortality the authors believe can be low-
ered by (1) constant alertness on the part of the surgeon and
the staff to avoid errors in diagnosis, (2) more rapid diagnosis
so that the patient will receive the benefits of operation sooner,
(3) use of a slow blood drip preoperatively with or without
intravenous administration of fluids (when blood from a “bank”
is not readily available, infusions of a saline solution .should
be given) and (4) adequate fluids should be given to restore
water balance.

Partial Agenesis of Corpus Callosum: Diagnosis by Ventricuiographic
Examination, A. B. Cass and D. L. Reeves, Los Angeles. — r>. 667.

Removal of Procaine from Cerebrospinal Fluid During Anesthesia. H.
Koster, A. Shapiro, R. War-bow and M. Margolick, Brooklyn.— p. 6S2.

Warm Moist Air Therapy for Burns. S. Smith, R. Risk and C. Beck,
Chicago. — p. 686.

Traumatic Subcutaneous Rupture of Normal Spleen. —
Wright and Prigot report the thirty cases of subcutaneous
rupture of the normal spleen due to trauma observed at the
Harlem Hospital from Jan. 1 to Sept. 1, 1938. Operation or
necropsy proved that the spleen was the injured organ in these
cases and histologic section showed normal splenic tissue. Nine
of the patients were from 5 to 10 years of age. Of these,
eight were injured in automobile accidents and the ninth by
a fall against the curbstone. In the age group from 11 to
20 years there were five patients, of whom only two were
struck by automobiles, one was injured while riding in an
automobile, one was struck by a bicycle and one was injured
while coasting. Alcohol played a prominent part in the injuries
of seven patients from 21 to 30 years of age. Three were hurt
by falling while drunk, one was involved in an automobile
accident while inebriated, two were injured by automobiles and
one either fell or jumped from a fourth story window. Two
of six patients between 31 and 40 years of age were victims
of assault and battery, three were involved in automobile acci-
dents and one fell and injured himself while under the influence
of liquor. There were three patients from 43 to 61 years of
age and two of these were injured by automobiles and the
cause of injury to the third was undetermined. Seven of the
thirty patients were women. The diagnosis of subcutaneous
rupture of the normal spleen is not easy. There are no signs
or symptoms pathognomonic of this condition; therefore each
case must be considered on its own merit. The symptoms and
signs of rupture of the spleen are chiefly those of local injury
and hemorrhage, shock and peritoneal and diaphragmatic irri-
tation. Abdominal pain is the most common complaint. This
pain is usually sharp and lancinating and is localized in the
left upper quadrant. However, it may be described as gen-
eralized abdominal soreness and is sometimes more acute in
the other quadrants. All the patients either entered with this
symptom or had it while under observation. The symptom
next in order of frequency is dyspnea. Eight of the patients
complained of being “short winded” or had some form of
respiratory distress. Vomiting occurred in three and diarrhea
in two. In all cases there were abdominal tenderness and
spasm. The trauma which produces the splenic injury may
cause contusion of the abdominal wall. In 110 case were there
any external marks on either the abdomen or the back. The
erythrocyte count and the value for hemoglobin may be normal,
but in all except one case in the series the latter was low,
ranging from 40 to 80 per cent. The erythrocyte count ranged
from 2,400,000 to 4,400,000 per cubic millimeter. The leuko-
cyte count ranged from 6,000 to 23,850 per cubic millimeter
and not infrequently failed to rise with increasing tempera-
tures. The abdominal tap has proved to be of invaluable aid
in the diagnosis of subcutaneous injury of the abdominal vis-
cera. If the result is negative but the patient continues to
show signs of concealed hemorrhage, it should be repeated.
The differential diagnosis must exclude lesions above the dia-
phragm and retroperitoneal as well as intra-abdominal condi-
tions” The diagnosis is most frequently missed because a
history of trauma is not obtained or, if one is obtained, it is

Effect of Overactivity and Disuse on Joint Cartilage.

Freund discusses the behavior of cartilage under ultraphvsio-
logic conditions (increased pressure) and infraphysiologic condi-
tions (disuse). He finds that functional stimuli below or above
the physiologic optimum, if active over a long period, are dele-
terious to joint cartilage. The damage does not remain limited
to the joint cartilage in growing persons but draws the bony
epiphysis into participation by stopping further endochondral
ossification. The time factor is of greatest importance in the
development of pathologic changes in the joint cartilages. The
pressure force may stay within normal limits; nevertheless, it
will damage the joint cartilage if it is continuously active over
a long period. The same is true of disuse. Too little or too
much use of joint cartilage over a long period is detrimental.
This is confirmed by almost every day’s operative and necropsy
material and does not need proof by animal experimentation.
With genu valgum or genu varum, for instance, typically
hypertrophic arthritic changes develop in older age. Marginal
exostoses and degeneration and fibrillation of joint cartilage
will be present at the condyles with increased weight bearing,
while atrophy and retraction of joint cartilage are noticed in
the condyles with less weight bearing. Whether the pressure
force is intense and working over a relatively short period or
whether it is within physiologic limits but of protracted or
continuous action, the result will be the same: the joint car-
tilage will lose its normal elasticity and will suffer irreparable
damage. With the loss of elasticity, the ways are opened for
the different processes of cartilage degeneration, even for reac-
tive resorption from below by bone marrow — all changes pre-
ceding and accompanying hypertrophic arthritis. Any definite
alteration of function for a long period (infraphysiologic and
ultraphysiologic demands) is certain to lead to degenerative
changes of joint cartilage and may be followed by the whole
syndrome of fully developed arthritis deformans, the more
probably the longer the joint is exposed to unphysiologic use.

California and Western Medicine, San Francisco

51:145-216 (Sept.) 1939

Some Indications for Roentgen Ray Treatment. U. V. Fortmann,
Cleveland. — p. 151. ,-

Water Absorption from Colon and Its Relation to Motility, n-*

Bonoff, Los Angeles. — p. 154. -

Pharyngo-Esophageal Diverticula: Modified Technic for One* S
Operation. J. H. Shephard, San Jose. — p. 156. . , Tr

•Gonadotropic Hormone of Pregnant Mares’ Serum: Its Ctinica
in Gynecology. G. J. Half, Sacramento.— p. 159.

Sulfanilamide and Suffapyricfine in Treatment of I a nous In „ . *

T fr, Pnnummiri C S. Keefer, lJOStOn.

Urinary Tract Infections in the Newborn. W. M. Happ. Bctcrl)
Hills, Calif. — p. 166 .

Gonadotropic Substance in Gynecology. — Hall used
equine gonadotropic substance in 135 cases of various Bi' ncc
logic disorders. Of the patients with menstrual disturbanc
57.6 per cent were cured, 47 per cent of those with gemtal_ »)P
plasia were cured and twenty-four of the forty-three (». P
cent) who were treated for sterility became pregnant. A num
of the patients necessarily fall into more than one group,
example, a patient whose primary complaint was sterility -
also have had associated dysmenorrhea or hypomenorrhea,
one who complained of the subjective symptoms m cstnk*- ■
deficiency might also have had genital hypoplasia, dysmeno
or oligomenorrhea.

Volume 113
Number 20

CURRENT MEDICAL LITERATURE

1841

Endocrinology, Los Angeles

25: 337-490 (Sept.) 1939

Assay of Progesterone by Production of Artificial Pregnancy-Response
of Feline Uterus. H. B. Van Dyke, New Brunswick, N. J., and J. S.
Chen, Peking, China. — p. 337.

•Effect of Prolactin on Mammary Gland Secretion. H. L. Stewart Jr.
and J. P. Pratt, Detroit. — p. 3*17.

•Observations on Adrenalin Level in Blood Serum During Insulin Hypo-
glycemia and After Metrazol Convulsions. Gert Heilbrunn and E,
Liebert, Elgin, 111. — p. 354.

Estrogen-Progesterone Induction of Mating Responses in Spayed Female
Rat. J. L. Boling and R. J. Blandau, Providence, R. I. — p. 359.
Induction of Mating and Ovulation in Cat with Pregnancy Urine and
Serum Extracts. W. F. Wimlle, Chicago.- — p. 365.

Technic for Hypophysectoniy of Pigeons. J, P. Schooley, Cold Spring
Harbor, N. Y. — p. 372.

Infiuence of Prolonged Etherization, Trauma and Hemorrhage on Sur-
vival Period of Adrennlectomized Rats. R. S. Weiser and Helen
Knott, Seattle. — p. 379.

Studies on Respiration of the Newt: II. Effect of Temperature in
Hypophysectomized, Immature, Thyroidectomized and Pancreatectomized
Males. C. M. Pomernt, Cambridge and Worcester, Mass. — p. 385.
Studies on Inhibitory Hormone of Testes: II. Preparation and Weight
Changes in Sex Organs of Adult Male White Rat. B. Vidgoff, R.
Hill, H. VeUrs and Rosa Kubin, Portland, Ore. — p. 391.

Effect of Castration on Body Weight and Length of Male Albino Rat.
H. S. Rubinstein, A. R. Abarbanel and A. A. Kurland, Baltimore. —
P. 397.

Study of Muscular Efficiency in Rjits Injected with Anterior Pituitary
Growth Factor. E. B. Plattener and C. I. Reed, Chicago. — p. 401.

Effect of Prolactin on Mammary Secretion.— The nurs-
ing history and breast secretion of 330 consecutive nursing
mothers were recorded by Stewart and Pratt for the first ten
postpartum days. Of the 380 mothers, 333 nursed their babies ;
20 7 were full-breast nursing, seventy were part-time nursing and
fifty-six deficient nursing. Of the fifty-six deficient lactating
mothers only twenty-four expressed their desire to nurse the
baby for at least six weeks, to receive injections of prolactin
in an attempt to improve the milk supply and to pump the
breasts every four hours for a minimum of five days (from the
fifth to the ninth postpartum day). Ampules of identical appear-
ance containing 5 cc. of solution to he injected' daily were
differentiated by the labels 68A and 60A. The contents of these
ampules remained unknown until the study was concluded. After
the results were tabulated, it was learned that ampules 68A
contained 1,000 pigeon units (Riddle) of lactogenic hormone.
Ampules C0A contained no hormone. In addition to the defi-
ciency cases, ten part-time nursing mothers were studied. The
average daily milk secretion of 184 cc. on the fifth postpartum
day of fourteen deficient mothers receiving prolactin increased
to 212 cc. the following day. There was a decrease in seven
of the fourteen cases on the seventh day, the average output
falling to 20S cc. From the seventh to the ninth day there was
a progressive increase to 258 cc. The average total gaitj dur-
ing tlie entire period was 74 cc. In relation to the amount
secreted on the fifth day, this represents a gain of 40 per cent.
In three women the milk production was less on the ninth than
on the fifth day. None of tins group were discharged with
full-breast nursing. Ten mothers receiving the control solution
showed a gradual rise from an average breast secretion of
219 cc. on the fifth day to 311 cc. on the ninth day. The total
average gain during this period was 92 cc., or 42 per cent. In
two tlie amount of milk produced on the ninth was less than
on the fifth day. No mother in this group was discharged with
full-breast nursing. The average gain of primipara and multi-
para was 88 cc. (42 per cent) and 81 cc. (44 per cent) respec-
tively. In tlie ten women in whom the breasts were pumped
every four hours and the baby did not nurse, tlie average gain
was 71 cc., or 43 per cent. In fourteen the breasts were pumped
immediately after tlie baby nursed; in these the average gain
in milk secretion was 89 cc., or 39 per cent. The average
secretion on tlie fifth day of fourteen mothers less than 30 years
of age was 215 cc. It increased to 325 cc. on the ninth day.
In ten mothers more than 30 years of age the average output
on tlie fifth day was I7G cc. On tlie ninth day it was 227 cc.
All twenty-four deficiency cases were seen, at tlie end of six
weeks. Ten mothers in the prolactin and control groups had
dried up tlie breasts because of insufficient milk supply. Those
who had received prolactin showed no significant increase of
milk secretion over tlie control group. Part-time nursing
mothers whose milk production on the fifth day was more than
300 cc. produced a greater average increase of milk secretion
than the deficiency group. This series averaged 341 cc. on the
fifth day and showed -a progressive daily rise to 450 cc. on the

ninth day. The total average increase of 109 cc. was greater
than either the control or prolactin cases in tlie deficiency group.
Tiie percentage increase, however, was less (31 per cent).
Multiparas showed a greater increase than primiparas. Tlie
two mothers in this group discharged with fuli-breast nursing
were muitiparas.

Blood Epinephrine After Insulin Hypoglycemia and
Metrazol. — Heilbrunn and Liebert determined the activity of
epinephrine and epinephrine-like substances in tlie blood serum
in patients during various hypoglycemic states. The curves of
those patients evidencing shock showed an inadequate adrenal
response to insulin ninety minutes after tlie injection, while tlie
nonshock curves displayed a marked rise in the epinephrine
level of tlie blood at this time. Tlie epinephrine output of a
third group was dependent on the muscular movements; this
was confirmed by observations on the epinephrine level of tlie
blood serum after metrazol convulsions. Tlie epinephrine level
reflected directly the various stages of insulin hypoglycemia.
At the time of deep coma the epinephrine lev'el was low, while
it rose to a high level at the time of recovery.

Iowa State Medical Society Journal, Des Moines

20 : 427-478 (Sept.) 1939

Ocular Disorders Due to Exogenous Toxemia, W, L. Benedict,
Rochester, Minn. — p. 427.

Diagnosis and Management of Carcinoma of Breast. N. F. Hicken,
Salt Lake City. — p. 430.

Respiratory Allergy: Survey of 2S3 Consecutive Cases Seen in Office
Practice from July 1937 to December 1938. L. J. Halpin, Cedar
Rapids. — p. 439.

Perennial Type of Nasal Allergy. J. E. Reeder, Sioux City. — p. 446.
Status of Ophthalmologists and Otolaryngologists in a State Medical
System. S. B. Chase, Fort Dodge.— p. 44S.

Uses of Benzedrine Sulfate in General Practice. R. L. Gorrell, Clarion.
— p. 451.

Recurrence of Undulant Fever Following Sulfonamide Therapy. M. C.
Schroeder, Monroe. — p. 453.

Journal of Lab. and Clinical Medicine, St. Louis

24 : 1227-1338 ’(Sept.) 1939. Partial Index
•Influence of Vitamin D on Serum Phosphatase Activity in Arthritis.

P. \V. Smith, A. D. Klein and I. E. Steck, Chicago. — p. 1227.
Neural Depressing Effect of Trichlorethylene. H. S. Rubinstein, E.

Painter and O. G. Harne, Baltimore. — p. 1238.

Mechanism of Gold Therapy in Rheumatoid Arthritis. D. H. KHng,
Los Angeles; D. Sashin and J. Spanbocfc, New York. — p. 3241.
Antigenic Properties of Streptococci Killed by Ultraviolet Light. M.
Murray, Cincinnati.— p, 1245.

•Basal Metabolic Rate of Normal Individuals in New Orleans. A. G.
Eaton, New Orleans. — p. 1255.

Hemolysis Produced by Staphylococcus Colonies and Toxin on Agar
Mediums Containing Various Animal Bloods. R. H. Rigdon, Nash-
ville, Tcnn. — p. 1264.

•Estrogenic and Chorionic Gonadotropic Hormone in Normal Preg-
nancy and in Toxemia of Pregnancy. S. L. Sieglcr, Brooklyn, —
p. 1277.

Sulfapyridine in Blood of Guinea Tigs After Oral Administration.

A. R. Armstrong and D. R. Muirhead, Hamilton, Ont.— p. 1281.
Determination of Vitamin C in Urine. H. N. Holmes and Kathryn
Campbell, Oberhn, Ohio. — p. 3293.

Vitamin D and Serum Phosphatase in Arthritis.— Smith
and liis co-workers determined the serum phosphatase activity
after prolonged medication with vitamin D in cases of atrophic
and hypertrophic arthritis and concluded from their study that
serum phosphatase activity does not promise to be of value as a
diagnostic aid in arthritis as there is a wide distribution of
values above, below and within the normal range. The possi-
bility of its value as an aid in differentiating between tlie atrophic
and hypertrophic types is again negated by the wide distribution,
regardless of tlie somewhat higher average that was obtained
in a limited number of hypertrophic cases. Also there is a possi-
bility that tlie shift in the serum phosphatase activity, observed
to occur in patients who have ultimately benefited from vita-
min D, might prove to constitute a basis for prediction as to
the suitability of sucli therapy. Further investigation is needed.

Metabolism of Normal Individuals in New Orleans.—
As a practical result of comparing tlie four commonlv used
standards for determining tlie metabolic rates in ninety-eight
women and sixty-two men (apparently normal students and
stair of the Louisiana State University) Eaton arrived at a set
of corrections which may be applied to existing standards in
predicting tlie basal heat production of individuals in New
Orleans and, it is hoped, in other parts of the deep South. Fie
proposes to employ a correction factor of — 10 per cent to all

1842

CURRENT MEDICAL LITERATURE

Jour, A. Jr. A.
Nov. 1 ], 1939

values of the Aub and Du Bois standards or — 11 per cent for
men and — 7 per cent for women to the recent Mayo Founda-
tion standards. These corrections are shown to be valid statisti-
cally. The cause of the lowered basal metabolic rate in warm
climates has been discussed by many investigators. It is a fact
that metabolism is somewhat proportional to the average annual
temperature, although the relationship cannot as yet be expressed
as a linear function. Lessened desire for strenuous physical
exertion and greater ability and desire for relaxation must be
considered as probable factors in lowering the metabolic rate.
Whatever the cause may be, the lowered basal heat production
lessens the strain on the heat-eliminating mechanism and makes
life more comfortable in a subtropical climate, especially during
hot humid nights, when heat is so difficult to dissipate. The
mechanism by which this adaptation is brought about is as yet
obscure.

Hormones in Pregnancy.— Siegler presents the quantitative
determination of the total estrogenic and chorionic gonadotropic
hormones in five normal pregnancies and in one case of toxemia
of pregnancy, which toxemia was alleviated by the administra-
tion of large doses of -estradiol benzoate. An average gradual
increase in the total estrogenic hormone eliminated was observed
in the five normal cases of pregnancy, from 3,500 rat units per
liter of urine on the thirtieth day following the first missed
menstrual period, reaching a peak at term of 82,000 rat units,
after which there was an abrupt decline of the concentration of
the total estrogenic hormone to 2,200 rat units on the first post-
partum day to 200 rat units on the fourth postpartum day. The
lowest amount excreted on the thirtieth day was 1,800 and the
highest 4,800 rat units. The lowest concentration at term was

70.000 and the highest 100,000 rat units. Conversely, in the
determination of the chorionic gonadotropic hormone there was
a sudden increase from 7,500 mouse units per liter on the four-
teenth day after the first missed menstrual period to its peak of

140.000 mouse units on about the thirtieth day. Thereafter there
was an abrupt decline, with a level below 10,000 mouse units
after the sixtieth day to an average of about 4,500 mouse units
to the termination of pregnancy, becoming negative on the fourth
postpartum day. The lowest concentration in the first two weeks
following the first missed menstrual period was 4,500 and the
highest was IS, 000 mouse units. The lowest amount at the
peak was 96,000 and the highest was 210,000 mouse units. In
the several instances in which the serum bad been used in the
assaying of the total estrogenic and gonadotropic hormones, the
amounts estimated coincided with those found in the urine.
The hormone determination in the case of toxemia of pregnancy
showed a rise in the amount of gonadotropic hormone in the
fifth and sixth months. An increase in blood pressure, the
presence of albuminuria and edema in the following month with
a higher level of gonadotropic hormone concentration, and a
subnormal amount of total estrogenic hormone followed. These
higher levels persisted with the severe toxemic symptoms until
estradiol benzoate was given. Following this the level of
gonadotropic hormone fell to almost normal, the level of the
total estrogenic hormone rose in amount and the toxemic symp-
toms subsided.

Kansas Medical Society Journal, Topeka

40:361-404 (Sept.) 1939

Treatment of Gastric and Duodenal Ulcer. W. Walters, Rochester,
Minn. — p. 361.

The Approach Years. W. S. Horn, Fort Worth, Texas. — p. 368.
Treatment of Paroxysmal Tachycardia with Apomorphitie. G. E. Finkle,
McPherson. — p. 372. _

Treatment of Intractable Pain. D. F. Coburn, Kansas City.-~p. 373.
Sinus Trouble and Its Non operative Treatment. \\ . B. Granger,
Emporia.— p. 375.

Nebraska State Medical Journal, Lincoln

24: 321-360 (Sept.) 1939

Organic Background of Mind. F. Kennedy, New York.—p. 321.
Fractures of Hip: Pie a for Internal Fixation. A. F- O Donoghue, Sioux
City, Iowa. — p. 329. . . ,,,

Present Day Trends in Anesthesia. S. D. Miller, Lincoln, p. 334. __

Pain Relief in Normal Labor and Operative Obstetrics. R. M. Grier,

Evanston, 111. — p. 33S. ^

New and Effective Support for Joints. \\- L. ?" c ^' ,

Clinical Recognition and Treatment of Thyroid Deficiency States and
Other Disorders of Hypometabohsm. L F. Gardiner, Onaha,-p. 345.
Rheumatic Fever in Nebraska. E. Thompson. Omaha .-p. o4.

Diseases of Chest from Point of \ iew ot Broncho^copist. H. E. Kull>,
Omaha. — p. 350.

Philippine Islands Med. Association Journal, Manila

10: 395-466 (July) 1939

^ndioSManiK 39 f S E ' eVCn ^ H ’ andN -

T BaSdo.— p f 403 r Cit ' Zen ^ rmy ' V - Luna ’ Manila < an i J- Salcedo Jr.,
Development of Parenchymatous Diseases of Liver. H. Kaunitz, Manila.

Biologic Assay (Rat Growth Method) of Syrup Preparation of Vitamin
Bi. S. G. Jao, Manila. — p. 427.

Rocky Mountain Medical Journal, Denver

30 : 605-684 (Sept.) 1939

Prolonged Labor. C. B. Ingraham, Denver. — p. 622.

What Should We Do to Improve Medical Facilities and Care? L. E.
viko, Salt Lake City. — p. 626.

Office Treatment of Common Rectal Disorders. V. G. Jeurink. Denver.
— p. 629.

Stale Medicine, the Social Menace. L. E. Likes, Lamar, Colo.— p. M3.
Presentation of Bronze Tablet to the Medical School of the University of
Colorado by the Denver Clinical and Pathological Society, in Memory
of Dr. Henry Setvali. C. Powell, Denver. — p. 638.

Virginia Medical Monthly, Richmond

60:513-574 (Sept.) 1939

Hospital Care for Indigent and Low Income Group: Plan for Subsidiz-
ing Accessories of Medicine. W. B. Martin, Norfolk. — p. 513.

Plan for Relieving the Burden of Medical Costs. J. Hundley Jr.,
Lynchburg. — p. 516.

Significance of Abdominal pain in Children. T. D. Jones, Richmond.—
p. 518.

^Report on. Use of Sodium 5, 5-Diphenyl Hydantoinate in Fourteen
Selected Cases of Epilepsy at the Virginia State Colony for Epileptics
and Feebleminded. O. M. Weaver, D. L. Harrell Jr. and G. B.
Arnold, Colony. — p. 522.

Aphthous Stomatitis Treated with Sulfanilamide: Report of Two Cases.
J. L. Lane, Rocky Mount, N. C., and P. P. Vinson, Richmond. —
p. 52S.

Acute Encephalitis Without Apparent Cause, S. Newman and F. II.
McGovern, Danville.— p. 529.

Addison's Disease with Failure of Cortical Extract Therapy: Case
Report. H. G. Hadley, Washington, D. C. — p. 530.

Abdominal Pain Complicating Pregnancy. G. J. Levin, Norfolk. — p. 530.

Sodium Diphenyl Hydantoinate for Epilepsy.— Weaver
and his associates used sodium 5, 5-diphenyl hydantoinate in
the treatment oi fourteen epileptic patients, who received the
drug for periods of from two weeks to three months. Eight
of the patients have been definitely benefited, six of them espe-
cially so. The results in the other six have proved so adverse
that it was necessary to discontinue the treatment. _ Nine of
the patients had a diminution in the number of. their convul-
sions ; two had a reduction in the severity of their convulsions.
The general mental condition of six improved. _ There was a
definite improvement in the postconvulsive state in three of the
patients. A marked improvement in personality ensued .in two.
The numerous psychotic episodes disappeared in one patient
who had had them. Two patients made gains in weight. One
patient developed a rather unusual — certainly for her— state ot
well being. The two patients who were most improved were
receiving phenobarbetal in addition to the other drug. This
suggests synergistic action. As to the unfavorable resu ts,
six patients were extremely drowsy for from two to six weeks
after medication with the drug. Three suffered profound psy-
chic distress. Three had an increase in the number of their-
seizures. Three complained of persistent and severe headache.
A severe cutaneous reaction developed in five patients; m
of these this was complicated by edema of the face, Lues
reactions disappeared on temporary withdrawal of the drug
(though in two cases there was a later recurrence), une
patient, who had been having only a fe.v grand mal ctmvu
sions a month, began to have frequent and uumerous petit m
convulsions. One patient who had never before been mcot '
tinent became so after receiving the drug for several \vce-
One patient had an acute abdominal crisis that simulated ac
appendicitis. One patient had a severe gastritis and diarrnca-
Loss of appetite occurred in two. It is a powerful drug
appears to be more toxic and dangerous than l ,lie,,oba ™‘ '

In their opinion the patient receiving the drug should be
the physician’s constant observation. In the cases that '
benefited the improvement was not solely a diminution 1
frequency and a lessening in the severity of the setzu e -
-ould quite probably have been brought about by mass -
of phcnobarbital, bromides or chloral) but m sacral «-«
rather remarkable improvement in the patients venMWg
behavior and mental alertness occurred. The drug s ou jj *
-egarded as valuable for the treatment ot convulsive d.so

Volume 113
Number 20

CURRENT MEDICAL LITERATURE

1843

FOREIGN

An asterisk (*) before a title indicates that the article is abstracted
below. Single case reports and trials of new drugs are usually omitted.

Brain, London

as: 227-340 (Sept.) 1939

* Acute and Subacute Necrotic Myelitis. J. G. Greenfield and J. W. A.
Turner, — j>. 227.

Some Observations on Central Pain. D. Kendall.— p. 253.

Venous Drainage of Brain, with Special Reference to Galenic System,
B. Schlesinger, — p. 274.

Neurologic Sequelae of “Kern icterus/* G. M* Fitz Gerald, J. G. Green-
field and B. Kounine. — p. 292.

False Diverticulum of Lateral Ventricle Causing Hemiplegia in Chronic
Internal Hydrocephalus, D. \\ r . C. Northfield and Dorothy S. Russell.
— p. 331.

Abnormal Cortical Potentials Associated with High Intracranial Pres-
sure. D. Williams. — p. 321.

Acute and Subacute Necrotic Myelitis. — Greenfield and
Turner report three cases of necrotic myelitis and assert that
clinically the cases of necrotic myelitis fall into two distinct
groups ; the acute group, which they illustrate by one case, and
a subacute group, represented by the original two cases. Acute
necrotic myelitis shows itself by a rapid destruction of function
of the spinal cord in the lumbar and sacral segments, with, at
least in their case, a fairly rapid ascent of the signs to the lower
dorsal segments. Owing to the rapidity of disturbance of func-
tion of the cord a flaccid paraplegia develops, and in none of
the recorded cases has there been any sign of recovery from
this. In the subacute type the disease is of gradual onset and
slowly progressive course, usually without any remission, though
in one case there was some recovery of power in the legs for
from two to three months. The presenting symptom is usually
weakness of the legs, though this may be preceded by severe
pain in the distribution of the sacral segments or by dysesthesia
in the lumbar and sacral areas. The differential diagnosis of
acute necrotic myelitis presents considerable difficulty. While
syphilitic transverse myelitis may be excluded by a negative
Wassermann reaction, other types of acute myelitis, especially
those due to the demyelinating diseases, are likely to cause con-
fusion. The demonstration of a spinal subarachnoid block is
the most valuable distinguishing feature between cases of spinal
compression due to epidural abscess or Pott’s disease and those
of acute necrotic myelitis. In the differential diagnosis of sub-
acute necrotic myelitis both amyotrophic lateral sclerosis and
subacute combined degeneration may cause some difficulty in
the early stages of the disease, but the development of sphincter
disturbance and sensory changes will soon exclude the former,
and the absence of dysesthesia in the hands and the normal blood
count and gastric analysis the latter. Chronic meningovascular
syphilis affecting the lumbosacral cord has to be excluded. The
most difficult differentia! diagnosis is the differentiation from
extramedullary or intramedullary tumors in the lumbosacral
region of the cord. The two main differential points are the
frequent occurrence of root pains and pain in the back in extra-
medullary tumors, and gradual ascent of the sensory level, which
is usual in cases of subacute necrotic myelitis and rare in cases
of tumor. The presence of subarachnoid block at lumbar punc-
ture will settle the diagnosis, since tumors at this level are
invariably associated with some degree of spinal block. Patho-
logically necrotic myelitis consists essentially of primary oblitera-
tive sclerosis of the small intramedullary and meningeal vessels
in the lower segments of the spinal cord and is associated with
great thickening of the walls of the larger meningeal veins and
sometimes also of the larger arteries. The degeneration of the
parenchyma of the spinal cord appears to be altogether secon-
dary to the vascular lesion.

British Journal of Ophthalmology, London

33: 585-048 (Sept.) 1939

Parenchymatous Syphilitic Keratitis and Syphilitic Atrophy of Optic
Aerve Treated with Sulfosm, V. Larsen. — p. 585.
unusual Condition of Posterior Surface of Cornea (Posterior Herpes of
Cornea). L. Staz.— p. 622.

Studies on Bacteriology of Hypojnon Ulcer: III. Bacteriologic Invest!-
fratton of 120 Cases of II J popj on Ulcer. A. J. Rhodes. — p. 627.
Infantile Dacryocystitis Treated by Surgical Diathermy. A. M.
aiacGinivray. — p. 630.

Rotating Cross Cylinder. M. Tree.— p. 632.

British Medical Journal, London

2: 593-630 (Sept. 16) 1939

Hydatid Disease: Errors in Teaching and Practice. L. Barnett. — p. 593.
Nonopaque Ureteric Calculi. J. C. Ross, — p. 599.

Etiology' and Treatment of Spasmodic Flatfoot. A. H. Todd. — p. 602.
Treatment of Leg Fracture Casualties in Central China War Zone.
W. G. Brown. — p, 604.

Irish Journal of Medical Science, Dublin

No. 165:645-736 (Sept) 1939. Partial Index-
Congenital Heart Disease in General Practice. P. T. O’Farrell, — p. 645.
Hematology' in General Practice. D. Mitchell. — p. 664.

Some Obstetric Hemorrhages. R. M. Corbet — p. 669.

Prevention and Treatment of Fevers. C. J. McSweeney.—- p, 073.

Some Aspects of Medical Jurisprudence in Relation to Practice. D. A.
MacErlean. — p. 684.

Treatment of Fluid in Thoracic Cavity'. E. T. Freeman.- — p. 691.
Clinicopatkologic Demonstration: Pathology of Heart Failure. W.
Box well. — p. 698.

Deep X-Ray Therapy in Prostatic Enlargement. R. A. Stoncy'. — p. 704.

Journal of Hygiene, London

SB: 471-596 (Sept.) 1939. Partial Index
Some Observations on Reversed Anaphylaxis. M. van den Ernie.— *
p. 471.

•Subjective Impressions of Freshness in Relation to Environmental Con-
ditions. T. Bedford and C. G. Warner. — p. 49S.

Effects of Morphine, Diacetyl morphine and Some Related Alkaloids on
Alimentary Tract: Part III. Cecum and Colon. G. N. Myers. — -
p. 532.

Some Observations on Classification of Enterococci. N. C. Graham and
Eileen O. Bartley'. — p. 538.

*Weil-Felix Reaction in Trachoma. R. Kirk, A. R. McKelvie and A. D.
Drysdale.— p. 553.

Further Observations on Relation of Decline in Number of Horse-Drawn
Vehicles to Fall in Summer Diarrhea Death Rate. G. S. Graham-
Smith.-— p. 558.

Sulfanilamide Treatment of Scarlet Fever. Jane O. French. — p. 581.

Freshness in Relation to Environment. — According to
Bedford and Warner the requirements for a pleasant and
invigorating environment can be stated: 1. A room should be
as cool as is compatible with comfort, since freshness tends to
increase as the temperature is reduced. 2. There should be
adequate air movement. During the winter season the air
velocity in the ordinary factory averages about 30 feet per
minute and in the majority of cases lies between 20 and 40 feet
per minute. At velocities much below 20 feet per minute feel-
ings of stuffiness are likely to arise. In summer weather or in
hot factories velocities rather higher than those mentioned are
desirable. 3. The air movement should be variable rather than
uniform and monotonous. The body is stimulated by ceaseless
change in the environment. Outdoors one is braced by the
changing play of the wind, and likewise the variations of air
movement which may be encountered indoors exert an invigorat-
ing effect. When ventilation is obtained through open windows
the air movement is likely to be variable, but with some
mechanical ventilating systems the air movement is undesirably
monotonous. In mechanical installations the air inlets should
be so designed and the velocity of discharge so arranged that
suitable eddying currents are set up. 4. The relative humidity
of the air should be kept reasonably low. It should not exceed
70 per cent and should preferably be much below that value.
5. The average temperature of the walls and other solid sur-
roundings should not be appreciably lower than that of the air
and should rather be warmer. The combination of cold walls
and warm air often causes a feeling of stuffiness. 6. The air at
head level should not be distinctly warmer than that near the
floor, and the heads of the occupants should not be exposed to
excessive radiant heat. 7. The air should be free from objection-
able odors.

Weil-Felix Reaction in Trachoma. — Various workers in
different countries claim that in serums from patients with
trachoma a positive Weil-Felix reaction is found and regard
this as evidence that the causal agent of trachoma is a Rickettsia.
Kirk and his colleagues therefore examined 200 serums from
Sudanese patients with trachoma and state that the study failed
to reveal any significant differences with regard to the Weil-
Felix reaction between them and twenty-two serums from non-
trachomatous controls or 1,000 serums taken, without reference
to trachoma, from a large and representative section of the
population. Clinical and serologic evidence suggests that typhus
is absent from the Sudan. For this reason the interpretation
of results is less liable to confusion in the Sudan than in coun-
tries m which positive Weil-Felix reactions may occur in a
varying proportion of the population, owing to typhus infections.

1844

CURRENT MEDICAL LITERATURE

Jour. A. M. A.
Nov, ]], I9j9

Annales de Dermatologie et de Syphiligraphie, Paris

10 : 641-736 (Aug.) 1939

Diabetes Insipidus in Course of Sarcoid of Boeck. M. Jersild.— p. 741.

Tuberous Sclerosis of Bourneville and Symmetrical Fibromatous Nevi
of th . e . Face - J- Watrin, P. Meignant and K. Weille.— p. 644.

Dermatitis of “Laundresses’' : Role of Chromium and Chlorine (in
France) . H. Rabeau and Mile, Ukrainczyk.- — p, 656.

Specific Syphilitic Balanitis. J. Follmann.— p. 681.

Peculiar Form of Leukonychia: Leukonychia in Wide Longitudinal
Band. J. Ferreira Marques. — p. 68S.

Dermatitis of Laundresses. — In a review of the literature
on the “dermatitis of laundresses” Rabeau and Ukrainczyk
show that especial attention has been directed to the important
part played by alkaline substances in the pathogenesis of occu-
pational dermatitides. Alkaline substances produce an altera-
tion of the epidermis which in turn predisposes to sensitization.
Thus soaps have not only an irritating but also probably an
eczematogenic action. As a result oi their dissolving effect
on the fats of the skin, the alkaline substances prepare the
way for sensitization. Experiments demonstrated that there
are persons who are sensitive to alkaline substances and who
lack the capacity to neutralize them when they are applied to
their skin. This deficiency has been found in 8 per cent of
normal subjects and in 90 per cent of patients with eczema.
Some investigators believe that sodium hypochlorite can elicit
allergic conditions and the authors determined that there is
another important factor of sensitization, namely chromium
compounds. In studies on the frequency of sensitivity for
Javelle water, which is used widely in France for purposes of
cleaning and disinfecting in households and for bleaching in
various industries, the authors used cutaneous tests as well as
a palpebral test. They found the palpebral test especially
helpful in that it revealed sensitizations not detectable by the
usual methods. The patient closes his eyes and a specimen
of the substance to be tested is applied to one of the eyelids.
The reaction is read after twenty-four hours. The authors
describe studies on the eczematogenic power of the different
substances used in laundering on patients sensitized to Javelie
water and to bichromates. These studies demonstrated the
absolute parallelism of these sensibilizations and the eczema-
togenic action. In studies and observations on different types
of Javelle water it was observed that the sensitization appar-
ently depends on the presence of bichromates. The authors
gained the impression that the intolerance for chromium pre-
cedes that for chlorine. They were able to collect 200 patients
presenting this double intolerance to chlorine and chromium.
The following occupations were represented : housekeepers,
employees of hotels and restaurants, laundresses, cement work-
ers, mechanics, pharmacists and physicians; moreover, there
were patients in whom the sensitization could be traced to
cosmetics such as powders containing lead bichromate. It was
found that solution of chlorinated soda and black soap are not
tolerated by the patients with double sensitization. The authors
think that this is due to the fact that solution of chlorinated
soda is often wrongly prepared from Javelle water and a little
Javelle water is occasionally added to black soap. They rarely
observed chemical intolerance to substances other than bichro-
mates and hypochlorites. They stress the social importance
of the dermatitis produced by Javelle water, pointing out
that they occur in different occupations and that they may be
of long duration.

The authors describe two cases of association of amebiasis and
cancer which illustrate these two eventualities. In one case the
neoplasm was localized on the transverse colon, in the other
case in the rectosigmoid. The authors show that an exact
diagnosis is of great importance, since if cancer is present
extensive and early excision is necessary. A reliable diagnosis
will be derived front the results of rectal palpation, of roent-
genologic examination and of rectosigmoidoscopy, complemented
if possible by biopsy. Digital examination of the rectum permits
the detection of indurated, irregular and perhaps painful masses.
The hardness is generally greater in cancer than in amebiasis,
as is also the adherence to the base and the tendency to bleed-
ing. Nevertheless the tactile examination may be confusing,
especially if the tumor is located high up. It is advisable to
complement it by rectosigmoidoscopy. The latter procedure is
indispensable if digital examination of the rectum is negative.
If after rectoscopy there is still uncertainty, biopsy should be
done. Roentgenoscopy is valuable particularly in cancers situ-
ated high up, which escape digital examination and even recto-
sigmoidoscopy. Trial treatment with emetine and arsenical
substances may also furnish valuable information.

Presse Medicale, Paris

47 : 1309-1324 (Sept. 2) 1939

-Medical Treatment in Suppurative Nontubercutous Pleuritis. P. Levy-

Vatensi, S. de Seze and J. Pines. — p. 1309.

Gas Masks and Correction of Ametropias. Cot, Moynier, Genaud and

Robert. — p. 3313,

Suppurative Nontuberculous Pleuritis. — Levy-Valensi
and his associates treated five patients between 29 and 59 years
of age who had high fever in consequence of streptococcic
pleuritis, evidenced on puncture. Peroral dosage with carboxvi-
sulfamidocho'soidin varied from eight tabloids of 0.2 Gm. each
administered daily to twelve (2.4 Gm.). Treatments lasted
from seventeen days to six weeks with progressive determina-
tions of increasing sterility. In two cases pachypleuritis was
roentgenologically established at the time of discharge from
the hospital. In their discussion of sulfonamide derivatives
used in antibacterial chemotherapy the authors favor those
belonging to the azo coloration group over the white because
of their freedom from toxicity and accidents, especially m
streptococcic pleuritis. The authors recommend early treat-
ment with sufficiently high dosage from the beginning, accord-
ing to the drug employed. Daily treatment should be con-
tinued until successive punctures show complete asepsis of the
interpleural fluid and a negative culture response. They do
not favor simultaneous peroral, intramuscular and intrapleura
dosing with sulfonamide derivatives or serous and vaccinal
therapy but recommend cardiac tonics and cardiovascular ana-
leptics and systematically continued puncture tests. For pre-
cautionary purposes they advise that the patient be kept m ®
for from eight to ten days after suspension of treatment, 1
resumption of dosing at one third strength for another nee
Repeated clinical and x-ray examinations may indicate residua
pachypleuritis. To overcome this an open air convalesced e
and "breathing exercises methodically pursued are indicate .

Schweizerische medizinische Wochenschrift, Basel

60 : 78I-SQ4 (Sept. 2) 3939. Partial Index
Use of Sulfapyridine in Internal Medicine. F. ScicJouno an

Tunet. — p. "81. „ t? nu«ef.~

Treatment of Pneumonias with Pyridine Sulfanilamide.

Journal de Medecine de Lyon, Lyons

20 : 475-502 (Aug. 20) 1939

* Amebiasis and Cancer of Large Intestine. A. Cade and M. Milhaud.

Cancer of Stomach in Young Subjects. L. Bouchut, M. Levrat and J.

Philippe.— p. 481.

Angina Pectoris oi Digestive Origin. C. R. Bocca.— p. 4S7.

Amebiasis and Cancer of Large Intestine.— Cade and
Milhaud demonstrate that from the diagnostic point of view
the relations between cancer of the large intestine and amebiasis
present three different aspects: (1) cancer can simulate amebic
dysentery, (2) chronic amebiasis can assume a pscudocancerous
form and (3) cancer and amebiasis may coexist. As regards
the concurrence of amebiasis and cancer, the authors consider
two possibilities: cither cancer may appear sooner or later after
amebic infestation or, in a patient with neoplasm, examination
of the feces luav reveal the pathogenic amebas of dysentery.

-Effect' of Rectally Administered Insulin Suppositories in
Patients. F. Wuhrmann.— p. 7S7. , F ,

Use of Milk from Collecting Depots for Human Milk '° r
of Nurslings. P. Fddweg. — p. 789.

Insulin Suppositories for Diabetic Patients.--'
mann directs attention to experiments with the recta • '

tration of insulin suppositories which Frahn and -
reported in the Ncdcrhndsch Tijdschrift voor Ceueesu-^
83:3784 (July 29) 1939, abstracted in The Journal
14, page 1525. In view of the possible practical * ^

of this rectal administration of insulin, \\ uhrmann t
trv it in cases of diabetes. He studied the blood
' of fourteen diabetic patients and of four persons tut Jjn

bolic disorders, following the rectal administrate on of ^
suppositories. The rectal administration oi ,c - ,

positories was combined with a sugar tolerance tc. ,

Volume H3
Number 50

CURRENT MEDICAL LITERATURE

1845

blood sugar values were determined before and for a certain
period after. More than fifty blood sugar curves of diabetic
patients were studied and eleven of the persons who were free
from metabolic disorders. Since the rectal administration of
glandular preparations requires much larger doses than does
the subcutaneous injection, the author designated 10 injection
units as 1 suppository unit. Thus, a 20 unit insulin suppository
contains 200 injection units. Since larger doses are required,
the author thinks that less refined forms of insulin can be
employed for rectal application, in that for instance the pres-
ence of protein substances does not constitute a hindrance in
this form of administration. He reproduces only a few of the
blood sugar curves which he obtained in the course of his
studies. He reaches the conclusion that measurable and effec-
tive quantities of insulin can be introduced by means of rectal
suppositories. However, he thinks that the extensive use of
insulin suppositories in the practical therapy of diabetes niel-
litus will require further clinical investigation,

Archiv fur Gewerbepathologie, Berlin

9: 407-508 (July 12) 1939. Partial Index
Fatal Subacute Industrial Lead Poisoning. W. Ehrhardt. — p. 407.
Demonstration in Pulmonary Tissue of Dust Containing; Silicic Acid by

Means of Fluorescence Microscopy. Margaret® Oberdathoff. — p. 435.
•Occurrence of Occupational Manganese Intoxication in Steel Industry.

H. Voss. — p. 453.

Progressive Bulbar Paralysis and Amyotrophic Lateral Sclerosis After

Chronic Manganese Poisoning. H. Voss. — p. 464.

Ocher Dust Lung. H. Otto. — p. 487.

Examination of Lung with Chromium Silicosis. E. Lettcrer. — p. 496.

Occupational Manganese Intoxication in Steel Indus-
try. — Reviewing the cases of manganese poisoning that have
been reported in the literature, Voss demonstrates that, in com-
parison to the wide technical use of manganese and its com-
pounds, the number of occupational manganese intoxications is
small. As explanations for this the author suggests that appar-
ently only a small number of persons have the predisposition
for manganese poisoning, that not all manganese compounds
are capable of exerting a toxic action in the organism, and that
danger of occupational poisoning exists only where manganese
or manganese compounds are inhaled or swallowed in adequate
quantities and for a comparatively long period. Small quantities
of manganese, such as are used in the ceramic industry in the
preparation of lacquer and in the dye and glass industries,
apparently are not sufficient to elicit chronic manganese intoxi-
cation. Impairments of the central nervous system by man-
ganese have hitherto been observed in persons engaged in the
mining of manganese ores, in the sorting and handling of ores
containing manganese, in the processing of pyrolusite (manga-
nese dioxide) and in those who come in contact with manganese
vapors or who work with metallic manganese. In the steel
industry manganese intoxications may be produced not only by
manganese vapors but also by the dust of ferromanganese. The
author reports the clinical history of a man, aged 33, who for
ten months had worked part of the time and for seventeen
months all of the time in a deficiently ventilated room, tending
a number of ferromanganese grinders. For more than two
years the man felt well, but after that the typical symptoms of
manganism developed: masklike face, amyostatic symptoms, dis-
turbances in speech and walk, micrographia, compulsory weep-
ing and laughing, stuttering, and disturbances in the potentia
coeundi. Moreover, there were mild polyglobulism and mono-
cytosis. The increased manganese content of the feces, which
was still manifest more than eight months after the man had
ceased working with manganese, indicates that the patient’s
organism had stored manganese. That other men who worked
under the same conditions did not develop manganism does not
contradict the causal significance of manganese in the reported
case because an individual predisposition seems to play a part.
Since nervous lesions caused by manganese frequently remain
constant or gradually increase, it is somewhat surprising that
considerable improvement resulted in the reported case. How-
ever, other cases have been reported in which cessation of con-
tact with manganese, on appearance of the first symptoms, was
followed by great improvement or complete cure. The author
points out that this case cannot be cited as proof of the toxicity
of metallic manganese, because some oxidation takes place in
the course of grinding and it is possible that products of oxida-
tion exert the toxic action.

Klinische Wochenschrift, Berlin

IS: 1045-1076 (Aug. 5) 1939. Partial Index
Elimination of Coproporphyrin in Spontaneous Urine of Human Subjects
Under Influence of Irradiation. B. G. Hager. — p. 1045.

Carbon Monoxide and Hypertension. M. Staemmlcr and G. \V. Parade.
— p. 1049.

Synthesis of Hippuric Acid During Normal Pregnancy and During Puer-
perium. \V. Neusveiler,—- p. 1050.

Clinical Aspects of Addison’s Disease. F. Heni. — p. 1052.

Vitamin C Content of Blood and Question of Vitamin C Deficiency.
W. von Drigalski. — p. 1056.

•Disturbance in Coagulation of Blood in Jaundice Due to Obstruction and
Its Treatment by Vitamin K. F. Holier and F. Wuhrmnnn.— p. 1058.
Substitution for Condensing Action of Gallbladder in Case of Exclusion
of Gallbladder. M. Kunsztler. — p. 1067.

Vitamin K and Coagulation of Blood in Jaundice.—
IColler and Wuhrmann show that the hemorrhagic tendency in
obstructive jaundice, which is greatly feared by surgeons, has
found an explanation in recent years. The favorable therapeutic
effect of vitamin K in jaundice corroborates the assumption that
a K avitaminosis exists. This is not surprising when it is con-
sidered that vitamin K is fat soluble and that fat resorption is
impaired in obstructive jaundice. After reviewing the clinical
history of one case in which vitamin K exerted a specific effect,
the authors say that they were able to demonstrate the prompt
action of vitamin K on the coagulation time and on the hemor-
rhagic diathesis in nine cases of obstructive jaundice (five cases
of cholelithiasis and four cases of carcinoma of the pancreas or
choledochus). They also state that analogous observations were
reported by Danish and American authors. In hepatocellular
icterus, especially cirrhosis of the liver, vitamin K seems to
exert no effect, which suggests that the regenerating action of
vitamin K on prothrombin presupposes a more or less intact
function of the hepatic cells. However, the retardation in the
coagulation which is observed in nontropical sprue can be
promptly counteracted by vitamin K. In this connection the
authors direct attention to the fact that Fanconi ascertained in
1928 that in infantile sprue (intestinal infantilism) there occurs
a form of hemorrhagic diathesis in which C avitaminosis does
not appear but in which a hypothrombinemia exists. The K
avitaminosis in nontropical sprue is understandable when it is
considered that a disturbance in resorption is an essential factor
in this disease.

Vrachebnoe Delo, Kharkov

21 : 371-450 (No. 6) 1939. Partial Index
•Symptomatology and Therapy of Brucellosis. A. A. Tarpi. — p. 375.
Treatment of Ulcer Patients with Provitamin A — Carotene. M. S.

Levinson and V. hi. Kushko.— p. 381.

Autohemotherapy in Ulcer Disease. O. E. Amcbislavskaya. — p. 385.
Effectiveness of Linzer’s Method of Treating Syphilis. D. A. Bykhov-
skaya. — p. 389.

Intramuscular Ichtbammol Injections in Inflammation of Female Geni-
talia. K. P. Levitskaya. — p. 393,

Hypnosis Therapy of Pruritus Cutaneus. N. G. Bezyuk. — p. 397.

Brucellosis. — Tarpi’s observations on sixty patients treated
at the Tropical Institute of Stalinbad (Tadjisk Republic)
between 1932 and 1936 revealed that forty-six presented a
gradual onset, fourteen an acute onset, and that the undulant
type of fever was observed in only eighteen cases. Among the
characteristic symptoms were noted persistent fever, painful
sensation in the bones and joints of arthraigic rather than of
arthritic type, and the appearance of painful subcuticular nodes
located, as a rule, on the upper third of the arm and on the
digital phalanges. These persisted for from fifteen to thirty
days. Pustular, papular and roseolar rashes were observed dur-
ing the various stages of the disease. In 85 per cent of the
cases there were profuse sweats. The spleen was enlarged in
41 per cent, the liver in 53 per cent and there was an orchitis
in 18 per cent. A mild degree of hypochromic anemia with
leukopenia (from 4,000 to 5,000) and lymphocytosis was the
rule. In the cases in which a positive blood culture was obtained,
Brucelia melitensis was the organism found. The author was
not able to differentiate, on the basis of clinical signs, maltose
fever from Bang’s disease. Diagnosis is best made by the blood
culture method.. It takes from twelve to twenty-one days to
grow the organism. The allergic brucellin test was positive in
all of lu's cases as well as in a number of the laboratory workers
who had contact with laboratory animals. The coexistence of
malaria had an aggravating effect on the course of brucellosis.
The average duration of the disease was six months. There
were no fatalities in this series. Mcthenamine, calcium, acri-

1846

CURRENT MEDICAL LITERATURE

Jour. A. M. A.
Nov. 11 , 1939

flavine hydrochloride, collargol, arsphenamine and ethoxy-
diamino-acridine lactate did not prove to be of much therapeutic
value. Autohemotherapy was without effect, whereas citrated
blood transfusions were effective in the beginning of the disease.
Vaccine prepared from avirulent strains of Brucella suis and
given intravenously in increasing doses proved to be the most
effective therapy in the series.

Nederlandsch Tijdschrift v.' Geneeskunde, Amsterdam

83: 3981-4088 (Aug. 12) 1939. Partial Index

Treatment of Pemphigus in Aged Persons by Means of Germanin, E.
Zurhelle. — p. 3982.

Case of Diffuse Sclerosis and Its Heredity. G. P. Frets. — p. 3987.

Treatment of Schizophrenia with Insulin and Metrazol. G. W. Kastein.
p. 3994.

•Considerations on Removal of Corpus Luteuin Verum During Early Preg-
nancy and Progesterone Content of This Organ and of Mature
Placenta. J. J. Duyvene de Wit and V. M. Oppers. — p. 4001.

Further Investigations on Formation and Therapy of Renal and Vesical
Calculi. A. Polak. — p. 4009.

Vitamin C in Therapy. M. van Eekelen. — p. 4015.

Removal of Corpus Luteum During Early Pregnancy.
— Duyvene de Wit and Oppers report a case in which the
corpus luteum of pregnancy was removed on the eighty-third
day after the last menstruation. From this time until the sixth
month of pregnancy progesterone was administered. Unimpaired
by occasional uterine contractions, the pregnancy took a normal
course. The authors further cite reports from the literature,
comprising 131 cases, in which the corpus luteum was removed
during the first four months of pregnancy. A review of these
cases discloses that in the absence of substitutional therapy
abortion results in 23.7 per cent of the cases. With regard to
the treatment, the authors take the following position : In
ovariectomies during pregnancy, progesterone should be given
prophylactically and for some weeks after the operation. If
there are no threatening symptoms and a careful supervision is
possible, an expectant attitude can be taken, because in three
out of four cases the pregnancy will remain intact and take a
normal course without substitutional therapy. A dear under-
standing of the progesterone exchange can be obtained only if
it is determined how much progesterone exists at a certain time
in the organs preparing it, in the blood, in the organs con-
suming it and in the products of excretion. In the case reported
by the authors, Duyvene de AVit’s bitterling test was employed
for the determination of the progesterone content. The corpus
luteum of pregnancy which was removed from the woman
weighed 1.3 Gm. and it was found to contain 33 micrograms of
progesterone per gram of tissue. This is about twice as much
as is found in a mature menstrual corpus- luteum. The placenta,
which weighed 480 Gm., contained 640 micrograms of proges-
terone.

Acta Radiologica, Stockholm

20 : 325-414 (Aug. 21) 1939

Method for Determination of Heart Size by Teleroentgenography (Heart
Volume Index). S. Jonsell. — p. 325.

Roentgenologic Observations in Renal Tuberculosis. A. Renander. —
p. 341.

•Roentgen Therapy in Nonspecific Chronic Arthritis. S. N. Bakke. —

p. OJ/.

Pneumatosis Cystoides Ventriculi et Jejuni. R. Baumann-Sclienker. —
p. 365.

Radiologic Treatment of Cancer of the Rectum. Elis Berven.— p. 373.
Easily Made “Safety Device” for Roentgenologic Apparatus. S. R-

Kjellberg. — p. 391. , .

Gastroscopic and Roentgenologic Observations in Membranous Gastritis.

K. Lundbrek. — p. 394. w • •

Roentgen Diagnosis of Pneumatosis Cystoides Intestinorum xiomims.

Diaphragm Construction as Contribution to Screening-Off Technic in
Teleroentgen Therapy. O. Sandstrom.— p. 406.

Roentgen Therapy in Nonspecific Chronic Arthritis.

Bakke rapidly reviews various theories proposed to account

for the beneficial effect of roentgen rays on nonspecific chronic
arthritis and reports the results that he obtained in a serial
roentgenographic examination of 55S persons. He regards pri-
mary calcareous deposits in the soft tissues surrounding the
joints (chiefly shoulder, knee, loins and hip) as catch basins
for infective matter released into the blood stream by lesions
elsewhere, thus conditioning inflammation and pain, and attrib-
utes the beneficial effect of roentgen rays to their action on the
inflammation set up in the capsular ligaments of the joints.
The author tvas able to verify his theory of the significance of
primary lime deposits by roentgenologically testing the soft

tissues of the shoulders of 200 persons ranging in age from
20 to 69 years who had never previously complained of pain in
that part of their body and by discovering that twenty-six of
these (13 per cent) showed larger or smaller calcium accumu-
lations (three bilaterally). Of these twenty-six, the age group
from 20 to 29 was represented by five cases. The 555 patients
with nonspecific chronic arthritis roentgenographically examined
included 230 male and 325 female subjects, the age level ranging
from 20 to 89, with the greatest incidence in the ages between
30 and 70. Tests made were followed up with oral or written
inquiries. Subsequently 523 were reexamined and divided into
four groups with the following results: no change 11.9 per
cent, improved 15.3 per cent, greatly improved 34.6 per cent
and cured 38.4 per cent, irradiation thus benefiting 88.3 per cent
in some way. The total number of actual cures, represented
by 38.4 per cent, amounted to 213 cases (age level 40 to 49,
sixty-two cures; age level 50 to 59, sixty-eight). Grouped
according to the chief seat of the arthritic or periartliritic ail-
ment, there were 170 shoulder cases with 103 cures, 148 knee
cases with fifty-seven cures, 103 loin cases with twenty-seven
cures and eighty-three hip cases with fifteen cures. The dose,
adjusted to the nonresident character of the majority of the
patients, was administered daily or at most every other day,
the regular dose amounting to 100 roentgens per field. Every
joint received serially four or six such doses, the series varying
from one to four or five and in stubborn cases to eight, at
intervals of from four to eight weeks While the knee received
100 roentgens in the course of from four to seven days, the
shoulders, loins and hips received 150 six times, the hand 100
four times and so on. The author’s unit skin dose was about
750 roentgens. The analysis of failures indicated that unim-
proved patients received on an average 1.38 treatments com-
pared with 2.14 for the others and seems to suggest the caution
not to discontinue treatments prematurely.

Ugeskrift for Laeger, Copenhagen

101: 889-914 (Aug. 3) 1939

Oxygen Therapy in Theory and Practice. C. Sonne. — p. 889.
•Avitaminosis K in Infants as Cause of Hemorrhagic .Diathesis. II*
Dam, E. Tage-Hansen and P. Plum. — p. 896.

Shock after Painting of Throat. O. Dige-Petersen. — p. 904.

Avitaminosis K in Infants and Hemorrhagic Diathesis.
— Dam and his associates say that in normal children an avi-
taminosis K, usually moderate, develops in the first days after
birth and usually disappears after a week. This avitaminosis k
causes a hypoprothrombinemia which must be regarded as the
cause of the common slight hemorrhagic diathesis in the new-
born. Whether or not jaundice is present seems to be without
significance. The avitaminosis is assumed to be due to a defi-
cient supply of vitamin K through the intestine. In some cases
of icterus gravis of the newborn, anemia of the newborn an
congenital dropsy, considerable hypoprothrombinemia was estab-
lished. Since the administration of vitamin K in two of u ,e,r
cases was followed by a rapid rise in prothrombin, the authors
conclude that there was an avitaminosis IC in these cases,
complete lack of prothrombin established as early as twent)-
four hours after birth is ascribed to reasons other than deficicn
resorption from the intestine.

101 : 915-946 (Aug. 10) 1939 f

Content of Carotenoids and Vitamin A in Mother's Milk with .|7 C '
Regard to Its Dependence on Diet. T. K. With and C. Fnd

Water and Salt Metabolism from Practical Surgical Viewpoint. '•
Aalkjier. — p. 925. .. - Therapy*

Defective Nutrition in Denmark and Its Significance i
Johanne Christiansen. — p. 929.

Roentgen Examination of Appendix. V. Jensen, p. >3 — 7 r rtr< 4 m 3 n o.
Investigations on Effect of Insulin on Gastric Secretion. .

Encephalitis after Vaccination. A. Eldahl. — P- 938. Serum-

Death from Serum Sickness after Treatment with Pneumococcus
P. Borch Madsen. — p. 940.

Effect of Insulin on Gastric Secretion.— Horshna""
wind on examination of ten schizophrenic patients that in > ■
ima a considerable rise in the acidity of the gas r ' ( -
ecurs after an initial fall. The rise begins after the bio"*
as reached its low phase. The acidity decreases after
Iministration of cane sugar solution or dextrose so
so immediately after dextrose intravenously in doses
rminate the effect of insulin.

The Journal of the
American Medical Association

Published Under the Auspices of the Board of Trustees

Vol. 113, No. 21

Copyright, 1939, by American Medical Association

Chicago, Illinois

November 18, 1939

SULFAPYRIDINE IN THE TREAT-
MENT OF PNEUMONIA

NORMAN PLUMMER, M.D.

AND

HERBERT K. ENSWORTH, M.D,

NEW YORK

The only agent of proved value in the specific
treatment of pneumonia heretofore has been antipneu-
mococcus serum. While effective in many types of
pneumococcic pneumonia, it has been costly, frequently
unavailable, often tedious and occasionally impossible to
give. The advent of sulfapyridine has given us another
effective specific agent, and this time one that is com-
paratively inexpensive, more readily available and more
easily administered.

During the year that has passed since Whitby 1
described experiments in which sulfapyridine afforded
complete protection in mice against as high as 10,000
lethal doses of pneumococci, a large number of articles
have appeared in the medical literature concerning the
use of this new therapeutic agent.

On the experimental side, Fleming 3 has found that
the drug retards the growth of pneumococci in human
blood in concentrations as low as 3 mg. per hundred
cubic centimeters. He 3 subsequently demonstrated that
the blood of patients taking sulfapyridine has a much
increased antibacterial power against the pneumococcus.
MacLean, Rogers and Fleming 4 have shown that
pneumococci vary in their sensitivity to the drug but
that this variation is associated not with the type of
pneumococcus but with the individual strain. Greey,
MacLaren and Lucas 5 have shown that sulfapyridine
is superior to sulfanilamide, to a glucoside derivative
of 4:4' diamino diphenyl sulfone (prornin) and to
hydroxyethyl-apocupreine dihydrochloride in pneumo-
coccic infections in mice. Hilles and Schmidt 0 have

The sulfapyridine and serum were supplied by the Lederle Labora-
tories, Inc.

This investigation has been conducted under a grant of the Josiah
Macy Jr. Foundation.

. Read before the Section on Pharmacology and Therapeutics at the
Ninetieth Annual Session of the American Medical Association, St. Louis,
May 17, 1939

From the New York Hospital, the Second (Cornell) Medical Division
and the Department of Pathology of Bellevue Hospital and the Depart-
ment of Medicine ^ " ** *' '*''*' * College.

1- Whitby, L. neumococcal and Other

Infections, with Pyridine, Lancet 1:

1210 (May 28) 1938.

. _ ? T'-rr 1, : \ ■ ’■ . _ The Antibacterial Action in Vitro of 2-(/»*

\ ' ' Pyridine on Pneumococci and Streptococci,

u ■' '■ •: The Antibacterial Power of the Blood of

Receiving 2-(p-Aminobenzenesulfonamido) Pyridine, Lancet 2:
564 (Sept. 3) 1938.

Ti Rogers, K. B., and Fleming, Alexander: M. &

u. 693 and Pneumococci, Lancet 1: 562 (March 11) 1939.
fu 5 ' ^ recy » -P* MacLaren, D. B., and Lucas, C. C. : Comparative
Chcmoth erapy in Experimental Pneumococcal Infections, Canad. M. A. J.
(April) 1939.

» * H”les, Carolyn, and Schmidt, L. H.: Sulfanilamidopyridinc [2-(p*
Ammobenzenesulfonnmido) pyridine] in Experimental Infections with
I9i9 XXU Pneumococcus > Proc - Soc. Exper. Biol. & Med. 40 : 73 (Jan.)

reported that the drug is effective in experimental type
XXII infections.

On the clinical side, reports have come from a
variety of localities. In England, Evans and Gaisford 7
used sulfapyridine in 100 cases of pneumonia with a
mortality rate of 8 per cent. In a control series the
mortality was 27 per cent. In India, Anderson and
Dowdeswell 8 in an alternated series of 100 cases
observed a mortality rate of 16 per cent in the controls
and 2 per cent in the treated. In South Africa, Agranat,
Dreosti and Ordman® in a cooperative study embracing
550 cases of pneumonia, obtained either a marked
reduction in mortality (in a general mine hospital) or a
shorter period of pyrexia (in native mine hospitals).
In Canada, Graham, Warner, Dauphinee and Dickson 10
and Meakins and Hanson 11 have reported favorably on
the drug.

In this country, Flippin, Lockwood, Pepper and
Schwartz 12 in Philadelphia used sulfapyridine in a
series of 100 cases of typed pneumococcic lobar pneu-
monia with a mortality rate of 4 per cent (excluding
three cases under treatment twelve hours or less). A
preliminary report has been published by us. 13 Finland,
Spring, Lowell and Brown 14 have used sulfapyridine
alone or in combination with serum in the treatment of
175 cases of pneumonia due to specific types of pneumo-
cocci, with good results. Encouraging reports concern-
ing the use of the drug in childhood pneumonia have
come from Barnett, Hartmann, Perley and Ruhoff 15
in St. Louis, from Wilson and his associates 10 in Cin-
cinnati and from MacColl 17 in Durham, N. C.

A summary of the replies to a questionnaire 18 sent
out by The Journal to approximately 100 physicians

/. Javans, u, xu.., ana uaisiora, >V. F.: .treatment of Pneumonia witu
2-(/>-Aminobenzep.esulfonamido) Pyridine. Lancet 2: 14 (July 2) 1938.

8- Anderson, T. F., and Dowdeswell, R. M.: Treatment o£ Pneu-
monia with M. & B. 693, Lancet 1 : 252 (Feb. 4) 1939,

9. Agranat, A. L.; Dreosti, A. O., and Ordman, D.: Treatment of
1 neumoma with Z-Cp-Aminobenzenesulfonamido) Pyridine (M. & B. 693),
Lancet 1: 309 (Feb. II) 1939. '*

„ U Graham Duncan; Warner, W. P.; Dauphinee, J. A., and Dickson,
?■ 1 reatment of Pneumococcal Pneumonia with Dagenan (M.

& B. 693), Canad. M. A. J. 40:325 (April) 1939.

Meakins, J. C., and Hanson, F. R. : The Treatment of Pneumo-
coccic Pneumonia with Sulfapyridine, Canad. M. A. J. 40:333 (April)

Flippin, H. F-, and Pepper, D. S. : The Use of 2-(/>-Aminobenzene-
sulfonamido) Pyridine in the Treatment of Pneumonia, Am. J. M. Sc.
106: 509 (Oct.) 1938. Flippin, H. F.; Lockwood, J. S.; Pepper, D. S.,
and Schwartz, Leon: The Treatment of Pneumococcic Pneumonia with
Sulfapyridine: Progress Report on Observations in 100 Cases, T. A.
M. A. 112: 529 (Feb. 11) 1939.

13. Plummer Norman, and Enswortfa, Herbert: Preliminary Report
of the Use of Sulfapyridine in the Treatment of Pneumonia, Bull. New
\ork Acad. Med., 2d series 15 ; 241 (April) 1939.

14 L Finland, Maxwell; Spring, W. C„ Jr ; Lowell, F. C„ and Brown,
1. W.: .Specific Serotherapy and Chemotherapy of the Pneumococcus
Pneumonias, Ann. Int. Med. 12: 1SS6 (May) 1939

M 1 R A - A. M and RuhoiT,

M. B.. The Treatment of Pneumococcic Infections m Infants and Chib
Sulfapyridine, J. A. M. A. 112:518 (Feb. 11 ) 1939
16. Wilson, A. T.j Spreen, A. H.t Cooper. M L * *5tevet«rm *tt p .
Cullen, G. E., and Mitchell, A. G.: Sulfapyridine in the Trrat’nmn* of
Pneumonia m Infancy and Childhood, J. A. M. A. 112: 1435 (April 15)

14:277 a (M°areh) r 'l939. Cli " icaI Expcr!cnce w!th Sulfapyridine, J. Pcdiat.

Cheniislo- Tt! 1 Mi A^2: llThlly t) “ d

1848

PNEUMONIA— PLUMMER AND ENSWORTH

Jour. A. M. A.

Nov. 18, 1939

working with sulfapyridine embodies experience with
the drug in about 1,800 cases of pneumonia in adults
and 650 in children. It is here stated : “While there is
much to be learned about the exact place of sulfa-
pyridine in the treatment of pneumonia, it appears to be
a very useful measure in many cases when properly
employed. ’ Caution in its use is advised until more
evidence of its usefulness and safety is available, and
the necessity for continuation of typing is emphasized.
Sulfapyridine has been accepted for inclusion in New
and Nonofficial Remedies. 10

Pharmacologic and toxic aspects have been covered
by Wien 20 Long, 21 Marshall, Bratton and Litchfield, 22
Johnston, 23 Stokinger, 21 Long, Bliss and Feinstone, 25
Cooper Gross and Lewis, 20 Schmidt and Hughes, 27
Hoyt and Levine, 28 Bryce and Climenko 20 and Suther-
land. 30

That pneumococci can rapidly acquire tolerance or
fastness to sulfapyridine has been demonstrated in
laboratory animals 31 and in man. 32

MATERIAL AND PROCEDURE

The present report deals with our experience and
that of our associates with sulfapyridine at the New
York Hospital and at Bellevue Hospital. 33 We have
administered sulfapyridine to 2 70 patients suffering
from pneumococcic pneumonia, either typical (lobar)
or atypical.

As soon as the clinical diagnosis of pneumonia is
made, sputum and blood are obtained for bacteriologic
study and a blood count is taken ; sulfapyridine therapy
is then started immediately. In nearly every case one
or more x-ray films of the chest are taken. Frequent
urinalyses are done and blood counts are repeated.

Our routine order for sulfapyridine is for 2 Gm. as
an initial dose, followed by 1 Gm. every four hours until
16 Gm. has been given. At this point it is decided
whether the drug should be stopped or continued. Most
of the patients need no more. Complicated cases, cases in
which the response is inadequate and, in particular, the
bacteremic cases are continued on the drug, usually at
the 6 Gm. a day rate. A few patients have been given
0.5 Gm. every two hours. Occasionally, after the first
course, the dose is increased to 1.5 or 2 Gm. or reduced
to 0.5 Gm. every four hours. In some cases consider-

If ^ *' ’ — XT — 'ind Nonofficial Remedies, Report of Council

on ; , J. A. M. A. 113: 1831 (May 6) 1939 ..

2( of 2-(/>-AminobenzenesuIfonamido) Pyridine,

Quart. J. Pharm. & Pharmacol. 11:217 (April-June) 1938.

21. Long, P. H.: Sulapyridine: Preliminary Report of the Council
on Pharmacy and Chemistry, J. A. M. A. 113: 538 (Feb. 11) 1939.

22. Marshall, E. K., Jr.; Bratton, A. C., and Litchfield, J. T., Jr.:

"■ ** ~ ,J — an d Its Soluble

Treatment with M.

Toxicity and Absorption
Sodium Salt, Science S8 :

23. Johnston, F. D.:

& B. 693, Lancet 2:120(

24. Stokinger, H. E.: The Absorption, Acetylation and Excretion of
Sulfapyridine, Bull. New York Acad. Med., 2d series 15: 252 (April)
1939; Proc. Soc. Exper. Biol. & Med. 40:61 (Jan.) 1939.

25. Long, P. H., and Feinstone, W. H.: Observations on the Absorp-
tion and Excretion of Sulfapyridine, Proc. Soc. Exper. Biol. & Med. 39:
486 (Dec.) 193S. Long, P. H.; Bliss, Eleanor A., and Feinstone, W. H.:
The Effects of Sulfapyridine, Sulfanilamide and Related Compounds in
Bacterial infections, Pennsylvania M. J. 42 : 483 (Dec.) 1938.

26. Cooper, F. B.; Gross, Paul, and Lewis, Marion: Chemotherapeutic

Evaluation of Sulfanilamide and 2-(Sulfanilamido) Pyridine in Type II
Pneumococcal Infections in Mice and Rats, Proc. Soc. Exper. Biol. &
Med. 40 : 37 (Jan.) 1939. „ „ . 4 . , ^ ,

27 Schmidt, L. H., and Hughes, H. B.: Absorption and Excretion of
Sulfanilaimdopyridine (2-Para-Aminobenzenesulfonamido Pyridine), Proc.
Soc. Exper Biol. & Med. 40 : 409 (March) 1939.

28. Hoyt, R. E., and Levine, Milton: In Vitro Studies on the Action
of Sulfapyridine, Proc. Soc. Exper. Biol. & Med. 40:465 (March)

3939 ♦

29 Brvcc, D. A., and Climenko, D. K.: Sulfapyridine in Pneumonia,
J. A. M. A. 112: 1182 (March 25) 1939. . . - .

30. Sutherland, M. E.: 1 *- v ~" Administration of

M. & B. 693, Lancet 1:12 , ,, , ~

31. Ross, R. W.: Acquil t0 M. i; ts.

693, Lancet 1: 1207 (May 27) 1939.

31 May, Kenneth: A Fatal Case of Pneumococcal Meningitis, Treated
with M. & B. 693, Lancet 1: 1100 (May 13) 1939.

33 Cases observed on the First Medical Division at Bellevue Hospital
are included through the courtesy of Drs. I. Ogden Woodruff and James
Liebmann: on the Fourth Medical Division through the courtesy of Drs.
Charles Nammack, Mennasch Kalkstein and Saul Solomon.

able help may be obtained from the level of free drug
m the blood. For that determination we have used both
the Marshall method 34 and that of Werner; 33 the
latter has a short modification sufficiently accurate for
clinical work. Rectal administration of the drug has
been tried, but absorption is either quite small or lackin''
altogether. 0

RESPONSE

In a large majority of instances a marked fall in
temperature and in pulse rate occurred within twenty-
four hours, and many times this had already begun hv
the time the second dose of sulfapy’ridine had been
given. Associated pari passu with these changes were

Table 1. — Distribution of Cases and Mortality Rate by Types

Total

Mortality

Type

Cases

Deaths

Rate

I

6.3%

II

Ill

IV

V

O

8.7%

VI

vii :::

*)

lWo

4 2V,

VIII

IX

X

XI

0

o

xii : .

o

xnr

o

1

XIV

7

3

XV

0

0

XVI

o

0

XVII.

XVII i

XIX

XX

XXII

XXIII

XXIV

XXV

XXVIII

XXIX

Unclassified..
Mixed

Totals. . .

3

6

3

3

1

3

3

5

1

1

SO

IC

270*

1

0

0

0

0

1

1

0

0

1

0

2

Ttf

lo.cr*

i s.c%

* Serum was used in addition In 102 of the cases, ns follows: type I.
20: II, 9; III, 17; IV, 4; V, 10; VI. l: VII, id: VIII, 15; X, 1: XI. '■
Xir, 1; XIV, 2; XVII, 1; XVIII, 1: XXIV, I: XXV, 1: XXVIII, 1.

t Eleven ot these were fatnl within twenty-four hours of onset o*
therapy. Corrected mortality, 8.5 per cent.

a decrease in toxemia and a subjective improvement.
Bacteremia— in some cases what appeared to he an
overwhelming bacteremia — was usually promptly con-
trolled, although the patients with bacteremia tended
to have a moderate degree of fever for a week or more
after the original fall in temperature. Not every bac-
teremic patient whose blood was sterilized recoveret ,
however. The physical signs seem to go through the
usual cycle.

The marked frequency with which the temperature
falls in pneumococcic infections when sulfapyridine
is given, together with the fact that in other infections
in which we have used the drug such a fall is muci
less frequent or does not occur at all (e. g. staphylococcic
empyema, non-pneumococcic pneumonia), leads us
believe that the temperature response is not mere!) a

sntipyretic effect. _ ,

We have been interested in finding out whether
ise of sulfapyridine would interfere with the caps 1 '
if the pneumococcus and consequently^ with ty pi fc*
Vhitby 1 observed that when mice are injected m
leritoneally with pneumococci and then treated "
ulfapyridine the capsule shows degenerative c ! ia !'k .(
’elling and Oli ver, 30 reporting one case, and l<_ _

34. Marshall, E. K„ Jr., and Litchfield, J. T.. Jr.: The Deterra

i Sulfanilamide, Science SS:85 (July 22) 1938 floi*.

35. Werner, E. A.: Estimation of Sulfanilamide in nioiog.

ancet 1:18 (J an. 7) 1939. Tneu nut'*.

36. Telling. XL, and Oliver, A.: Cmc of Aminohenrenrjah'M 1 '
ype III. with Massive Collapse. Treated with 2-(fi-Aroinolien

nido) Pyridine, Lancet 1:1391 (June 18) 1938.

Volume 113
Number 21

PNEUMONIA— PLUMMER AND ENSWORTH

1849

rence, 31 reporting two cases, observed that the capsules
of pneumococci recovered from the sputum of patients
being treated with sulfapyridine failed to react with the
type-specific serum with which they had originally
reacted. We have not been able to confirm this find-
ing. Repeat typings are done on our patients when
the original typing has not shown a fixed type (I, II,
V and VII). In a series of seventy-five such retypings,
capsular swelling occurred whenever pneumococci were
present, even after as much as 40 Gm. of drug had
been given. Furthermore, there has been no interfer-
ence with the capsules of pneumococci recovered from
the blood, spinal fluid or pleural exudate after as much
as 200 Gm. of sulfapyridine. There was one excep-
tion to this : poor capsular swelling in organisms
recovered from the blood of a patient with bacteremia
and endocarditis was observed after 140 Gm. of sulfa-
pyridine had been given, but subsequent blood cultures
typed easily, even though the drug was continued.

In a more recent article, McIntosh and Whitby 38
state that they have seen capsular degeneration only in
peritonea] samples and believe that the nonencapsulated
coccus found by Telling and Oliver was probably pres-
ent simultaneously with the original type III coccus
observed but persisted in the sputum after the other
had disappeared. In this connection it should be kept
in mind that the bacterial flora in the sputum often
changes during the course of pneumonia whether any
specific treatment is given or not.

EFFECT ON THE MORTALITY RATE

Of the 270 patients with pneumococcic pneumonia in
our series, thirty-four (12.6 per cent) died. If eleven
cases in which death occurred within twenty-four hours
of the beginning of treatment are excluded, the rate
becomes S.5 per cent. The distribution by types is
shown in table 1.

It is interesting that the mortality rate at Bellevue
Hospital was 15.3 per cent (10.3 per cent if twenty-

Table 2. — Distribution of Bactcrcmic Cases by Types

Type Cases Deaths

1 6 2

II 2 1

III 6 2

IV 3 2

V 3 1

VII ^ 1

VIII 4 0

X 1 I

XII 1 0

XIV 2 ' 1

xx i o

XXIII 1 I

XXV I o'

Totals 33* 12 (34.3%)f

* Serum was used in twenty-two of the cases: typo I, 0; II, 2: III, 2:
IV, 2; V, 3; VII, 3; VIII, 3; XIV, 1.

t Four of these were fatal within twenty-four hours of onset of
therapy. Corrected mortality, 23.S per cent.

four hour cases are omitted) and in the New York
Hospital group, composed of seventy-six patients from
a higher economic level, 5.4 per cent. The incidence
of accompanying systemic disease and alcoholism was
high at Bellevue Hospital and late admission was
frequent.

Thirty-five patients with bacteremia were encoun-
tered; twelve died (34.3 per cent). If four cases in

_ 37. Lawrence, E. A.: Type III Pnemococcus Pneumonia: Effect of
~'\r'Aminobenzenesti!fonamido) Pyridine in Treatment, New York State
J- 39:22 (Jan. I) 1939.

3S. McIntosh, James, and Whitby, L. E. H. : The Mode of Action of
Drugs of the Sulfonamide Group, Lancet 1 : 431 (Feb. 25) 1939.

the twenty-four hour group are excluded the mortality
rate becomes 25.8 per cent. The distribution is shown
in table 2.

In any evaluation of our statistics it must be borne
in mind that, of the 270 patients with pneumococcic
pneumonia treated with sulfapyridine, 102 were given

Table 3. — Toxic Reactions: Based ott 323 Patients
Treated with Sulfapyridine

Cases

1. Gastrointestinal

Nausea 165 (52%)

Vomiting 129 (40%)

Severe vomiting . 35 (11%)

2. Skin

Generalized morbilliform rash 5

Questionable, atypical, rash 2

3. Blood

Anemia 2

Granulocytopenia 0

4. Liver

Jaundice (preceded therapy) 1

5. Kidney

Ureteral stone 2

Hematuria without proved stone:

Gross 2

Microscopic 2

Nitrogen retention 3

serum also. The patients in this series were not alter-
nated between drug alone and drug and serum ; we now
have available serum for all types, and the problem
of the value of serum in conjunction with sulfa-
pyridine is now being studied at Bellevue Hospital in a
cooperative program of the First, Second and Fourth
medical divisions and involves strict alternation of cases.
In the present series, generally speaking, serum was
used for the more seriously ill patients. For example,
of the thirty-five patients with bacteremia twenty-two
received serum as well as sulfapyridine. It is there-
fore not possible to give an exact mortality rate on the
basis of the present series either for sulfapyridine alone
or for sulfapyridine plus serum.

However, the clinical recovery of a number of the
patients seemed more rapid and certain when serum
was used. At least from a theoretical point of view
it would be rational to expect a surer response when
the effect of the specific antibodies contained in serum
is added to that of sulfapyridine, which apparently acts
directly on the bacteria, probably by neutralization of
some metabolic function or enzymatic activity, 30 and
is not concerned with the immunity mechanism. It
may be that the use of serum in conjunction with sulfa-
pyridine will further reduce the low mortality rate,
which, it appears, can be obtained with sulfapyridine
alone. It will take some time to determine this, and
until the question is determined we believe that the use
of serum should not be abandoned.

BLOOD SULFAPYRIDINE LEVELS

There is a marked individual variation in absorption
and acetylation of sulfapyridine. With our routine
dosage we obtained blood levels of free drug ranging
from traces to 25 mg. per hundred cubic centimeters.

Six patients had blood determinations made at hourly
or two hourly intervals after the onset of therapy.
Sulfapyridine was detected in the blood within an hour,
rose steadily for about twelve hours and then began
to level off. Subsequently the level in a given case
usually remained fairly uniform as long as the same
dosage was maintained. Increasing the dosage after
tliis level increases the blood level, but not in proportion
to the extra amount of drug given.

39. Whitby, L. E. H.:
2: 1095 (Nov. 12) 1938.

Chemotherapy of Bacterial
McIntosh and Whitby. 58

Infections, Lancet

18fi0

At what time after administration of a dose of sulfa-
pyridine should blood be taken for determination of
the blood level? In an effort to answer this we made
hourly determinations in five cases and found that, once
the initial period of rise mentioned is over, there is no
significant variation in blood level between one dose
and the next. Consequently we feel that blood may be
taken at any convenient time.

Marshall and Long 40 have recently advocated the
use of sodium sulfapyridine by vein when absorption
of sulfapyridine from the gastrointestinal tract is poor,
when prompt action of the drug is imperative or when
patients are vomiting. Blake and Haviland 41 have dis-

join;. A. II. A.
Nov. 18, 1939

several _ cases in which there was no prompt response,
increasing the dose had no appreciable effect on the
clinical course. The cases in which this was tried, hmv-
ever, were complicated cases ; two were severely bac-
teremic and one was a case of empyema.

TOXIC REACTIONS

The phase of the problem concerned with toxic reac-
tions is of great importance, and careful attention has
been given to it. Our data in this regard are based on
the 270 cases of pneumococcic pneumonia and in addi-
tion fifteen cases of pneumonia in which we could isolate
no pneumococci, five cases of subacute bacterial endo-

PNEUMONIA — PLUMMER AND ENSWORTH

Table 4. — Summary of the Fatal Cases

Name

Drug,

Scrum,

Age

Type Gm.

Units

Comment

1. J. K.

65

Unclassi- 1G
fled

0

Sick several weeks at home and
two weeks in hospital: au-
topsy: bilateral patchy pneu-
monia

2. T. D.

55

III G

0

12 hr. case: admitted with bac-
teremia on 9th day

3. M. V.

5S

IV 17

0

Consolidation of right lower
lobe by x-ray: improving
until sudden expectoration of
large amounts of foul pus:
probably abscess: no autopsy

4. J. H.

71

IV 33

310,000

Arteriosclerotic heart disease
with fibrillation and decom-
pensation; admitted with
bacteremia on 8th day

5. E. R.

67

Unclassi- 32
fled

0

Emaciated Negress with history
of weight loss, weakness,
abdominal pain for 1 year;
onset indefinite; no autopsy

G. J. S.

CO

III 3

0

12 hr. case: admitted late,
probably during 2d week

7. P. C.

77

IV 2

0

6 hr. case: arteriosclerotic
heart disease; onset indefinite

S. L. D.

GO

I 6

230,000

Admitted 8th day: responded
temporarily; then relapsed

9. H. B.

71

VIII 11

0

Semicomatosc on admission: in
bed 4 wks. previously, with
practically nothing to eat

10. G. T.

56

IV 13

414,000

Baeteremie patient who failed
to respond

11. H. S.

10

Unclassi- 11
fled

0

Admitted for cardiac decompen-
sation and ascites: had respi-
rators’ infection which event-
uated into pneumonia

12. C. W.

54

VII 233

300,000

Persistent bacteremia; pneumo-
coccic endocarditis and men-
ingitis

13. M. H.

75

Unclassi- 5
fled

0

Responded to drug; delirium
caused transfer to psychiatric
ward where sulfapyridine was
not given; spread of pneu-
monia and death

14. C. W.

45

HI 17

350,000

Admitted 4th day with bacter-
emia, 100 colonies per cc.

13. A. G.

37

I 4

240,000

12 hr. case: admitted on 8th
day with bacteremia

10. ,T. M.

81

XXIII, 13
XXIV

0

Bacteremia type XXIII; did
fairly well until drug was
stopped through error

Name

Drug, Serum,

Age Type

Gm.

Units

Comment

17. J. K.

6S

V

2

200,000

24 hr. case: could swallow only
1 dose; arteriosclerotic heart
disease with fibrillation ami
decompensation

18. J. P.

82

III

7

130,000

24 hr. case: arteriosclerotic
heart disease with fibrilla-
tion; autopsy: pneumonia
and calcified aortic stenosis

19. J. S.

37

V

5

240,000

24 hr. case: admitted 7th day
with bacteremia; had been on
drinking bout

20. T. P.

44

VII

36

400,000

2 wks. severe alcoholism before
admission about 10 th day
with bacteremia; blood steril-
ized in 24 hours

21. M. C.

70

XIV

5

0

15 hr. case: emphysema and
chronic bronchitis with term-
inal pneumonia; parkinsonism

22. A. M.

56

XIV

2

40,000

8 hr. case: auricular fibrilla-
tion; cardiac decompensation

23. T. C.

51

XVII

2S

190,000

Admitted in diabetic acidosis:
temporary response to drug
therapy ,

24. J. V.

38

Unclassi-

fied

7

0

Admitted 4th day; vomited:
refused medication after 1st
day

25. L. C.

62

Unclassi-

fied

17

0

Semicomatosc on admission:
blood pressure 190/140: drug
given by Levine tube

26. A. M.

56

XXIX

15

0

Blood pressure 200/130; uremia
and pneumonia

27. C. S.

GG

XXIV

38

0

Admitted in cardiac failure;
temporary response to drug,
then became uremic

2S. G. J.

40

II

2

275,000

8 hr. case; baeteremie patient
admitted in extremis on 12 th
day ftlA ,

12 hr. case; blood pressure -10/
SO; knowm arteriosclerotic

heart disease for 5 years

29. E. W.

67

III

4

300,000

30. R. M.

63

XIV

16

5S0,000

Admitted with uremia and bac-
teremia

31. J. M.

63

IX and
XVIII

10

0

Arteriosclerotic heart niseo.e,
sudden death after tempera-
ture normal several days

32. M. H.

69 VIII and 75
streptococcus

0

Arteriosclerotic heart disease,
probable cardiac death

Acute rheumatic fever wirn

33. E. N.

17

VIII

50

100,000

34. R. M.

12

X

10

0

pneumonia ...

Acute rheumatic fever win*
pneumonia and bacteremia,
died 40 hr. after admission

solved 2 Gm. of sulfapyridine in 1 liter of 5 per cent
dextrose in saline solution by heating the solution nearly
to boiling; this preparation may then be given intra-
venously or by hypodermoclysis.

CORRELATION OF BLOOD LEVEL WITH
CLINICAL RESPONSES.

Flippin and his associates found that good clinical
responses occurred in cases in which the blood level
was only from 1 to 2.8 mg. per hundred cubic centi-
meters and that there was no apparent correlation
between the blood level and the rapidity of^ recovery.
We likewise are unable to state what an adequate
blood level might be. Some of the best responses that
we have had occurred in the “lowest level” group. In

40 Marshall, E. K„ Jr., and Lons, P. H.: Sodium Sulfapyridine,
TAM A 112: 16/1 (April 29) 1939. . t

4l' Blake,' F. G., and Haviland. J. W.. Sulfapyridine in Pneumococcal.
Streptococcal and Staphylococcal Infections, read before Association ot
American Physicians May 2, 1939 (to be published).

carditis and thirty-one miscellaneous cases. The inci-
dence of the various reactions is given in table 3.

Nausea and vomiting is almost certainly central m
origin. It rarely occurs until from 4 to 6 Gm. of^ulia-
pyridine has been given, and it has been shown 1 tna
giving sodium sulfapyridine by vein causes vomiting.
We have found no satisfactory way to control it snor
of allowing the blood level to fall. Here again, how-
ever, individuals vary greatly; some vomit when ti
blood level is only 2 or 3 mg. per hundred cubic centi-
meters and others do not vomit when the blood ie' 1
reaches 8 or 9 mg. Usually the drug could be continue^
in spite of vomiting, which frequently lessens as recov-
er}' takes place. , ,,„,i

Four of the five patients with morbilliform rash
received between 30 and 40 Gm. of drug; the o i »
16 Gm. The rash cleared promptly when the sui
pyridine was stopped.

«» 4 «”S e a r „<* PMfeots /lad ' fEUi!0m ' , ~-n-u M
encountered leillo ghbin n ? ,nor fal/s ;

r re severe '" ^hlecti^ 5 ’ sue h al red Wood
f io W„ eo / 0 caused °'% t Wo be

°r V ; d ' vit ^ra w i, of be J, 0 " r 50 p ei er " :,n h °th’th°h ever ’

ot * eco V£r

S “"Sf ' -'"-ProtS “ n, S<0 1 fr on“'"S

Pe-t/“‘o?7 ■» s,-;r • *?«?

Wins \ver e n / 0 / St pure acetvl } ldne y which Sto,les Were

Pa „,, - saw
m ■"•/■"•/. ?:,.r -- ™, Dr -

IV ORTH

W s tatjo,j s 3 „ ,

S^sstigg

12 ZflVS 3 2/> _

• ,o . / . ,J . *2°"

/- » •;

4 /*0/J9

1 — I

Ch an 2.- pi- . 11 ** / „ I I

" ,K ‘l«ra tbl , i ' 1

J " “•- fou, W but SarcS n ,tse2f -

e niporpr,. ,

in

i , h™*/

" at "* s,on «

“ladder and ,, ' Vas done r J,Ue rpreter7 Native
c °'Upo sed ’f Uret ers ; Grave/ vL te , d as stones

n P " r o other acet yhted sulf Ua ysis this n ° tInd «i the
n ° ne Was a sJ p aUents W ou^cf^dWe. P ° Ved to he

I s ? 55 Witbt^pt n*° stone ,y” d n Werf ering

47 l ' JCof endocarr7,V efr °;

autopsy „ d f,s or Wac .

Present/ y ’ n ° st on es J£?

, , Jn three ar? , r - '° Und butZT^ ftse

Wood ure a d ' u °’ial Ca c, Pt . ,jf arctjo n

of b/dney (Z ,tr0gen was 0 ; tem P°rary e]p

*%"* recoup- S »'f* Pj %y "’‘“■ont oh°“ ° f &
/- besides the'/ nsi,ed - " 5e "'as ch.sco/ si gni
, first hand T ca se s JIf t/l C ° ntj uued and

h etl iaturin .Pledge * e P r ^sem

/rao — / 6 I * \> . i a ,/9 /»

1/9/39 i/.

9

1852

PNEUMONIA — PLUMMER AND ENSWORTH

COMPLICATIONS

1. Empyema . — This was encountered thirteen times.
In all but two cases, signs suggestive of fluid were
present before therapy was begun.

2. Otitis Medici and Mastoiditis . — One patient was
admitted with this condition complicating a type VIII
pneumonia.

3. Pleural Effusion . — Six sterile nonpurulent effu-
sions occurred. All the patients recovered on repeated
thoracentesis.

4. Endocarditis and Meningitis . — These conditions
occurred once each, in the same case. It is Interesting
that in this case signs of meningitis and a positive spinal

Table 5. — Distribution of Cases by Age

Years

Cases

Deaths

12-19

1G

2

20-29

36

0

80-39

50

3

40-49

60

3

50-59

50

7

00-09

37

11

<0-79 .

G

80-89

2

2

fluid culture for type VII occurred three weeks after
admission, but both subsequently cleared up on con-
tinued drug therapy. Recurrence was noted, however,
when the patient was in a terminal state nearly three
weeks later.

comment on the fatal cases

The fatal cases are summarized in table 4. Eleven
of the thirty-four patients clied within twenty-four
hours of the onset of therapy. Of the remaining, eight
had serious organic disease affecting the cardiovascular
system, two had been on drinking bouts, one was in
severe diabetic acidosis on admission and one was
uremic on admission. In two other cases the drug was
prematurely stopped through error, and this seemed to
play a part in the eventual outcome.

As table 4 sug-
gests, no selection
of cases was made,
and sulfapyridine
was not withheld
because of the ap-
parent terminal
condition in any
case.

SUMMARY AND
CONCLUSIONS

1. An analysis of
270 cases of pneu-
mococcic pneumo-
nia reveals that
treatment with
sulfapyridine re-
sulted in a short-
ened period of pyrexia, a sterilization of the blood
stream and a low mortality rate.

2. Blood determinations for sulfapyridine show an
irregular but prompt absorption and fail to show a
correlation between the blood level and the clinical
response.

3. The incidence of serious toxic reactions is low.
Nausea and vomiting are frequent.

4. Whether serum should be administered also,
particularly to seriously ill patients, is still sub judicc.

4i:c'73 A/unO 4/12/M 4/13/39

Jour. A. M. A.
Nov. 18, 1939

5. Examination and typing of any available bacterio-
logy specimens— sputum, blood, spinal or pleural
fluid should not be abandoned. It gives information
of value in diagnosis, in prognosis and in possible
further specific therapy.

REPORT OF CASES

Case 1 (chart 1). — D. M., a woman aged 37, was admitted
to Bellevue Hospital on the sixth day of acute illness. Physics 1
and x-ray examinations showed consolidation of the right lower

lobe. Type I pneumococci were recovered from the sputum and
from the blood. On sulfapyridine she improved, and the blood
became sterile. Through error, sulfapyridine was stopped after
16 Gm. had been given, whereupon the temperature rose and
the blood culture again became positive. When administration
of the drug was resumed the blood again became sterile and
the patient recovered, although a low grade fever persisted for
nearly three weeks.

Case 2 (chart 2). — S. V., a woman aged 26, was admitted to
the New York Hospital on the fourth day of acute illness. She
gave a past history of rheumatic fever and rheumatic heart
disease. On admission the sputum showed type II organisms
and the blood culture showed 25 type II pneumococci per cubic
centimeter. The physical and x-ray examinations revealed pneu-
monia involving the right middle lobe, the right lower lobe and
the left lower lobe. Sulfapyridine was started shortly after
admission to the hospital. On the second and third days after
admission, which were the fifth and sixth days of illness, a total
of 458,500 units of type II rabbit serum was administered. The
toxemia subsided promptly. Blood cultures were taken daily
for the first four days and were sterile. After treatment was
commenced the patient made a rapid recovery. There was no
nausea or vomiting and no other reaction to either the sulfa-

pyridine or the serum. mm

Case 3 ( chart 3). — A. D., a woman aged 68, was ncTmittcd
o Bellevue Hospital on the fourth day of a very acute illness.
Dn admission the sputum showed type III pneumococci an
he blood contained 25 type III organisms per cubic centimeter,
["he leukocyte count was only 5,980. Sulfapyridine was startc
is soon as the clinical diagnosis of pneumonia was made. La r j
m the second day 200,000 units of rabbit serum was mjectca
ntravenously. The toxemia was quickly controlled. Later oloo
:ultures were sterile. The white blood cell count rose ro
1,980 to 13,150 during the period in which sulfapyridine wa
liven. Because of the grave prognosis in such a case, the dri g
vas continued until 46 Gm. had been given.. There was n
astric irritation and no other untoward reaction.

Case 4 (chart 4).— H. C., a Negro aged 32, 'vas admitted |o
iellcvue Hospital on the fourth day of his disease. The spu ”
howed type V organisms. Blood culture was Sterne. 3
nd x-ray examination revealed consolidation of the ... .

f the right upper lobe. He received 16 Gm. of sulfapyridine,
ecovery was prompt and uneventful.

Case 5 (chart 5) .-A. S., a woman aged 28 was * * c
ic New York Hospital on the third day ot 4 In«s with P ^
lonia involving the entire left lower lobe. On admiss

PNEUMONIA— PLUMMER AND ENSWORTH 1353

Volume 113
Number 21

sputum showed type XVIII pneumococci. The blood culture
was sterile and the white blood cell count was 14,800. Sulfa-
pyridine was started the day of admission and was continued
for three and one-half days until 20 Gnt. had been administered.
There was a quick response to the drug and no reactions
occurred.

140 East Fifty-Fourth Street.

ABSTRACT OF DISCUSSION
Dr. Russell L. Cecil, New York: In these reports on
chemotherapy in pneumonia one notices the strikingly low
death rate. The standard death rate from pneumonia at Belle-
vue Hospital runs from 35 to 40 per cent. In serum treated
cases this was cut about half in two. With sulfapyridine, the
death rate was reduced to 12 per cent. If the cases in which
death occurs within twenty-four hours are eliminated, it is 8
per cent. In a series of seventy-five odd cases that Dr. Law-
rence and I have seen in private practice, the death rate runs
about 5 or 6 per cent with sulfapyridine. This is a better
figure than we have ever been able to obtain with serum
alone. The fact remains though that when serum is used
under ideal conditions, such as those obtaining at the Rocke-
feller Institute, at Harlem and in certain other places, the
figures are almost as good as with sulfapyridine therapy, if
we make an exception of type III, in which serum has not
been so striking as sulfapyridine. One of the most interesting
features of this paper is the remarkable effect of sulfapyridine
therapy on type III pneumonia. The death rate in our work
in New York has usually run around 40 to 50 per cent, some
winters even higher. In Plummer and Ellsworth’s series the
death rate in the type III cases was only 11 per cent. In
thirty-eight cases of type III pneumonia which we have treated
this winter in private practice, in which we had expected a
death rate ordinarily of 50 or 50-odd per cent, the death rate
was only 10 per cent. Pneumonia has been milder this winter
than usual, but that is because the distribution of types has
been different. The good old type III pneumonia is just as
severe as it has ever been. The same is true of type II
pneumonia. We have had a particularly high incidence of
type III and a low incidence of types I and II. Take any
group of type III pneumonias this winter or any other winter
and they run true to form. We have a double-barreled gun
for the treatment of pneumonia, and whether we need both
barrels or only one remains to be seen. Dr. Bullowa and
Dr. MacLeod expressed it very well when they said that
serum fortifies the pneumonia patient; sulfapyridine injures the
pneumococcus. For the present we must keep our serum
handy and use it in severe cases along with sulfapyridine, and
we must continue to type our pneumonias in order that we
may get all the better oriented with regard to this new form
of therapy.

Dr. H. F. FLimN, Philadelphia: There is less variation
from year to year in the virulence of the pneumococcus in
the lower types, particularly type I infections. Since last fall
my associates and I have treated over 500 adult pneumonia
patients with sulfapyridine. Of this number 101 represent
type I. Twenty-one of these had positive blood cultures with
a mortality rate of 14.3 per cent. The mortality rate for
the entire type I series was 5.8 per cent. During this same
time eighty-eight patients of type I were treated with various
forms of therapy at the Philadelphia General Hospital. In
those receiving nonspecific, serum and sulfapyridine treatments
the mortality rates were 44.4 per cent, 11.5 per cent and 3.7
per cent respectively. We have found it advisable to give
rather large total doses to those with blood stream infections.
In such cases a total of 25 Gm. and usually more has proved
necessary, as it is important to continue the drug despite a
normal temperature. Some significance can be placed on the
white blood count following the administration of sulfapyridine.
In most instances the critical drop in temperature is closely
followed by a marked reduction in the total white blood count,
but if it remains elevated it is wise to look for a spread in
the infection or for complications. Our experiences correspond
to those of Drs. Plummer and Ensworth concerning the toxic
manifestations of sulfapyridine. The gastrointestinal symptoms
of nausea and vomiting have proved the most troublesome.

To combat these we have used with varying success such
adjuvants as intravenous chlorides, chloral hydrate, barbiturates
and, more recently, nicotinic acid. Microscopic hematuria has
been detected in approximately 5 per cent and gross hematuria
in 1 per cent of our patients. Careful pathologic studies in
the fatal cases have failed to show any evidence of renal
damage attributable to the drug. This question of possible
renal involvement is one that remains to be properly evaluated.
We have not had enough occasions to use both serum and
sulfapyridine in the same case to express an opinion as to the
merits of combined therapy. At this time we feel that sulfa-
pyridine is an effective drug in the treatment of pneumococcic
pneumonia and, if used with regard for its toxic effects, it is
a therapeutic agent with a satisfactory margin of safety.

Dr. F. Janney Smith, Detroit: In the preceding eight
years at the Henry Ford Hospital, 678 adults suffering from
lobar pneumonia were treated by all methods. There were 253
deaths, giving a mortality rate of 37 per cent. In the past winter
seventy unselected, consecutive adult patients were treated with
sulfapyridine. There were six deaths, or a mortality of 8.5
per cent. Two of the patients died after being in the hos-
pital fourteen hours or less. If those could be subtracted, the
mortality rate would be 5.5 per cent. The average amount of
the drug administered was from 15 to 25 Gm. Failure of
prompt defervescence in three cases led to the justifiable sus-
picion that another organism than the pneumococcus was
responsible. Autopsy showed that in two of these instances
the staphylococcus was responsible and in one the tubercle
bacillus. Nausea was the common toxic manifestation. No
serious effect was shown on the blood picture. Illustrating
renal toxicity, one patient, a white woman aged 54 with type
III pneumonia, whose treatment was begun on the eighth day',
showed a 3 -f- albuminuria and few red cells before the begin-
ning of the drug treatment. After 8 Gm. of the drug, anuria
developed. Renal function was reestablished in two days, but
a new consolidation developed on the contralateral side and
death occurred without further specific treatment. Autopsy
and microscopic studies showed acute toxic nephritis with
tubular degeneration and focal necrosis, the picture being
similar to that seen in some of the metallic poisons, particu-
larly mercury, except that it was focal instead of diffuse.
There was also present focal necrosis in the adrenals. Another
patient, a white man aged 64 with type IV pneumococci in
the sputum and blood, had an excellent response to the drug
but died after eighteen hours of normal temperature of a ven-
tricular tachycardia. It is impossible to state whether this
complication was due to his disease or whether it was related
in any way to the drug therapy.

Dr. L. D. Thompson, St. Louis: I have observed this
winter two series of cases, one treated with type specific serum
and one with the drug. The series are not comparable because
the serum treated patients were picked. They consisted of
types I, II, V, VII, VIII and XIV but no type III patients,
whereas the drug treated patients included a large number of
youngsters, that is below 2 years of age, and also a large
number of type III patients. However, I think that some of
the figures are significant. Of the 121 type specific treated
patients five died, a mortality rate of 4.13 per cent. When
you consider some of the circumstances of those deaths, it is
even more striking. Of the five deaths, two were in type I,
one patient seen first on the fourteenth day and one seen first
on the fifth day. One had type II pneumonia, seen for the
first time on the eighth day. Two had type V, one seen on
the sixth day and one on the twenty-first day. I can make
the statement that in this series no patient seen before the
fifth day was lost. Another striking feature was that in the
serum treated cases we had an appreciable incidence of type
VII and type VIII pneumonia with no deaths at all, although
the bacteremia in type VII was 15.3 per cent and in type VIII
was 5.2 per cent. In the drug treated cases, 145, we had a
gross mortality of 10.3 per cent. Twenty-five odd cases of
those were type III, with a mortality rate of 16 and a fraction
per cent. In type VII cases, drug treated, we lost one out of
four and in type VIII, drug treated cases, we lost one out of
six. Neither of these deaths occurred in a case of bacteremia.
In this small series the drug appeared to be definitely less

1854

DIAGNOSIS OF PNEUMONIA— POOLE AND FOUSEK

Jot)R. A. M. A.
Nov. 18, 1939

efficient for types VII and VIII than did the type specific
serum. Another point of difference with the drug treated series
is that three patients seen before the fifth day died, one type III,
one type XVIII and one we were unable to type.

Dr. Jesse G. M. Bullowa, New York; How can we select
patients who require serum as wei! as sulfapyridine ? Drs.
Bukantz, deGara and I studied the concentration of polysac-
charide in the blood of twenty-five patients. Twenty-one had
either small amounts or no polysaccharide. These patients all
recovered after treatment with sulfapyridine, with serum and
with the combination. The four patients who had large amounts
of polysaccharide in the blood died. A patient with pneumo-
coccus type VII pneumonia was seen on the third day of the
illness and was refractory to serum given in large amount. The
elevated temperature continued and on the ninth day, when the
blood was heavily invaded, he was given serum and sulfapyridine.
He was very much improved. When the sulfapyridine was
stopped after a period of eight days, the patient again became
ill, and on the thirty-second day of the illness he was again
given sulfapyridine, with the result that the temperature and
the pulse fell. During this time the patient made his own anti-
bodies. The fall in concentration of capsular polysaccharide
was coincident with clinical improvement. Then treatment was
withheld for a while. He had a persistent atelectasis, which on
bronchoscopy showed granulation tissue in the bronchus. The
atelectasis cleared, but the blood of the patient, who was
apparently getting well, was reinvaded. This time meningitis
developed. The patient’s organisms had apparently become fast
to the sulfapyridine, and ultimately, having developed a bacterial
endocarditis, he died. It is possible that pneumococci of types
II and V, which are related, may be more resistant to the
action of sulfapyridine than some other pneumococci. A patient
29 years of age, with a pneumococcus type II pneumonia, was
treated on the third day, receiving an initial dose of 5 Gm. of
sulfapyridine and I Gm. every four hours thereafter. Though
we obtained a concentration of 7.5 mg. of free sulfapyridine
per hundred cubic centimeters, the patient died on the fourth
day with a rising temperature.' The requirement of an adequate
concentration of sulfapyridine is illustrated by a patient who
had a double infection, in whom pneumococcus type IX was
found in the sputum and pneumococcus type V in the blood on
the third day. There were then only six colonies. He received
240,000 units of pneumococcus type IX rabbit serum; his tem-
perature and pulse fell on the fifth day and there were antibodies
for pneumococcus type IX. We did not obtain a very high con-
centration of sulfapyridine in spite of the unusually high dosage.
On the fourth day he had 1.7 mg. per hundred cubic centimeters
of blood. Apparently the sulfapyridine had no effect on the
bacteremia due to pneumococcus type V; it had increased on
the fifth day to 123 colonies. He died on the sixth day.

Dr. W. D. Sutliff, New York: Drs. Plummer and Ens-
worth and other workers with hospital facilities are laying a
firm foundation for the use of sulfapyridine in general practice.
They are showing not only that sulfapyridine is an effective
therapeutic agent but that it must be used with certain precau-
tions. During the same period as that during which the authors’
figures were collected, the pneumonia control division of the
Ne W York City Department of Health assembled similar figures
from a large number of physicians for, patients treated at home
as well as in the hospital. During January, February and
March 1939 a total of 1,354 reports were returned by physicians
who received serum, from the department of health. Pneumonia
cases caused by eight different pneumococcus types were treated
with serum. The fatality rate varied from 4.5 per cent for 396
serum treated type I cases to 13.7 per cent in ninety-five type
II cases. Fatality rates for other types ranged between these
two extremes, with the exception of type XIV, which showed
the very low fatality rate of 2.4 per cent in eighty-five cases,
owing in part to the fact that this type was found in children
and infants in about 50 per cent of the cases. Chemotherapy
was employed by the general practitioner for only 228 patients.

It was apparently employed for patients who were more seriously
ill, as the fatality rate of 228 patients who had both serum and
chemotherapy was 17 per cent. The gross fatality rate for all
patients treated with serum or treated with chemotherapy in
addition to serum was 8.8 per cent. All cases of certain pneumo-
coccus types were treated with rabbit serum, and all cases of

other pneumococcus types were treated with horse serum and
the results were equally satisfactory. Since April 15 when
sulfapyridine was released for general sale, 126 patients treated
with sulfapyridine alone have been reported to the New York
City Department of Health, Pneumonia Control Division. This
group of cases shows a fatality rate of 5.6 per cent which
approximates closely to that reported by Drs. Plummer and
Ensworth and other observers in hospital practice. These cases
all bad bacteriologic diagnosis performed in the New York City
epai tment of Health, Pneumonia Control Division stations.
Dr. Herbert K. Ensworth, New York: The question of
picking cases for treatment with sulfapyridine or with serum
or the combination is something which will have to be worked
out. Fleming recently published in the Lancet a bacteriologic
means of doing so which takes twenty-four hours. He deter-
mines whether the particular strain of the inciting organism is
susceptible to sulfapyridine or not. That is an interesting way
of doing it ; if the process can be shortened so that we can get
treatment started without undue delay it may be very valuable.
Dr. Bullowa’s demonstration of the significance of the poly-
saccharides in the urine is interesting also and it may be that
from this will develop another useful aid in selecting the method
of therapy most suitable for the individual patient. The present
day' results with serum, as Dr. Sutliff showed, are excellent.

I think it shows one thing about serum, that serum is getting
better; it is becoming more refined, more concentrated and more
effective. All the reports of serum in recent times have shown
results superior to those obtained with the serum of ' the older
days. This also applies to type III serum, formerly thought
to be of little value. We and others have seen type III pneu-
monia cases in which definite improvement which appeared to
be due to serum has occurred. At the present time, however,
sulfapyridine appears to be lowering the mortality rate in all
types even more than serum does.

THE ETIOLOGIC DIAGNOSIS OF PNEU-
MONIA IN CHILDREN BY RAPID
TYPING OF NASAL CULTURES

FRANKLIN D. POOLE, M.D.

AND

MILDRED D. FOUSEK

NEW HAVEN, CONN.

Advances in the treatment of pneumonia both with
serum and with drugs have increased the importance of
the etiologic diagnosis. In children, attempts to circum-
vent delay due to lack of sputum by obtaining tracheal
specimens have been made by Bullowa 1 and by Kra-
huh'fc, Rudomanski and Cunningham.-

Beebe , 3 Kneeland 4 and Webster and Hughes
reported that in respiratory infections in children the
respiratory pathogens, e. g. pneumococcus, influenza
bacillus and hemolytic streptococcus, appear in cultures
from the nasal passages. In the middle fossae of the
nose in cases of lobar pneumonia, Felty and Heatley
described the presence of pneumococci which cornu
sponded to the type found in the sputum- Emmi"
found that in early pneumonia in children the high y
parasitic pneumococcus type I could be quicly)

From the Children's Center of the New Haven Orphan A s i ,“Jjj c j ne .
e Department of Pediatrics of the Yale University School o * .

Aided by grants from the Fluid Research Fund of the U

^°° Bullowa?"”" G. M.: The Management of Fncumonia, New rk,

*2° r Krahulfc Lambert! Rudomanski, Victor, and Cunningham, fi«rsCj

itramuscular Administration of Antipneumococcal Scrum in Intan
lildrcn, Proc. Soc. Exper. Biol. & Med. 40:18-21 pan.) WA

3. Beebe, Agnes R.: Personal communication to the “ ut A ors j Ex p f r.

4, Kneeland, Yale, Jr.: Studies on the Common Cold, J.

1’ Websilfu T.^nd Hughes, T. P-: The Epidemiology of Vn'°™
ecus Infection J. Exper. Med. 5 3 = 535 - 5 ^ (JanA lWl. Eo’ar

6. Felty, A. R-, and Heatley, C. A.: The Aasi a aassag

jenmonia, J. A. M. A. 86: 1195-1197 (April J ) ppetnnoflkr

7, Baker, Conrad: Nose Cultures in Children with Cooa
lesis, Yale University, 193J.

Volume 113
Number 21

DIAGNOSIS OF PNEUMONIA— POOLE AND FOUSEK

1855

recovered from nasal swabs through mouse inoculation.
These observations led us to explore the possibility of
rapid typing of pneumonia in children using the quel-
lung reaction on pneumococci which might appear in
blood broth inoculated with a nasal swab.

Fig. 1. — Simplicity of normal flora.

METHOD OF STUDY

The basic medium was a fresh beef heart infusion
broth with 2 per cent defibrinated rabbit’s blood, 1 cc.
volumes being used in ordinary test tubes and kept on
the desk. The beef hearts were infused within twenty-
four hours of slaughtering. The small volume and
storage at room temperature were used to shorten the
period of incubation. The nasal swab consisted of the
ordinary wooden applicator tipped with cotton. The
culture of the nose was taken by passing the swabs
far back into the nasopharynx. Sometimes this was
possible in only one nostril. One swab was left in the
tube of blood broth and incubated at 37.5 C. Another
swab taken at the same time was used to streak a blood
agar plate made up of fresh beef heart blood agar with
5 per cent defibrinated rabbit's blood. The second swab
was then placed in a tube of plain broth ; after shaking,
1 cc. of the fluid was inoculated into a white mouse.

The clinical material consisted of patients suspected
of having pneumonia admitted to the pediatric service
of the New Haven Hospital. Of these, thirty-two
proved to have lobar pneumonia, eight bronchopneu-
monia, one capillary bronchitis, two bronchitis and five
acute upper respiratory infections and questionable
uncvimovi! ns .

RESULTS

Figures 1 and 2 are reproductions of photographs of
nasal cultures on blood agar plates in a normal child
and in lobar pneumonia respectively. Figure 1
(normal) shows the simplicity of the normal flora,
which consists merely of diphtheroids and staphylococci.

1 "" ? ' ' ) shows the predominance of

:s that in cases of pneumonia one
can get the pneumococci in almost pure culture from
the nose and that only a small volume of medium is
required constitute the basis of the success of the
method.

rhirtv-four cases of pneumonia and severe respira-
tory infections were typed by the rapid method. The

time required in typing ranged from one and three-
quarters hours to six hours. In the average case from
three to four hours’ incubation of the 1 cc. volumes
of blood broth inoculated in the manner described was
all that was necessary to obtain a culture suitable for
a typing of the pneumococci. On the other hand,
when a 5 cc. volume of blood broth was used, from
twelve to eighteen hours was found to be the time
necessary for incubation before the quellung reaction
could be employed successfully.

The accompanying table, summarizing the cases of
lobar pneumonia, bronchopneumonia and upper respira-
tory infections examined, shows the organisms obtained
from the nose and throat, from white mouse inocula-
tion, from blood culture and from exudates from the
ear and pleural cavity.

RESULTS

The table shows a contrast between the predominance
of the parasitic pneumococcus in the nasal cultures on
the one hand and the variety of organisms of the throat
on the other hand. Pneumococci were recovered from
the nasal cultures in twenty-nine of the thirty-two cases
of lobar pneumonia. In six instances a check on the
method of the typing by nasal cultures was possible by
means of a comparison of types found in blood cultures,
pus -from the ear, pleural cavity and nose; the nasal
method was upheld six times (cases 1, 7, 10, 11, 14
and 18). The nasal method failed in three cases
(cases 6, 23 and 32). The unsuccessful examination
for pneumococci in the nose, as in cases 6, 23 and 32,'
was made on the first and second days of disease and
could not therefore be ascribed to a late examination,
as might have been expected from Baker’s work.

Tig. 2. — Predominance of pneumococci in nasal culture from a child
with lobar pneumonia.

Tire three cases in which the method failed were typical
of lobar pneumonia in respect to onset, physical signs
and roentgenograplu'c evidence.

Several types of pneumococci were recovered from
the nose, the throat or other sources in seven cases of
lobar pneumonia (cases 4, 5, 17, 21, 27, 29 and 31)
and in one case of bronchopneumonia (case 34). In
the three instances (cases 4, 5 and 17) in which the
distinction could be made, a highly parasitic pneumo-
coccus was found in the nasal culture.

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r ppcr respiratory Infection

Volume 113

Number 21

PNEUMONIA IN CHILDREN— SMITH AND NEMIR

1857

In five cases of bronchopneumonia the pneumococcus
was not found in the throat culture (cases 34, 37, 38,
39 and 40) but was present in the nasal cultures in all
but one (case 40). Pneumococci were absent in the
throat cultures in seven cases of bronchitis, upper
respiratory infections and questionable pneumonias
(cases 41, 42, 44, 45, 46, 47 and 48), whereas they
were present in every case in the nasal culture. In
one case of bronchopneumonia the pneumococcus was
not recovered from either the nose or the throat cul-
ture, but an unclassified type was obtained from mouse
inoculation but not from aural exudate, which contained
a hemolytic streptococcus (case 40).

SUMMARY

The method of rapid typing of nasal cultures has
some limitations but is of value in the etiologic diag-
nosis of pneumonia. The method is of special value in
pediatrics but, judging from Felty and Heatley, 0 it may
be valuable also among adults. Even with the advent
of chemotherapy in pneumonia the method still is of
importance, because it is desirable to know whether or
not the inciting agent is a pneumococcus or a hemolytic
streptococcus. If the etiology is pneumococcic it is
important to recognize the high parasitic strains which
usually occur in lobar pneumonia and to recognize those
strains which are more common in bronchopneumonia
or the so-called “atypical” or viral pneumonias.

THE SULFAPYRIDINE TREATMENT OF
PNEUMONIA IN CHILDREN

CHARLES HENDEE SMITH, M.D.

AND

ROSA LEE NEMIR, M.D.

NEW YORK

There have been a number of reports concerning the
use of sulfapyridine in the treatment of pneumonia in
infancy and childhood during the past few months. 1 A
review of the literature will not be made here. The
present series of ninety-three cases is reported because
of the successful results in lobar (pneumococcus) pneu-
monia from the use of the drug in small doses and for
a short time.

These patients were treated with sulfapyridine in
the Children’s Medical Service of Bellevue Hospital
between January and July 1939. All patients under 12
years of age having pneumonia had a bacteriologic study
with cultures from the throat by the technic described -
for pneumococcus typing and blood agar plates for
streptococcus study in many cases (table 1). No
attempt was made to have a control series, since the
early results made it seem unfair to withhold the drug
from sick children. Our experience with many hun-
dreds of cases during the past years is a reasonable
index of the expected course and outcome of pneumonia

From the Department of Pediatrics, New York University, and the
Children’s Medical Service of Bellevue Hospital.

Subject matter presented before the Panel Discussion on Management
of Pneumonia in Infancy and Childhood, Section on Pediatrics, at the
Ninetieth Annual Session of the American Medical Association, St. Louis,
May 18, 1939.

1. Barnett, H. L.; Hartmann, A. F.; Perley, A, M., and Ruhoff,
M. B.: The Treatment of Pneumococcic Infections in Infants and Chil-
dren with Sulfapyridine, J. A. M. A. 112: 51S (Feb. 11) 1939. Fiippin,
H. F.; Lockwood, J. S.; Pepper, D. S., and Schwartz, Leon; The Treat-
ment of Pneumococcic Pneumonia with Sulfapyridine, ibid. 112 : 529
(Feb. II) 1939. Wilson, A, T.; Sprcen, A. H.; Cooper, M. L.; Steven-
son, F. E.; Cullen, G. E., and Mitchell. A. G.: Sulfapyridine in the
Treatment of Pneumonia in Infancy and Childhood, ibid, 112:1435
(April 15) 1939,

2. Vinograd, Julia; Nemir, Rosa Lee, and Park, \V. IL: The Rapid
Typing of Pneumococci hy the Neufeld Reaction Directly from Laryngeal
Swabs from Infants and Children, Am. J, Dis. Child. 51:792 (April)

in childhood. . All patients had roentgenograms taken
during the pneumonia with anteroposterior and lateral
views, often repeated.

The diagnosis of the clinical forms of pneumonia was
made on the basis of criteria previously outlined. 3 The
varieties studied during this period are noted in table 2.
The majority of the patients had lobar pneumonia
(seventy-nine of the ninety-three), distributed from 2
months to 13 years of age. There were twenty-nine
patients under 2 years with lobar pneumonia and fifty
over 2 years (table 1). All of the eleven patients with
bronchopneumonia were under 2 years of age.

Sulfapyridine was given by mouth, in most cases
crushed and mixed with cereal, apple sauce or fruit
juice. It was usually given shortly after a meal to
minimize the possibility of nausea or vomiting. In the
early cases 0.2 Gm. per kilogram of body weight (1)4
grains per pound) was given on the first day, and half
this amount on the subsequent days. We soon found
that equally prompt defervescence was observed with
three fourths of this dosage in children over 2 years.
The infants, however, seemed to require the original
dosage, and this was continued for them. No child
received more than 4.5 Gm. a day, and the average total
amount given to a child was 5.48 Gm. "The average
total dosage for an infant under 2 years was 3.99 Gm.

Half of the patients were treated for only two days
and 75 per cent for not more than three days. The
average duration of treatment was 2.6 days. It is our
experience that if sulfapyridine affects the course of
the pneumonia it does so within eighteen to thirty-six
hours. In the first few cases treated it was given for
from five to six days after the crisis, but the prompt
fall of temperature after the drug is begun led us to
shorten the time of administration. In the larger part
of this series the drug was continued for only eighteen
to twenty-four hours after the crisis. No definite recur-
rences of pneumonia have been noted. Five patients had
subsequent short rises of temperature, probably not true
relapses of pneumonia.

Blood sulfapyridine determinations were done on
many but not on all patients. The concentration was
found to vary widely with the same dosage of drug,
from less than 1 mg. to 12 mg. per hundred cubic
centimeters. Three patients whose concentration was
0.8 mg. per hundred cubic centimeters had a crisis
completed within eighteen hours after the drug was
given. The average blood sulfapyridine determination
was from 2 to 4 mg. per hundred cubic centimeters,
and with this level in most cases prompt crisis was
noted.

UNFAVORABLE REACTIONS

The most frequent reaction was vomiting, usually of
only one or two doses, occurring in 15 per cent of the
patients. This symptom was never severe enough to
require stopping the drug. Vomiting can be greatly
reduced by giving the sulfapyridine with food or directly
after meals, a precaution which is often neglected in
hospital practice. None of the patients became cyanotic
from the drug, although several were cyanotic when it
was first given. Extreme restlessness and delirium were
observed in four patients, one of whom had a blood
sulfapyridine concentration of 12 mg. per hundred cubic
centimeters, the highest in our series. This baby bad a
peculiar agitated expression and constantly threw him-
self about. His extreme restlessness required the use of

y. w xrvjng, ana Andrews, Lh 2 abeth T.: Value

T f nf/ S n.fu Ct 'l” S study of I’neumonia, Am.

Oct D 22 C 1933 ’ (iSay) 3 : Gr “ d ' Forl - Kew York Acad. Med.,

1858

PNEUMONIA IN CHILDREN —SMITH AND NEMIR

Jour. A. M. A.
Nov. 18, 1939

restraints to prevent falling out of bed. This agitated
restlessness is not a part of any pneumonia picture.
All four of these patients presented an alarming state;
they had a peculiar intense pallor, although they were
not anemic. They were improved by sedatives (pheno-
barbital), by a large amount of fluids and bv discon-
tinuing the drug for one or two doses. Two' of these

Table 1 .— Bacteriology and Age Distribution of Patients
with Pneumonia

Only One Pneumococcus More Than One Pneumococcus

r

Under 2 Years

A _

2-13 Years

—

Under

2 Years

2-13 Years

Pneumo-

coccus

Type

Lobar

Other

Forms

of

Pneu-

monia

Lobar

Other

Forms

of

Pneu-

monia

Lobar

Other'

Forms

of

Pneu-

monia

Other

Forms

of

Pneu-
Lobar monia

I

2*

7

l

1

Ill

2

1

2

IV

I

1

2

V

1

4

1

VI

4

u

4

1

at

5 1

VII

1

l

2

VIII

i

1

1

XI

XII

l

3

XIV

4

it

0

4

i

'I*

XV

XVI

2

1

4

XVII

I

1

9

1

XVIII

1

9

XIX

i

2f

1

9

it

0 1

XXII

i

1

XXII!

9

i

XXIV

l

i

XXIX

l

XXXI

l

XXXII r

i

Pneumococcus

unclassified..

i

0

1

i

i

No pneumococ-

cus

u

5

Str. viridnns...

i*

Total patients

22

c

30

1

7

G

14 1

* One ease of omnyema in each pneumococcus type as indicated,
t One patient died in each pneumococcus type as indicated.

babies were placed in oxygen tents without improve-
ment of the nervous symptoms. A transient mild hema-
turia was observed in one patient. This child had
received only 0.12 Gm. per kilogram of sulfapyridine ;
hematuria appeared on the third day of treatment and
cleared within a few day's. It must be pointed out that
hematuria occasionally' occurs in pneumonia without the
use of sulfapyridine. No other toxic symptoms were
observed.

RESULTS

The prompt and consistent precipitation of crisis
following the oral administration of sulfapyridine has
been reported by many' observers, and our experience
is no different. This reaction occurred within eighteen
to twenty-four hours in sixty-nine of the seventy-nine
patients with lobar pneumonia. Of course, it is possible
that the drop in temperature of some of the patients
coincided with the normal crisis, but such an explana-
tion cannot account for all the reactions, particularly
in those treated very early in the disease. Many of the
patients treated on the eighth to the eleventh day were
acutely ill with type XIV pneumonia, in which the
average duration is from eight to fourteen days. 4

It has been stated that, although sulfapyridine pro-
vokes a crisis, the disease runs its course, and the con-
solidation does not resolve sooner than it would have
done it untreated. This suggestion is contrary to our
experience. The x-ray' shadows and the phy’sical signs
begin to clear at once just as they do after a normal
crisis.

T~ x Kosa Lee: The Significance of Pneumococcus Typing in

th- Pneumonias of Childhood, read before the Section on Pediatrics,
Amefi“n Medical Association. St. Louis. May IS. 1939. to he published.

The three patients with lobar pneumonia who failed
to show the typical response to sulfapyridine were all
infants under 2 years of age, all severely ill. It is pos-
sible that the sustained temperature, in the first one of
these patients was a febrile evidence of sulfapy'ridine
intolerance or intoxication, since this baby had other
signs of. reaction, namely extreme restlessness, delirium,
pallor and marked anorexia. His blood sulfapyridine
determination was 12 mg. per hundred cubic' centi-
meters. The second patient is remarkable only because
he required forty-eight hours’ therapy to produce a
crisis. The third baby' had pneumonia three times previ-
ously' at . Bellevue Hospital, some of these atypical
pneumonia. We cannot explain his unusual reaction to
sulfapyridine.

In five cases of lobar pneumonia, although the usual
reaction occurred after sulfapy'ridine, secondary short
febrile rises occurred. It has been suggested that the
bacteriostatic action of sulfapyridine may produce
improvement for a short time and then be followed by
a relapse. There were only five patients whose tem-
perature charts might be so interpreted. Only one of
these cases clinically' appeared like a pneumonia during
the second temperature rise which y'ielded promptly to
renewed treatment. The dosage of sulfapyridine was
probably' inadequate in case 5, but readministration of
the drug was followed by prompt crisis. The other
three patients had no new signs of pneumonia. One of
these received no more drug, and the fever subsided
just as promptly as in the cases in which it was given,
so that it is not certain that any' patients had true
relapses. Short febrile episodes are often seen in hos-
pital patients from insignificant causes. These three
patients may' all have had transient fever not associated
with pneumonia. Roentgenograms in all five cases
showed clearing pneumonias and no new consolidation.

It is noteworthy that four of the five patients had pneu-
mococcus type XIV pneumonia, a disease known for
its severity. It is suggested also that type XIV pneu-
monia may require a somewhat greater dosage than the
other pneumococcic pneumonias.

Table 2. — Clinical Diagnosis of Patients Studied

Number of Pntients

Total Lived Died Empyenm

Lobar pneumonia 79 <5 a -

Bronchopneumonia 11 7 4f <

Lobular pneumonia 1 0 l(autops>;

"Subacute” pneumonia* 2 2

* Patient who died had pyopneumothorax, pneumococcus unclasdfleii

t One infant died and was found to hove pneumothorax SIX
empyema. _ 7r nn ,j

J Type of pneumonia described by Lincoln. E. 3L; jmitn, l. .
Kirmsc, T. W.: Subacute Pneumonia in Children, J. lethal.,
published.

In eleven cases of true bronchopneumonia we hate
failed to observe the same dramatic, prompt response
to sulfapyridine seen in cases of lobar pneumonia. 1
temperature of the patients with bronchopneunion
remained elevated, and they' seemed only s yS 1 -
improved. Our series of this form of pneumonia
year is small, however. Four of the eleven pa <
died, approximately the average mortality ra c
bronchopneumonia during the past eight years, t ’ .
longer time will be needed to evaluate su a P.
therapv in this form of pneumonia . Rohn re)

5. Kohn. Jerome, c. ai.: Sulfapyridine Treatment in ^j'

Children, Including Treatment of ° Xew Tort, in

lefore American Academy of 1 Pediatrics. Region J,

1 9 J 9 ; ab^tr., J. PccHat. 15: 4*9 (Sept.) 193 J*

Volume 113
Number 21

PNEUMONIA IN CHILDREN— SMITH AND NEMIR

1859

effect on bronchopneumonia in his experience at the
Willard Parker Hospital.

One patient clinically thought to have bronchopneu-
monia died and at autopsy was found to have lobular
pneumonia, probably from aspiration. The walls of the
bronchi were normal. This months old baby was
admitted to the hospital for a diarrhea from which he
was recovering when he developed pneumonia. Type
XIX pneumococcus was found. The baby was treated
promptly with sulfapyridine but died within thirty-six
hours after the onset of the pneumonia.

There was one death among the seventy-nine patients
with lobar pneumonia. This severely ill 16 months old
baby died suddenly on the third day after admission to

DAYS FEVER
BEFORE DRUG

DRUG STARTED

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UNKNOWN

cases;

16

15

12

Vv

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Vv

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DAYS GIVEN

112 3

4 5

JLI

TOTAL WITH CRISIS IN 1 DAY 69

Typical response of sixty-nine cases of lobar pneumonia in which there
was a crisis within twenty-four hours after sulfapyridine was started. At
the right is shown the number of days the drug was given in each case.
Note the short duration of its administration in all except a few (early)
cases.

the hospital. A roentgenogram taken the day before
death showed a pyopneumothorax (not diagnosed
clinically), which was probably responsible for the
death. No autopsy was obtained.

Only one patient developed empyema, an infant with
type I lobar pneumonia. He developed physical signs,
and a roentgenogram indicated suppurative pleurisy.
On pleural tap 2 cc. of thick pus was removed, from
which type I pneumococcus was cultured. No further
pus was ever found and the patient promptly recovered.
This abortive course of empyema has been rarely
encountered in our many years of observation of
empyema, especially that following type I pneumonia.

Pneumococcic bacteremia was found in only one
patient, a boy of 8 years, with type I lobar pneumonia.
His defervescence occurred within eighteen hours in the
typical manner. The drug was cut after thirty-six
hours, and the report of the blood stream invasion was
obtained after the drug had been discontinued. Even
with this small amount of therapy, the blood stream
was sterile. As a precaution the drug was readminis-
tered for twenty-four hours, hut all further blood cul-
tures were sterile. Streptococcus viridans was found in
two blood cultures from a patient with bronchopneumo-
nia. The blood cultures were sterile after several days’
treatment with sulfapyridine, and the patient recovered.

COMMENT

The consistent prompt crises observed in our patients
with lobar pneumonia following the oral use of sulfa-
pyridine is convincing to us that the drug is very
efficacious in treating pneumococcic pneumonia (and
perhaps also that due to the streptococcus). But the
value of a therapeutic agent in pneumonia cannot be
established in one season’s time, since pneumococci are
known to vary in their distribution and virulence from
year to year. It may be that results will be less good
in more serious epidemics.

In the present season we have had a lower percentage
of type I pneumonia ( 10.9 per cent for the present year
as compared to 17.8 per cent average for the past six
years). There were probably more mild cases this
season than usual, although many patients were very
severely ill.

The failure of bronchopneumonia to respond favor-
ably to sulfapyridine may he explained on the basis of
etiology, since the bacteriology is variable and often no
pneumococci are found. If a filtrahle virus is the
etiologic agent of bronchopneumonia, as has been sug-
gested by various workers and by some experimental
work with animals, 0 the explanation for the different
reactions of these patients to the drug is probably
indicated. Sulfapyridine has not been especially useful
for diseases due to filtrahle viruses.

For the older child sulfapyridine may well be the
answer to the treatment of lobar pneumonia in the great
majority of cases. In this age group (2 to 13 years)
pneumonia is a milder disease with a much lower inci-
dence of bacteremia and deaths than in adults. Even
though the death rate in children may not be greatly
affected, since it is already low, the shortening of the
disease and the avoidance of complications justify the
use of the drug. There may always be some patients
who will require specific antipneumococcus serum ther-
apy as well as the bacteriostatic agent sulfapyridine.
Infants who are debilitated, chronically ill or anemic
and who may be unable to produce their own immune
bodies may need specific serum as well as sulfapyridine.
The necessity for obtaining a pneumococcus typing,
preferably before chemotherapy is given, is clear. If
sulfapyridine is not effective in the usual time, from
eighteen to twenty-four hours, specific serum may be
given without delay if typing has already been done.
In comparing results from different clinics with sulfa-
pyridine in pneumonia, it is important to compare the
results with reference to the types of pneumococci. It
is known that the duration, severity and fatality of
pneumonia is directly associated with the pneumococcus
types.

We wish to reiterate that it is not necessary to con-
tinue sulfapyridine for many days in the fear of a
relapse. In this series the drug was given only 2.6
days on an average. If the few earl)' cases are excluded,
this time drops to 2.3 days. The average total amount
was 3.99 Gin. for infants under 2 years and 5.4S Gni.
for patients 2 years of age and over. The largest
amount given to any patient was 13.25 Gm. The advice
to “try to stop the drug after 300-450 grains (20-30
Gm.) have been given” 7 seems unwise in suggesting
that these large amounts are usually needed. Sulfa-
pyridine may be a poisonous drug in some cases, as is
indicated hv the reports of cyanosis, hematuria, leuko-

6. McCordock, H. A., and Muckenfuss, R. S.: Similarity of Virus
Pneumonia in Animal to Epidemic Influenza and Interstitial Broncho-
pneumonia m Man, Am. J. Path. 9:221 (March) 1933.

/. Report of the Committee on Immunization and Therapeutic Pro-
cedures. American Academy of Pediatrics, June 1939, p. 13.

1860

Jour. A. M. A.
A' of. IS, 1939

LESIONS OF THE NECK—BAUMGARTNER

pema, delirium, liver damage and even death associated
with the use of the drug. We believe that sulfapyridine
should be given no longer than is necessary to effect
a crisis and should be stopped very soon thereafter. To
continue medication longer is unfair to the patient, just
as it is with any drug having a cumulative poisonous
action. The fact that we have observed no true relapses
and have had no toxic symptoms of importance indi-
cates the value of a wider trial of the small dose and
short administration. Others 5 have produced a crisis
by one day’s treatment and even by a single large dose.

RESULTS

1. From January to July 1939, ninety-three patients
were treated with sulfapyridine; seventy-nine with
lobar pneumonia, eleven with bronchopneumonia, one
with lobular pneumonia and two whose pneumonia was
classified as “subacute pneumonia.”

2. In bronchopneumonia there was no apparent effect
on the course in any of the eleven patients, four of
whom did not survive.

3. In uncomplicated lobar pneumonia with small
dosage, for two or three days only, a crisis occurred
within eighteen to twenty-four hours in seventy-four
of the seventy-nine cases. In the five other cases crisis
occurred in forty-eight hours. One death occurred
from pyopneumothorax. The short duration of therapy
is emphasized not only because of its success but also
because of the very few untoward reactions observed.

Twenty-Seventh Street and First Avenue.

CONGENITAL LESIONS OF THE NECK
CONRAD J. BAUMGARTNER, M.D.

LOS ANGELES

edge of the embryologic anatomy of the neck is essential.
The frequency of recurrences noted following surgical
attack is evident testimony to the fact that a fundamental
knowledge of the subject is not generally held. In the
short space allotted, therefore, I shall sketch diagram-

Fig. 2.-~-Appearance of branchial fistula tract which has been
injected with iodized oil. Note direction corresponding to the sterno*
mastoid muscle and medial arching of the tract at the level ot tnc
middle portion of the posterior belly of the digastric muscle.

The neck with its complex embryologic evolution is
particularly subject to developmental anomalies. Among
these may be mentioned branchial cysts and fistulas,
cystic hygromas, submaxillary and submental inclusion
cysts, dermoids, an accessory auditory canal, a lingual
thyroid and an aberrant thyroid.

Copula

Tuberculurn impan
' CorAmeti Caecum

yroglossal duct

aas

3. B.~

„ 3B.G

4. B.R— -

4.BDR,

'Cervical sinus
Thyroid
^ ,y7 nic due r
Closing membrane

Ttvj

Fig. 1.-— Schematic drawing showing development of branchml
apparatus. I. M, mandibular arch; II. H., h y oid arch; 111, V, V,
third, fourth and fifth branchial arches, 1 B P., 2 B. P-, 3 B. r.,
first, second and third branchial pouches; IB. G. K., 2 B. u ft.
3 B. G. R.. 4 B. G- R., first, second, third and fourth branchial

grooves.

Successful surgical assault of any congenital lesion
consists of a complete reversal of the embryonic
processes causing the condition in question. Obviously,
in the subject being discussed at least a working knowi-

Read before the Section on Surgery, General
the Ninetieth Annual Session of the American
St. Louis, May IS. 1959.

and Abdominal, at
Medical Association,

matically a rough working model of some of the embry-
ology of the neck and its relationship to some of the
common anomalies.

EMBRYOLOGY

Although noteworthy studies of the branchial appa-
ratus have been made by His, Rathke, Born and others,
undoubtedly the greatest single contribution is that of
Wenglowski, 1 who in 1912 published a monograph
giving the results of a detailed study of serial sections,
of a large number of human embryos from 2 to 49 mm.
in length. The clinical applications of these results were
shown by Herbert Willy Meyer 2 in a series of studies
published in 1932.

During the second week of embryonic life certain
changes take place in the fetal foregut (fig- 1 )• IT 0 " 1
the interior lateral walls five outpouchings occur. J >esc
are the branchial pouches. Simultaneously the externa^
ectoderm becomes indented over the correspon m„
pharyngeal pouches. These are the branchial groo'es.
The pouches and grooves approach each other so >«
entoderm and ectoderm come into contact, the contrac
ing area being the closing membranes, which m g
bearing animals disappear, forming the gill clefts,
open from the pharynx to the exterior. The mesod nn
is thus pushed aside into six rounded bars, the wancm.
irehes, of which the first two partially telescope o
the r emainder, forming the cervical sinus, i-acn j — _

I Wenglowski. R.: Uebcr den Halsfistcln und CysUn, Arch-
'"' n 4 iUl Cyst, ,nd FismUc of «te

Min.’ Sure. 95 : 226-248 (Feb.) 1932; foolnote 3.

Volume 113
Number 21

LESIONS OF THE NECK— BAUMGARTNER

1861

contains a cartilaginous bar and in each is also the
anlage of one of the primitive aortic arches.

The first or mandibular arch gives origin to the
muscles of mastication, lower lip, mandible and anterior
part of the tongue, while the cartilaginous bar forms
portions of the middle ear and mandible. From the
second or hyoid arch are developed the structures of
the upper part of the neck and from its cartilage the
styloid process, the styloid ligament, the lesser cornu
of the hyoid and, with assistance of the third arch, the
body of the hyoid and posterior part of the tongue.

The remaining arches all give origin to structures in
the vicinity of the hyoid, the sixth giving origin to the
cricoid, arytenoid and tracheal cartilages.

As to the branchial grooves, no traces persist of any
with the exception of the first, which gives origin to
portions of the auricle and external acoustic meatus and
with it the possible, although rare, congenital anomaly
of the accessory ear.

Proceeding to the interior, one notes that from the
first branchial pouch are formed the auditory tube and
the tympanic cavity, the tympanic membrane arising
directly from the first closing membrane. In the second
pouch, lies the angle of the tonsil; but of particular
significance is the third pouch.

BRANCHIAL CYSTS AND FISTULAS

Wenglowski 1 demonstrated that from the third
pouch on either side two tubules descend into the
mediastinum to form the thymus. The course of these

Fig. 3. — Excision of branchial fistula, showing armamentarium and
method of massaging methylene blue into the tract. (By courtesy of
Surgery, Gynecology and Obstetrics.)

tubules is in the general direction of the sternomastoid
muscles, laterally to the thyroid and anterior to the
carotid sheath. Furthermore, Wenglowski was able to
demonstrate remnants of this tubule in adult necropsy
dissection.

There are several theories regarding the evolution of
branchial cysts and fistulas: 1. That they are caused

by vestigial remains of the branchial grooves or pouches.
2. That they are a result of an embryonic perforation
of the closing membrane. 3. That they are a persistence
of the cervical sinus formed by a telescoping of the
rapidly growing first and second arches over the remain-

Fig. 4. — Branchial fistula. The tract lies along and beneath the
sternomastoid muscle and extends up to the midportion of the posterior
belly of the digastric, where it arches medially to enter the tonsillar
fossa.

ing arches. 4. That they are due to remains of the
thymic duct, which descends from the third pharyngeal
pouch, as demonstrated by Wenglowski in 1912.

Now as one compares the anatomic direction of the
descent of the thymic duct with that of so-called
branchial cysts and fistulas, one finds a rather exact
corollary. Clinically these manifest themselves as a
fistula or cyst containing a mucoid or milky material,
having a uniformly characteristic position along the
anterior border of the sternomastoid, extending under
it but lying anterior to the carotid sheath. Although
occurring at any level of the neck, the tract invariably
runs upward beneath the anterior portion of the sterno-
mastoid muscle to the posterior belly of the digastric,
where it arches medially behind the stylopharyngeus
muscle to end in the tonsillar fossa. The course can at
times be demonstrated by x-ray examination preceded
by iodized oil injection of the tract {fig. 2). The tract
is lined with ciliated epithelium and layers of squamous
epithelium surrounded by stroma infiltrated with round
cells. As Herbert Willy Meyer has pointed out in bis
studies in 1932 3 and again in 1937/ these have nothing
whatever to do with any branchial cleft affairs and
should therefore he considered as thymic duct cysts and
fistulas. Complete removal to the pharynx is of course
necessary. I prefer to inject the tract with methylene
blue (fig. 3) and follow this with a saline irrigation
to remove the excess stain. This prevents discoloration
of the surrounding territory during, the dissection to

Arm. SuVg. 95:1-26 aaST) 1932. ' i 01

x«t, a?c C yst ami

1862 LESIONS OF THE

follow (fig 4). On completion of the dissection the

possible* (fit 5)'. in, ° “’ e Pharynx "’ l ™ ,his is
True branchiogenic fistulas do occur, but they are
indeed rare and must occur within the realm of the

NECK— BA UM GARTNER JouE . A . M . A

Nov. 18, 1919

direction to form the lateral lobes of the thyroid v nw
it is not universally agreed that the thyroid has mil
than one anlage, but the distribution of aberrant thyroids
can certainly be explained on this basis. J

lingual thyroid and thyroglossal duct

CYSTS AND FISTULAS

Dur ing the third week two rounded buds appear on

bud rlT L K e f th£ fil ‘ St tW0 arches ’ T,le anterior
\ l C tU JCrCU, “ m lm P ar , forms the anterior part,

nai nf rf n ° r bU ^ the C ° pula ’ forms the Posterior

P af t of tongue. From a depression-the foramen
caecum-between the two buds a tubule descends to
and around the hyoid bone and proceeds downward to
be the anlage of the thyroid. This tubule is the thyro-
glossal duct. Any arrest above the hyoid in its descent
will result in the anomalous lingual thyroid, which

Fig. 5. Branchial fistula. Tract has been dissected up to arched
passage into the pharynx; b, method of immersion of stump.

branchial apparatus, which at best is not much lower
than the hyoid, and the tract, instead of being lined
with squamous epithelium, is lined with vestiges of skin,
hair follicles, sweat glands and sebaceous glands.

ABERRANT THYROID

Proceeding with the erhbryologic study, Wenglowski
found that from the fourth pouch not only the para-
thyroids developed but that a comparative!}' short
tubule passed on either side in a somewhat medial

Catell and Hoover 5 reported as occurring only twice
in 7,600 thyroids operated on at the Laliey Clinic.
Normally the duct atrophies, but when it remains patent
in any portion a thyroglossal duct cyst or a fistula is the
result.

The clinical picture is that of a cyst or fistula,
which occurs near the middle of the neck, usually just
below the hyoid, and moves up on swallowing. With
the fistulous opening there is either a continuous or
an intermittent discharge of mucoid material. Trouble-
some symptoms such as a choking sensation and diffi-
culty in swallowing are rare, but secondary infection
is fairly common. All too frequently the cyst is mis-
taken for an abscess, and consequently a history of
repeated incision and drainage without cure is often
noted. Adequate surgical approach was fir st described

5. Catell, R. B„ and Hoover, W. B-: Lincual Thyroid Gland: Bff*?
of Case and Discussion of Aberrant Thyroid Tissue, S. Clin* * °*
America 9: 1355-1362 (Dec.) 1929.

Volume 113
Number 21

LESIONS OF THE NECK— BAUMGARTNER

1863

by Sistrunk. 0 It consists of a horizontal incision sur-
rounding the fistula or cyst (fig. 6). A central segment
of the hyoid is then removed (fig. 7) and, since identity
of the duct is usually lost between it and the foramen
caecum, a portion of the tongue tissue is cored out
between these two points (fig. 8).

SUBM AXILLARY AND SUBMENTAL INCLUSION CYSTS

The submaxillary and submental glands are formed
in the alveolar lingual groove directly behind the first
arch. They begin as small furrows, the posterior parts
of which close over to give rise to a number of buds
forming lobules of the gland. Any obliteration of these
tubules will produce inclusion cysts, in which case
surgical assault consists in removal of the offending
gland itself.

CYSTIC HYGROMA

In a recent review 5 of congenital lesions of the neck
I reported eleven thyroglossal duct cysts and fistulas
and four so-called branchial cysts and fistulas. We had
at that time four cases of cystic hygroma. After a

Possible position of
tubule*, above or
below Huoid bone
/

\ / " !P»^

Fig. 8. — Excision of thyroglossal duct fistula. The midportion of
the hyoid bone has been removed. From this point the tract is cored
out in the direction of the foramen caecum, which is about a 45 degree
angle, with the patient in the goiter position. Dissection is carried up
to a point at which the finger at the foramen caecum can be identified,
according to the method of Sistrunk. (By courtesy of Surgery, Gyne-
cology and Obstetrics.)

thorough study of cystic hygroma, Emil Goetsch 8 came
to the conclusion that these probably arise from seques-
trations of lymphatic tissue derived from the primitive
jugular sacs which failed to join the regular lymphatic
system. The tumor is a multilocular tumor (fig. 9)
lined with endothelium and containing a clear or straw
colored fluid, usually located in the neck near the junc-
tion of the internal jugular and subclavian veins. Diag-
nosis is often as easy as the treatment is difficult. These
lesions have invasive properties into any and all sur-
rounding structures, making complete removal usually
an absolute impossibility, and this, associated with a
high susceptibility to infection, results in a rather high
mortality. Figi 0 has recommended irradiation but
reports a rather high mortality, and I am inclined to

6. Sistrunk. W. E.: Thryoglossal Duct, Ann. Surg. 71: 121 (Feb.)
1920.

7. Baumgartner, C. J.: Surg., Gyncc. & Obst. 54: 948-955 (May)
1933.

S. Goctsch, Emil: Hygroma Colli Cystic and Hygroma AxHlare,
Arch. Surg. 36: 394-479 (March) 193S.

9. Figi, F. A.: Radium in Treatment of Multilocular L\mph Cysts
m Children, Am. J. Roentgenol. 21: 473 (May) 1929.

agree with Fleming 10 and Goetsch 8 that as complete
an excision as possible is the method of choice, except
in large tumors in very young infants, in whom radi-
ation might be attempted. I have seen one patient
apparently cured following an infection. In that par-

Fig. 9.-— Cystic hygroma, showing usual location of the multilocular
cystic mass.

ticular case an infection of a cystic hygroma followed
a septic throat which necessitated an attempt to relieve
the obstructive dyspnea by surgical intervention. Inva-

Fig. 10. — Excision of branchial fistula, showing assistant's finger
pushing outward in the region of the tonsillar fossa, as dissection is
earned to the pharynx. (By courtesy of Surgery, Gynecology and
Obstetrics.)

sion of tiny cysts into the muscles could be noted every-
where well down into the mediastinum and surgical
removal was considered most incomplete, yet after a
stormy convalescence there is no evidence of tumor
tissue five years later.

islh9oTat c ^) C ms? ystic Hj ' Erom3 of Keck> J - A - M - A - =

1864

ANESTHESIA— RUTH ET AL.

Jour. A. M. A.
Nov. IS, 1939

CONCLUSION

Surgical assault on any congenital lesion of the neck
necessitates at least a fundamental knowledge of the
embryologic anatomy of the neck. So-called branchial
cysts and fistulas are rare, and what are ordinarily
called branchial cysts and fistulas should be termed
thymic duct cysts and fistulas.

523 West Sixth Street.

ABSTRACT OF DISCUSSION

Dr. Herbert Willy Meyer, New York: The study of the
embryology of the congenital lesions of the neck has always
been a fascinating subject. It is an interesting fact that Dr.
Wenglowski, who has probably done more complete work in
this investigation than any other author, was a surgeon in
Moscow and not an embryologist. His friends, obstetricians
and gynecologists, furnished him with seventy-eight embryos
ranging in size from 2 to 49 mm. He further performed 144
autopsies on the neck region of infant cadavers and added the
study of fifty-nine adult autopsies. Of all of this material he
made wax reconstructions and showed the models at the sixth
and seventh Russian Surgical Congress. A theory based on
such complete and intensive work deserves serious considera-
tion. Wenglowski studied the branchial apparatus and the
development of the neck and such organs as the thymus and
thyroid glands. He showed that the branchial apparatus is
present in the first and second months of fetal life. Its greatest
development is at the end of the first month and it completely
disappears by the second half of the second month. The pha-
ryngothymic duct develops from the third branchial pouch and
passes downward laterally behind the thyroid duct, which
develops from the fourth pharyngeal pouch. The two lateral
lobes of the thyroid developing from the fourth pouch meet the
midthyroid lobe, which descends from the foramen caecum to
form the thyroid gland. The two pharyngothymic ducts passed
downward and forward to meet behind the sternum to form the
thymus gland. Normally these ducts disappear completely. If
only portions disappear, lateral cysts of the neck develop. If
an external opening forms on the skin and the entire duct
persists, a complete lateral fistula of the neck develops, emptying
into the pharynx through the tonsillar fossa. In the midline,
cysts and fistulas of the neck, developing from the lingual duct
and the thyroglossal tract, pass downward to the tongue from
the foramen caecum. A complete patent tract never is present
but only a strand of thickened tissue arising from lingual duct
structures or thyroid gland structures. As the hyoid bone
develops, it cuts this thyroglossal tract in half by pressure.
Frequently gland structures thereby are present under the peri-
osteum and in the midportion of the hyoid bone. Therefore, in
order to cure midline cysts and fistulas of the neck, a mid-
portion of the hyoid bone must always be removed and the
tract cored out from the tongue. Any cj r st or fistula of the
lateral portion of the neck above the level of the hyoid bone
may be a true remnant of the branchial apparatus. Any cyst
or fistula in the lateral portion of the neck below the level of
the hyoid must of necessity be a remnant of the pharyngothymic
apparatus.

Dr. Conrad J. Baumgartner, Los Angeles : I wish to thank
Dr. Meyer for his excellent discussion. It is frequently impos-
sible, particularly in children, to invert the stump as shown by
previous illustration. I have found it helpful in such cases to
have an assistant's finger push outward from the tonsillar fossa
in the direction of the dissection. As the finger of the assistant
is approached, the stump is severed and ligated.

PENTOTHAL SODIUM

IS ITS GROWING POPULARITY JUSTIFIED?

HENRY s. RUTH, M.D.

MERION STATION, PA.

RALPH M. TOVELL, M.D.

HARTFORD, CONN.

ALEXANDER D. MILLIGAN, M.D.

ELMVALE, ONT.

AND

DURANT K. CPIARLEROY, M.D.

PHILADELPHIA

The intravenous use of pentothal sodium in anes-
thesia has shown a definite and consistent increase
since it was first offered in 1934. A five year interval
is too short a period after which to assume a final atti-
tude on any anesthetic drug or technic. Nevertheless
it is a sufficient interval to indicate logically a way,
station in its history at which to pause for a critical
survey. Therefore it is our aim here to "examine the
record” of that which has taken place to date. This
examination will include a brief consideration of the
literature, certain observations concerning the technic
of its administration, and the scope of its rational appli-
cation in our hands.

» , LITERATURE

An editorial of a leading surgical magazine 1 in
March 1939 aptly stated the present position of intra-
venous anesthesia : “The increasing usefulness of intra-

Table 1 . — Reports of Administration of Pentothal Sodium

Cameron

Horsley

225

2,000

Kossebohm nnd Schrolber..
Jarman and Abel

. IS
1.W0
100

Dixon

18

La Brecque

SO

s,:oo

Carrairay and Carraway...

3,559

Ruth and TovelJ

5,300

Total

. 21.311

Heredity and Mental Diseases.— When we consider the
nature and etiology of the various mental diseases we become
aware of the fact that in less than 40 per cent of the patients
admitted to mental hospitals do we find evidence for a hereditary
basis, namely, in dementia praecox, manic-depressive, mental
deficiency with psychosis, and epilepsy. In the remaining 60 per
cent of the patients heredity may play a minor role, but the
important etiological factors are probably constitutional (exoge-
nous) —Landis, Carney, and Page, James D. : .Modern Society
and Mental Disease, New York, Farrar & Rinehart, Inc., 1938.

venous anesthesia for many types of operations has
never been as apparent as it has been recently.” This
statement may be confirmed further by a perusal of
the literature on the subject. More than 100 articles
dealing primarily with or touching on the use of pento-
thal sodium have been published. Medical opinion is
found to be predominantly favorable. v
* In animal experimentation, it has been found that
pentothal sodium may produce disturbances of cardiac
rhythm. 2 Conflicting evidence to this statement has
also been observed, a brief of which may be presented
as follows : A large percentage of animals showed no
change in the electrocardiogram, while another group
showed disturbances in rhythm and conduction which

From the Departments of Anesthesia, Hartford Hospital, Hartfo.d,
Conn., and Hahnemann Medical College and Hospital, Philadelpm -

Read before the Section on Miscellaneous Topics, Session o J
thesia, at the Ninetieth Annual Session of the American Aledica t --
ciation, St. Louis, May 17, 1939. . s. OW.

„ l. Adams, R. Charles: Intravenous Anesthesia, Svrg., Uyncc. ^ -

^ CS 2. / Gruh'r, ( ChaHes JL?' Gruber, Charles M.. Jr., the

A.: The Irritability of the Cardiac Vasus Aerve as Influence
Intravenous Injection of Barbiturates. fh’o^ittirato and I
J. Pharmacol. & Exper. Therap. C« : 215-228 (Jufij
C. M.: ' n,< * of Anesthetic Doses of Sodium Thiopento^ ^

Gruber*

The* Effects of Anesthetic Doses of Sodi
soaium Thio-Ethamyl and Pentothal Sodium on ‘ h L -V*'' WW'
the Heart and Blood Pressure in Experimental Animals. I urn.

47 f Tunc) 1937. Gruber, Charles M.; Haury, Victor C.. and
Charles M., Jr.: The Cardiac Arrhythmia, Characteristic j»jd.

barbiturates, as Influenced by Changes in Arterial Blood
63: 193-213 (June) 193S.

be/nL ten]p ° ra O '- 3 T; ^^ESTl/p 9/ .

rb nhm were " 1 QRS 0r J be ^ Tver eV'f^ciJ
lv, t/iOL!t fj, rec °rded «,/ ^ "' a ves c v 0 c ^anp- e o ?

e iiver y n - s ^ave 5 ee , ' t33e e/ectr c

a-up- cj,„. , . mice. 0 r* • 33 shown ^ ,

J p/

he iiy er -°scs ; la ;;-r ^ « )e e/ " on

dm ® ] ?/ 333 mice o V! been shown * , eCtr °

'z di r ave i «« ?*, ■»■£>«*

gf/7 Cn, "" c afied t0 ., C ”«* n J

%ht a n es th S - nal "’as /„-' s s, m/y i= a ^ P° s sibili tv ° n f

,v 0l! / d s ^esff, prese «ted JeC rf • "'^ejJever^P /de 'ica/

t s5&sa?S-«SiJ

■ and «?cceed rf° lu '" n,e T/S e ^Preslion of^^S tP'
mcr ea serf ■ ded *>y a ,1 P r ««arv „ « f ^stinTf Tile

peS , "•^SS!? 7 ^*SSi£ ,, ^5^ c ^iS?

5 n «mciT r d j?™?. «*rr»fr

Table 2 _pt Jeen soin eu .; 333atl on.

-~J~ "%/' , reta -*«

^^ == ====== == ^ =: ^*^ c nous p Cil . ,, 1 ,Cc d tires p x

«**

S^ : SS?fi:=P

iSSfecsrr-^L " ,e a ” cst *

AneV^* "' "* E, ^°Zl 0 f^T7 e

(Oct Tfte r ' J ' ^b Tf^T~~~

A A’SL ! Pen,0t '^ a n C r&««n of J * Q ' n - S ?3 5 “
< March) ! ‘jS‘uil}- of 'y' 1 and c,-„- Brit - ^ ° Us "■(ft s .

, 6. *' ln e(een *J rra '**av o Xt ^sstJi. T ^ ^Pma J

^otai * °*<*«Wo ns Xo. of
Cases

Total 6co

%Z 0,Dt -' y «®

R°H!*°UoT CUrctt aee..

inSfe^ ”. UMw ^o: *

15

^^ O f o w n ::; is

"'^aneou^ uf< T“C77; 5

Total 30

s “ r «*»i ^

i3^ and . t ' ra,n ^-..

j!>C" hoic,e «o«K:

f , 0 J> 5 r. J 3

:.- 2 S

. ’ «

&' 0/ •iSSjtoalir.V 26
WrrouZt-- - :ln " ro. 9

^J/aoeoS^ is

Total

• • • • CDs

-Ere ;,e,s of °l>era(,'o J)s E 0 . ,

F C J orot °ay CaSt

r . Sc ISsi 0ll n ? a tar «Ct.

£jf*ctoi^,, 3 c °foen " "

;;;;;

Jxfe ««a a ?o'- :; - ; ..."

Tot.-,!

E n' Kos *°n«r,,

r^^y-7 r,Y; ^

Total

d^^-a, : n, °" 1;i1 and°'t^-on of

a, ld Clrr a,ne ' 33

S(i, d , Cs ' o'wtlo, p n hundred’ ^-t In lr - lS: 20- 2 '

357.350' 'ntlino, Jr, ,C"Wn- ^, An alg. , ~ a!,0 ratorv r,, 6taff .

■f ir^na ^

-.Sim •

Urology

v lr ‘a°ioa Dy nn^, v-rap

I

^te""^ erna ' 30
1

04

10

GO

0 pj’°Bodlc s

SSsag^

t *

ta ***£a .::; <

T °fa) ••••■• s'

^otfefrj.

"'"•fferp. *••

Urology-;;--

-

Gran<3 total...

J05

SPilJf.

S«r« ry

p CD Weuio ffrom "

>toft f » , »...:

v < ’"'°PaloJr .7

Total

® r and total..

I«

" Si

-Utr

Ere...

J^aj*

, ,****rnia Co i v w !i of c„ *’ and p' *»

-vL| V >l. J. 7, E-\Pcr ° T r SI, 0rt ?”'Tnsti 0e . £

5S“te°X f Pk J k L P- » m rv ffects 03

33 -'fvaS^n 3 ^ ? f ■ WO S ° diUm

1866

ANESTHESIA— RUTH ET AL.

Jour. A. M. A.
Nov. 18, 1939

intravenously to human beings were located (table 1).
Of this group 2,980 are reported in detail in tables 2
and 3.

ADMINISTRATION

The preparation of the patient, the chemical and
pharmacologic effects and the preparation and method
of administration of pentothal sodium have been here-
tofore adequately described. 10 These aspects will not

Table 3. — Additional Statistics from Hartford Hospital Series

Females

Number

Duration

Minutes

Males

723

Average

2,000

Years Dosage Solution

Oldest

90

Average

Largest.

40.0 ee.

Results

Repeated Administrations

No. Cases

Satisfactory

.. 1,936

Not satisfactory

G4

o

Cyanosis

34

Spasm

0

Rigidity

4

3 times

Postoperative vomiting.. . .

2

7 >

Pallor

3

_

Excitement

2

Multiple ndmiiiis

trations 93

Hiccup

o

Miscellaneous 13

be repeated at this time. Certain factors concerning its
administration will be emphasized, however, and addi-
tional observations presented at this time.

Prior to the publication of the pharmacologic and
physiologic explanation of the value of the adminis-
tration of atropine or scopolamine before pentothal
sodium had been given, it was our practice to admin-
ister these drugs preoperatively. They not only effec-
tively counteract the parasympathetic overactivity of
this drug but minimize the likelihood of production of
excessive secretions. Morphine is prescribed in many
instances together with the atropine or scopolamine
but always in decreased dosages as compared to those
prescribed before inhalation anesthesia. (We regard
morphine sulfate one-eighth to one-sixth grain [0.0081
to 0.0108 Gm.] as the maximal dose.) In the aged and
debilitated, even though morphine is not administered,
and in every instance in which their use is possible,
either atropine or scopolamine is administered.

Caution regarding the speed of injection cannot be
overemphasized. The patient to whom pentothal sodium
is being administered has no active mechanism of
defense as. for example, is initiated by the irritating
action of ether. The facility with which patients may
be anesthetized has proved an ever present temptation
to make the induction even more startling by the too
rapid administration of the drug. A sacrifice of time
will increase the factor of safety. It has been our prac-
tice recently either to consume from one to two minutes
or more for the induction of anesthesia rather than
from twenty to thirtv seconds, or at least to pause
after the injection of 2 cc. of a 5 per cent solution to
estimate the depth of anesthesia produced. Recently a
2.5 per cent solution, instead of the usual 5 per cent
solution, has been employed with satisfactory results. 1 '
This solution further facilitates a slow injection and
appears to remove the possibility of the rare occurrence
of phlebitis.

, , Frederick C and Tovell, Ralph SI.: Anesthesia in Rela-

L. H., to be published.

It should be emphasized that respiratory depression
°“ urs , rea< lily following too rapid administration. No
difficulty should be encountered if the administration
is continued to the point of anesthetic saturation of the
tissues of the central nervous system at a rate suffi-
ciently slow to avoid depressive concentrations being
carried to the respiratory center. Experience in its
administration is the predominant factor in the problem
of timing the rate of injection) It appears that it is a
mean between a rapid injection, which quickly depresses
the respiratory center, and an injection which is suffi-
ciently retarded so that time is allowed for the drug’s
detoxification before anesthetic concentrations are pro-
duced. The function of respiration must be further
protected by diligent maintenance of a patent respira-
tory tract. Relaxation of the soft tissues about the
upper respiratory tract is apt to occur and thereby
impinge on its patency. At the same time) obtundation
of both pharyngeal and laryngeal reflexes does not
occur until quite profound anesthesia has become estab-
lished. Therefore, when an adequate airway cannot be
maintained by proper position of the head, insertion
of a nasopharyngeal airway rather than a pharyngeal
airway should immediately be carried out. At times,
if there is an interference with the efficiency of the
respiratory tract, recourse should be had to the usual
methods for its rectification which are employed during
inhalation anesthesia, which include endotracheal intu-
bation. Cyanosis should never be tolerated by the
anesthetist. A source of oxygen under low pressure
sufficient to inflate the lungs should be constantly avail-
able during the administration of pentothal sodium.

CONTRAINDICATIONS

The contraindications noted elsewhere 18 are recog-
nized by us. The drug is not employed when there is
a marked physiologic or mechanical interference with
respiratory function. At the pr&ient time the drug is
employed rarely for patients under 15 years of age and

Table’ 4. — Average Effect of Administration of Pentothal
Sodium on Blood Chemistry of Txvcnty-Five
Unselectcd Patients

Dextrose, mg

Urcn, mg

Creatinine, mg

Uric acid, mg

Cholesterol

Carbon dioxide

Icterus index

Hemoglobin, Gm

Red blood cells, millions

White blood cells, thousands.

Dlecding time, minutes

Venous coagulation, minutes.
Differential count

Polymorpbonuclenrs

Lymphocytes

Mononuclears

Hosinoph/ls

Basophils

Before

97

35

1.4
3.3

193

49.1

G.S

12.9

4.5

8.5
1.2

11.0

After

109

17

1.3

3.2
193

49.7

7.9

12.0

4.3

1.1

32.S

1 Day -4^
09
IS

1.3

4.0
159

49.7

fi.3

12.9

4.4
S. S

1.1
31.3

73.3

23.0

0.4

0.1

73.1
23.7

3.1
0.1

70.5

39.5
3.2
0.2

eldom below 10 years of age. The presence of cardiac
lysfun ction to the point of dyspnea is recognized as a
ontraindication. Varicosity central to the P 01 ™.,.
ejection serves as a contraindication or a possjo y
if slow entrance of the drug into the general arc
ion after injection is duly noted. Manipulations
urbing pharyngeal and laryngeal reflexes P r f “ cJt ,
d visain’ lit)' of employment of tins drug, unlessober
, dications for it are real and adequate, in sucn_

IS GWalo, .Mario: The Present » i of

aesthetic Agent, J. Connecticut M. Soc. 2:5a0-Sa, (Aot.I I*

•V

Volume 113
N umber 21

ANESTHESIA— RUTH ET AL.

IS 67

condition, preliminary topical anesthesia of the affected
mucous membrane is to be established. A definite devi-
ation from normal in the oxygen-carrying capacity of
the blood indicates caution in its application, as for
example in the presence of severe anemias. It would
not seem wise to employ it in the face of gross hepatic
damage, although we found in one instance that the
icterus index and bromsulphalein test were unaffected
by a forty-minute administration for an intra-abdominal
visualization in the presence of massive cancer of the
liver.

undesirable effects and their management

Sloughing of tissue and irritation at the site of injec-
tion may be prevented by the injection of a 2.5 per
cent instead of a 5.0 per cent solution. Respiratory
depression is rarely a problem with careful and experi-
enced administration but, when present, is best managed

disease. Pentobarbital sodium may be used as an alter-
native agent for this purpose. From 3 to 4 y 2 grains
(0.2 to 0.3 Gm.) administered intravenously will usually
suffice. 10

The results in thirty-four major intracranial pro-
cedures were gratifying. Its application in this respect
was initiated by a report that intracranial pressure is
not raised by its use 00 and by the freedom from hazard
of fire and explosion that is provided. Infiltration anes-
thesia is performed, and pentothal sodium is admini-
stered only when the patient becomes tired or restless.
Initially, it is injected in similar fashion as described
for prolonged operations under regional anesthesia.
In several instances it was not necessary at any time
to produce complete unconsciousness. This method
appeals to us because of its greater controllability as
compared to rectal instillations of other agents. The
simple apparatus for this purpose is shown in the

by inhalation or inflation of oxygen. Mus-
cular tremors may be annoying, but slow
administration usually overcomes them. If
not, resort should be made to another agent.
Postanesthetic headaches are rare. The fall
in blood pressure is minimal. Postanesthetic
nausea and vomiting are also rare.

APPLICATION

We feel that pentothal sodium is a valu-
able drug for operations of short or moderate
duration, when extensive muscular relaxa-
tion, particularly abdominal, is not required
and when there is no interference with respir-
atory function and laryngeal or pharyngeal
reflexes. Its use in our hands is adequately
shown in tables 2 and 3.

In addition, we would call attention to its
value in our hands i'n certain supplementary
capacities. The first of these is indicated
during the operative period under regional
or spinal anesthesia, when such is prolonged.
Here occasionally the patient may become
somewhat uncomfortable as the result of the
operative position. This condition is further
complicated by a progressive diminution in
the effects of the preanesthetic sedation.
Here we have found it quite advantage-
ous to administer intermittently minimal

amounts, just short of the establishment of Apparatus for continuous intravenous drip between administrations of pentothal sodium.

unconsciousness. By this means the patient

is rendered relaxed' and calm and there is a rees- accompanying illustration. The continuous intravenous
tablishment of the effects of the original preanesthetic drip flows between administrations of pentothal sodium
sedation. at an}' desired speed and prevents clotting in the needle.

Anesthetists are rarely called on today to anesthetize The operating time varied up to five hours and fifteen
patients suffering from toxic hyperthyroidism who have minutes, with an average time of two hours and forty
_ not been controlled medically before operation. Never- minutes. The largest single dose was 3.15 Gm., with
theless, instances occasionally occur in which preopera- an average dose of 0.95 Gm. hrom both surgical and

five treatment in this condition is of decreased value and anesthetic points of view we see reason to continue

it becomes essential to anesthetize these patients with a Jts use m such manner for major intracranial surgery

minimum of preanesthetic disturbance. In such a situ- u ,? \ ou . state , f Iat t I,s j P ort,on of the series is too

ation it has been our custom to visit the patient in his if* 11 * 0 be pnchiave . U should also be emphasized
room and to state that a blood test is to be performed. b J, * a ^ ^^nLd group ma " aged 0n,y

-Viter venous puncture, the unsuspecting patient is put ° ° 1

to sleep with just sufficient pentothal sodium to enable electrocardiographic and blood studies
his removal to the cart. Anesthesia is then continued An investigation into possible blood changes was
by inhalation methods. By such means we have been carried out by having tests, the results of which are

able to remove the patient to the operatin'! room and s ' 10 "’ n 111 fable 4, performed on the day of, but before

have the operation started without any evidence of ' R, Charter rYmnai communication ,o the aut i.o«

increase m the toxic manifestations of the patient's cofis. (jh B ln iS c ?jw Pressurc Durins Barlj!t ai Xar-

1S68

ANESTHESIA — RUTH ET AL.

the administration of, pentothal, immediately follow-
ing the conclusion of the operation, and in the morning
of the first day following its administration. These
were completed on twenty-five consecutive unselected
patients. 21 A slight but evidently insignificant rise in
the content of dextrose in the blood may be noted
immediately following the anesthesia, with a decrease
to the preoperative level the next day. Five patients,
however, showed a slight immediate decrease. Tire
apparent average rise in blood urea was, to a large
extent, accounted for by one patient who exhibited an
abnormally high preoperative reading with subsequent
additional rise. No changes of any significance were
shown in the remainder of the tests performed.

The control of the level of blood sugar is easier than
is the control of vomiting which may occur after the
administration of other anesthetic agents by inhalation.
Since vomiting may lead to the establishment of a dia-
betic acidosis, it is important to be able to control this
untoward reaction by employing pentothal sodium.
Patients over 40 years of age may have an associated
diabetes and marked cardiovascular disease. It is to
members of this group that pentothal sodium must be
given with extreme caution. 22

Starr 23 reports that the electrocardiograms taken
before, during and after pentothal sodium anesthesia
at Hartford Hospital have been examined by him. He
states that all the grams were normal and remained
normal throughout the experiments. The rates showed
only slight change. The PR intervals were not affected.
The amplitude, contour and direction of the QRS com-
plexes and T waves showed only slight, inconsequential
variations during the test.

summary

The contraindications to the administration of pento-
thal sodium are specific. Patients should he carefully
selected. Special care should be taken to maintain an
efficient airway and one should always be prepared to
administer oxygen by inhalation or by insufflation if
necessary. The maximal dose of 1 Gm. needs seldom
be exceeded. This potent drug should be administered
by an anesthetist competent to control all situations
that are likely to occur during the administration of
any general anesthetic agent. The drug has produced
satisfactory results in our hands. No postoperative
pulmonary complications were encountered and no oper-
ative fatalities occurred. In view of its apparent effec-
tiveness and safety, its growing popularity is warranted
and further exploration for possible application among
the groups of patients now receiving inflammable anes-
thetic agents by inhalation seems justified.

ABSTRACT OF DISCUSSION
Dr. George J. Thomas, Pittsburgh: My experience with
pentothal sodium has been very satisfactory, especially the results
of electrocardiographic study. At first an electrocardiographic
study was made of patients receiving pentothal sodium and
carried in the upper surgical plane of anesthesia. The result
of these cases showed no change on the myocardium or the
conductive system of the heart. Being encouraged by . these
results I proceeded to study this agent under unusual conditions.
For subjects my associates and I took patients with normal

21. From the Clinical Laboratories of the Hahnemann Medical College

5 n ^ ^Rat t ers on , Robert L.: Case Reports of Fatalities Following Intra-
venous Anesthesia. Proc. Am. Soc. Anesth,, Inc., Feb. 10. 1939.

" 23 °' Starr, Robert S-: Personal communication to the authors.

Jour. A. M. A.
A’ov. IS, 19J9

electrocardiograms and gave them 'a large dose of pentothal
sodium Electrocardiographic study while under this toxic dose
showed no. change. Five days later electrocardiographic study
of the patients showed no latent after-effects. A patient was
admitted to the hospital for an operation. He had a coronary
attack two years prior to admission. An electrocardiogram
showed evidence of bundle branch block due to infarction in
the ventricular septum. Numerous premature beats were present.
During and after anesthesia, tracings showed no deleterious
effect. In fact, following anesthesia the rhythm became regular
and the premature beats disappeared. Therefore I feel that the
more serious a cardiac condition in a case in which operation
is necessary, the more indication there is for pentothal sodium.
Preanesthetic medication is an important procedure for a satis-
factory intravenous narcosis, I would emphasize the use of the
opiates, atropine or scopolamine. We have used pentothal
sodium to stop the annoying convulsions that occur under ether
anesthesia. As a rule, 2 cc. of S per cent solution will stop
these convulsions in children. We have used pentothal sodium
from five minutes to three hours and fifteen minutes, from
5 years to 85 years of age, from 3 to 69 grains (0.2 to 4 Gm.)
in a series of 3,100 cases in the past two and one-half years.
We have bad no pulmonary complications or death attributed
to this type of anesthetic. I agree with the authors regarding
the intermittent technic. At St. Francis Hospital we have made
this possible and convenient by means of a simple apparatus.
For short operations we use the single syringe and a three way
stopcock. When the solution in the syringe is depleted wc are
able to refill the syringe by means of this stopcock. In opera-
tions consuming longer than twenty-five or thirty minutes the
cannula of the needle frequently becomes clogged with blood
clot. Because of this complication we use a manifold to which
we attach an ordinary intravenous needle. This makes it pos-
sible for us to administer salt solution and pentothal sodium
through the same needle.

Dr. Ralph Knight, Minneapolis : I quite agree about the
danger of muscular spasms of the pharynx and larynx during
pentothal anesthesia. At the University of Minnesota we have
a good many cases of malignant disease in the region of the
mouth and throat. The surgeons constantly asked for pentothal
anesthesia for biopsy and often even for destruction of the
lesions. Gas anesthesia was impracticable, the contemplated
procedure usually seemed too minor to warrant ether anesthesia,
and cautery destruction was usually planned. Under pentothal
anesthesia, even in the second or third plane of the third stage,
in many cases severe spasms of the tongue, pharynx and larynx
occurred as soon as the surgical procedure was started, causing
respiratory obstruction. Under pentothal sodium, respiratory
effort ceases promptly after the occurrence of obstruction.
Resuscitative measures were too frequently called for 3 iid were
sometimes difficult. Often too the surgery proved to he more
major than anticipated and it became still more of a problem
to maintain an open airway and satisfactory anesthesia. Jo
obviate these difficulties I attempted transnasal blind intubation
of the trachea and was surprised to find that it was not dimeu
under pentothal anesthesia. For a case of carcinoma of t ic
nose I attempted transoral intubation and found it not difficu
although it required much deeper pentothal anesthesia than w
transnasal method. The first injection of the pentothal sodium
must be more rapid than usual to obtain quick throat re ax
tion; then the injection must be continued, entirely ” w,cr '
direction of the one who is inserting the tube, until the ar} .
noids and cords relax and the tube can be inserted. This a
not over two minutes as compared with ten to fifteen nlinu
with gas and ether. As soon as the tuhe enters the tracnc,
respiration is usually stimulated. One has complete cetitro ,
even should respiration be somewhat overdepressed a ten
lations with oxygen from the machine will restore it to n
Pentothal sodium with intratracheal oxygen proved to w
ideal anesthetic for these head cases and with this JJ .
we adopted pentothal induction as the routine for miroaucuo
of intratracheal tubes whenever they are indicated for . . ..
of surgery, regardless of the anesthetic selected tor m f

Wc have now inserted almost 150 intratracheal tube
pentothal anesthesia.

Volume 113
Number 21

1869

ANDROGEN IMPLANTATION —VEST AND HOWARD

CLINICAL EXPERIMENTS WITH
ANDROGENS

XV. A METHOD OF IMPLANTATION OF

CRYSTALLINE TESTOSTERONE

SAMUEL A. VEST, M.D.

CHARLOTTESVILLE, VA.

AND

JOHN E. HOWARD, M.D.

BALTIMORE

From experimental observations it is well known
that androgenic substances are chemically changed
and excreted after entering the circulation. The effec-
tiveness of any androgenic preparation depends on
many factors. One of the most important, besides the
frequency of administration and the dosage, is the
method of administration. The use of various solvents,
the addition of fatty acids to the androgenic solutions,
esterification of the substances and many other varia-
tions have been studied in an attempt to increase the
efficiency of administration of androgenic substances.
The fact that pure crystalline testosterone is readily
absorbed by the body fluids undoubtedly leads to waste
when excess material is given. In order to overcome
this difficulty and to decrease the rate of absorption,
testosterone has usually been injected in an oily solu-
tion as the propionate. Injection of testosterone pro-
pionate has proved far more effective than the
equivalent amounts of free testosterone. The intensity
and duration of the action of testosterone has been thus
enhanced, and treatment of hypogonadism in human
beings has been satisfactorily carried out with injec-
tions at intervals of from three to four days. 1 From
the results of animal experiments it would appear that
when large amounts of testosterone propionate are
injected at such intervals an appreciable proportion of
the substance is wasted. Testosterone has also been
used clinically in the form of inunctions and by oral
administration. It is not entirely satisfactory in the
form of innunctions and when given by mouth enormous
amounts are necessary to elicit clinical response. A
method of administration which would tend to simulate
the secretion of this hormone by the testis has been
sought. If androgenic substance can be administered
so that the amount absorbed daily is not in excess of
the physiologic requirements, waste will be eliminated
and expense can be kept to a minimum. Before the
prevalent intramuscular injection of the testosterone
propionate in an oily solution is supplanted, a new
method must prove to be more convenient, more effi-
cient, less expensive and devoid of harmful conse-
quences.

The first use of pure androgens and estrogens by
subcutaneous implantation of crystals or pellets was
reported by Deanesly and Parkes 2 in 1937 and 1938.
Their work indicated that tablets of compressed crvs-

From the Janies Buchanan Brady Urological Institute and the Depart-
ment of Medicine of the Johns Hopkins University and Hospital.

This work has been aided by a grant from the Ciba Pharmaceutical
Products, Inc., which also supplied the testosterone, and by a fellowship
from the Lalor Foundation.

This method was presented in brief in a discussion before the Section
on Urology at the Ninetieth Annual Session of the American Medical
Association, St. Louis, May IS, 1939.

1. Vest, S. A., and Howard, J. E.: Clinical Experiments with the Use
of Male Sex Hormones: Use of Testosterone Propionate in Hypogonad-
ism, J. Urol. 40: 154-1S3 (July) 1938. Howard and Vest. 6

2. Deanesly, Ruth, and Parkes, A. S. : Factors Influencing Effective-
ness of Administered Hormones, Proc, Roy. Soc., London, s. B 124:
279-29S (Dec. 7) 1937; Biological Properties of Some New Derivatives of
Testosterone, Biochezn. J. 31: 1161-1164 (July) 1937; Further Experi-
ments on Administration of Hormones by Subcutaneous Implantation of
Tablets, Lancet 2:606-608 (Sept. 10) 193S. Deanesly, Ruth: Use of
Castrated Mice for Testing Androgenic Substances, Quart. J, Pharm. &
1 barmacol. 11: 79-S3 (Jan.-March) 193$.

tals implanted subcutaneously produced stronger and
longer effects of stimulation than similar doses given
by injection. Schoeller and Gehrke 3 later showed the
superior effect of implanted testosterone and testos-
terone propionate tablets in fowls. Having knowledge
at the time of the work that Deanesly was carrying out
in experimental animals, we first implanted pellets of
crystalline testosterone subcutaneously into a patient
with hypogonadism in the fall of 1937, but these pellets
were too small to produce any significant clinical
results. Three recent reports 4 have referred to the

£5

111

i

jHljjk

k

Fig. 1. — Tlie instruments used to make pellets of various sizes. A, the
press; B t the die with three sizes of pellets; C, the punches; D, the
assembled press with a punch in place; £, the heavy metal mallet.

implantation of small pellets of testosterone in human
beings with questionable results. In the- fall of 1938,
soon after Thorn 5 began his work with the implanta-

a. senoeuer, w..

t'f. %V A k ? ns mannlicher . an Kapauncn

Klin. Wchnschr. 17:694-

4. Lippross, O. : Ergebnisse der Behandlung mannlicher Kcimdrusem
hormonen, Munchcn. med. Wchnschr. S5: 1668-1672 (Oct. 28) 1938.
Foss, G. L.: Clinical Administration of Androgens: Comparison of
\ arums Methods, Lancet 1: 502-504 (March 4 ) 1939. Hamilton, J. B.,
and Dortraan. R. I.; Influence of the Vehicle upon the Length and
Mrength of the Action of Male Hormone Substance Testosterone Pro-
pionato Endocrinology 24:713.739 (May) 1939.

. , 5 - ’f, ° T ra » L., and Elenberg, Harry: Treatment of

-Adrenal Insufficiency by Means of Subcutaneous Implants of Pellets o
Desoxy-Comcostcrone Acetate (A Synthetic Adrenal Cortical Hormone),
Bull. Johns Hopkins Hosp. 64: 355 (March) 1939.

1870

ANDROGEN IMPLANTATION —VEST AND HOWARD

tion of moderate sized pellets of desoxycorticosterone
acetate, we began to make and implant pure testosterone
in large pellets weighing up to 800 mg. We have now
implanted these pellets into a series of thirteen patients
with hypogonadism. 0 We have implanted pellets sub-
cutaneously or intramuscularly in the leg, arm, back

point); D, end of injector showing obdurator extruding a pellet; E, same
as D but with two pellets being, extruded.

and scrotum. The pellets have been removed later and
reweighed in order to calculate the average amount that
has been absorbed daily. The actual curve of absorption
probably shows a gradual decrease as the size of the
pellet becomes smaller. Tissues surrounding the pel-
lets, which are foreign bodies, have been removed and
studied pathologically. Assays of the urinary andro-
gens and estrogens have been made before and after
implantation. A systematic study of various aspects of
pellet implantation with both crystalline testosterone and
some of its esters is now being completed and an evalu-
ation of the clinical results will be discussed in a forth-
coming report. 7 A study of the effects of testosterone
and its esters in the monkey, comparing the method of
injection with the implantation of pellets, is also in
progress. 8

Our purpose in this report is to present a new technic
for the subcutaneous implantation of solids such as
pellets of pure crystalline androgenic substance by
the use of an “injector” instrument. 9

If the slow absorption of subcutaneous androgenic
substance in pellet form was to be more efficient per
unit weight of material utilized, this advantage would
be offset somewhat by the impracticability of the neces-
sary incision for implantation. To obviate an operating
room procedure, the following method was devised.
Figure 1 A, B and C shows the press, die and punches
used to make pellets of three different sizes. The pellets
are shown in their cor responding slots. Figure 1 D

6 Howard. J. E.. and Vest, S. A.: Clinical Experiments with the
Use of Male Sex Hormones. Am. J. M. Sc., to be published.

' 7. Howard, J. E.. and Vest. S. A., to be published.

<! rest S A • Drew, Edwin, and Howard, J. E., to be published.

9. This’ instrument was developed with the assistance of Mr. Frederick
C. Wappler, of the American Cystoscope Makers, Inc.

Jour. A. M. A.
Nov. 18, 1939

shows the assembled press with a punch, in place
F igure IE shows the heavy metal hammer used to
pound the previously sterilized, powdered testosterone
into a very hard and compact pellet. These implements
can be boiled and the pellets are made under sterile
technic. It has • been impossible to make pellets of
uniform size and weight with such an apparatus, but
for practical purposes it has served -for our study. Many
factors probably affect the absorption rate, the foremost
of which are' the surface area , and the density of the
pellet. Other possible factors are the vascularity of
the site of implantation, the extent of the reaction to
the foreign body and the degree of hormone' deficiency.
For absolute comparative values regarding 'absorption
and clinical effect in a series of cases it would have
been ideal to implant pellets of identical size and weight,
but this was not possible.

Figure 2 A shows one of several instruments which
we have devised on the principle of the syringe in
order that solid pellets might be injected subcutaneously
or intramuscularly in the office instead of in an oper-

P4 .... -

'? ■■ • •
....

\

k

• -v 1

\l

• sisr i

■■■■- m

. ■: ■! B' ’

■ —

71

1 ;

■rf ~ A c

Fig. 3. — Method of depositing pellet by means of n nf» J (ocl(
instrument. A, instrument entering skin of leg through a ' . ijjnv

anesthetic; B, end of instrument below fascia lata , « ecn ^ned

pushed forward to extrude and deposit pellet (the fenestra n
by rotating window); C, skin clip to close puncture wound.

a’ting room. It shows the instrument with the fenestra
closed and the obturator slightly withdrawn. A sca pe -
like point serves to pierce the skin, leaving ? 5 ‘
linear opening. Figure 2 B shows pellets of t 1
caliber for which three sizes of instruments an **
used, depending on the amount of material one < *
to inject. The maximum amount injected tw 1

Volume 113
Number 21

ANDROGEN IMPLANTATION —VEST AND HOWARD

1S71

an instrument to date is two pellets of more than 400 mg.
each at one time. Figure 2 C shows the instrument
with the fenestra open and the obturator withdrawn.
Figure 2 D shows the end of the “injector” or
“implanter” with the fenestra open through which the
obturator is extruding a pellet. Figure 2 E shows how

A . ; B-

.Fig. 4 (case 1). — Appearance of patient, aged 21, with hypogonadism
before and after implantation of pellets of crystalline testosterone in muscle
of back. A, full view and genitalia before implantation; B, same ninety
days later.

two pellets cau be injected, one following the other.
1 he obturator can be entirely withdrawn and the pellets
inserted into the proximal end of the barrel as desired
instead of through the open fenestra. The fenestra
can be opened and closed at will by means of the rotary
barrel mechanism controlled at the handle.

The instrument is used in the following manner, as
shown in figure 3. A wheal is made in the skin of the
thigh with a solution of nupercaine. The instrument
with the pellets of testosterone inside and the fenestra
closed is pushed painlessly through the skin and, if
desired, beneath the fascia lata (fig. 3 A). In figure 3 B
the fenestra has been opened and the obturator is being
pushed forward to extrude the pellets in the muscle of
the thigh. The fenestra is then closed and the instru-
ment is withdrawn, leaving the pellet in place as shown
in fig, 3 C. A silver clip has been used to close the
puncture wound. A clip is not always necessary

because the margin^ of the skin of the 6 to 8 mm.
puncture wound usually approximate themselves.

The following two cases are reported as examples
of the clinical activity of testosterone when it is
implanted into man in the form of pure crystalline
pellets of large size :

Case 1.— History— W. A., a white youth aged 21, admitted
to the James Buchanan Brady Urological Institute March 21,
1939, complained of having "never matured sexually.” His
two brothers developed normally. The usual changes of puberty,
with the exception of the appearance of a few pubic hairs at
the age of IS to 16, did not occur in the patient. He stopped
school in the eleventh grade because of his underdevelopment.
His psychologic content was definitely male. Erections had
occurred frequently in the mornings since the age of 17, and
he masturbated several times a year but without ejaculation.

Examination . — Figure 4 A shows the typical eunuchoid
appearance. The patient was S feet 10)4 inches (149 cm.) tall
and weighed 142J4 pounds (64.8 ICg.). Roentgenograms showed
a normal skull and sella, but there was retardation in the
epiphysial closure of the bones. There was more than 25 but
less than 50 rat units of follicle stimulating factor per liter of

A - B

Fig. 5 (case 2). — Appearance of patient, aged 34, with hypogonadism
before and after implantation of large pellet of testosterone weighing 750
mg. into scrotum. In some respects this could be termed a “synthetic
testicle." A, full view and genitalia before implantation; B, same two and
one-half months later. Slower absorption of large pellet in scrotum was
taking place as compared to case 1.

urine. No hair was present on the face, extremities, abdomen
or chest. The breasts were normal. The voice was high
pitched. The penis was infantile (fig. 4 A) and only 5 cm.
long on^ complete extension. The testicles were about 4 to
5 mm. in diameter and were situated in the scrotum. The
outlines of the prostate and seminal vesicles were impalpable.
No secretion was expressed by massage of the prostatic region.

1872

Jour. A. M. A.
A’ov. 18, 1939

ANDROGEN IMPLANTATION— VEST AND HOWARD

Treatment . — March 25 three pellets of crystalline testosterone
weighing 277, 219 and 175 mg. were implanted in the right
lumbar muscles. (In this case we used three relatively small
pellets instead of one or two large ones because we wished to
study the absorption rate of pellets of this size compared with
the larger ones.)

Result . — The second day after implantation the patient began
to notice an increased frequency of erections and he masturbated
eight times in the subsequent three months. Ejaculation. occurred
for the first time in his life. The nipples soon became tender
with the appearance of small lumps underneath, more marked
on the left. At the end of the first month the voice began to

r.vr-*' i-W- v >■ : , r : • • ■

rig. 6. — Sections of tissue showing reaction around cavities where pellets
had been placed for three months in the subcutaneous tissue of arms ot
two patients. A. many giant cells with some round cells and leukocytes;
B, fibrous tissue, some of which is hyaline, and a dense collection ot
round cells.

crack and assume a lower pitch. At the end of three months
(June 23) a distinct increase of pubic hair had occurred, together
with the appearance of profuse, thin, short hairs on the lower
legs. The scrotum became larger and darker. The prostate
was then three fourths of the normal adult size and of normal
consistency and contour. The seminal vesicles were, however,
barely palpable. Normal prostatic secretion was expressed
The penis increased in diameter and when completely extended
measured 8.5 cm. Figure 4B shows the patient’s appearance
June 23, ninety davs after the pellet implantation. During
this period he absorbed the three pellets completely, an average
of at least 6.9 mg. a day. Pellets of this size absorb rapidly;
.his absorption rate was approximately twice that of what we

have found in other patients who received a single large pellet.
The patient is now continuing to develop with a single pellet
weighing 778 mg.

Case 2. History.- — J. R., a man aged 34, entered the James
Buchanan Brady Urological Institute April 1. 1939, His
brothers were normally developed. At the age of 15 the patient
had his present degree of pubescence. Since then he had had
an occasional erection, with rare masturbation without ejacu-
lation.

Examination . — The patient presented a eunuchoid appearance.
Figure 5 A shows the patient before treatment. He was 5 feet
5)4 inches (167 cm.) tall. A roentgenogram showed delayed
union of the epiphyses with the skeletal age of a youth 18 years
old. There was present 25 rat units of follicle stimulating
factor per liter. The genitalia were undeveloped (fig. 5-4).
The penis was 4.5 cm. long on complete extension. The testes
were 1 cm. long and were situated in the upper part of (he
scrotum. Considerable pubic, rectal and perineal hair was
present. No hair was present on the chin, body or extremities.
A tiny amount of prostatic tissue could be felt around the
urethra. The seminal vesicles were indefinite. No secretion
could be expressed by massage.

Treatment . — April 10 a pellet of pure testosterone weighing
750 mg. was implanted into the scrotum. The scrotum was
selected because of its superficial position where the pellet could
easily be palpated from time to time. It is possible that absorp-
tion from the scrotum is slower and not as satisfactory as from
muscle or subcutaneous tissue.

Result . — Figure 5 B shows the patient’s appearance two and
one-half months after implantation, at which time it seemed
by palpation that only about one third of the pellet had been
absorbed. During this time he complained of erections prac-
tically all night and frequently during the day. The testes
descended to the bottom of the scrotum so that the left came
to lie just adjacent to the pellet. The voice became deeper. He
gained 4 pounds (1,814 Gm.) the first two weeks and 3 pounds
(1,307 Gm.) the following two weeks. He began to masturbate
three or four times a week, with ejaculation. Slight tenderness
appeared in both breasts, especially the left. Hair began to
grow on the lower legs and the upper lip. In two and one-half
months (fig. 5 B ) the penis had increased in size and was now
6.3 cm. in complete extension. The prostate had developed
to about two thirds normal size. It was norma! in contour,
shape and consistency. Several drops of secretion could be
expressed which were normal in appearance and normal micro-
scopically. The seminal vesicles were easily palpable and
almost normal in size.

The clinical results, though just beginning in these
patients, is indicative of the activity of _ crystalline
testosterone when implanted subcutaneously in the form
of pellets. The method may prove to have important
clinical applications, but more extensive work is neces-
sary to establish this with certainty. .

It has been of interest to study the type of tissue
reactions which occur around pellets of testosterone.
Figure 6 A and B shows photomicrographs of the tissue
encapsulating pellets four months after implantation.
In figure 6 A the cavity in which the pellet was situa ec
s visible. Surrounding this cavity is granulation tissue
containing many foreign-body giant cells, an occasion,
eukocyte and some round cells, all lying in a fibroo .
natrix. In 6B (another case) there is less reac
o the foreign body, with only a rare giant cell, i
ibrous scar tissue has developed, some of wine i is *
ine. A dense collection and some diffuse round .. , „
ire seen. There is no evidence of unusual cc
eaction, metaplasia or carcinogenic activity.

It is possible that such an instrument ‘ (rj

leveloped and presented here might he appbca
njection of other solid medicinal materials. _
University Hospital, Charlottesville, Va.— -4 kxis
Itrcet, Baltimore.

Volume 113
Number 21

1873

CHILDHOOD TUBERCULOSIS— HALL

THE PROTECTION OF CHILDREN
FROM TUBERCULOUS ADULTS

FAIRFAX HALL, M.D.

NEW ROCHELLE, N. Y

There is a definite hazard to the health of children
from intimate association with persons about whom
little or nothing is known with regard to freedom from
tuberculosis or other communicable conditions. Since
parents are much more apt to have had adequate medi-
cal supervision than the servants in a home, the risk
to children from the latter is greater. Occasionally an
older member of a family, mistakenly thought to have
“chronic bronchitis” or “asthma,” is a factor to be
considered in safeguarding a child from tuberculosis.
School teachers with active tuberculosis are a menace
to their pupils.

The New York Tuberculosis Association in 1922,
through the instigation of Dr. Charles Hendee Smith,
made a study of the subject of protecting children
from tuberculous servants. 1 It was stated that . every
stranger who comes into our household carries an
insidious threat against our nearest and dearest, the
children,” and “it is high time to combat this very real
danger.” It was concluded that all persons in contact
with children should undergo periodic medical examina-
tions. _

It is unnecessary to detail the several instances
among my patients in which a primary tuberculous
infection was acquired from a servant or other member
of the household. Every physician with experience in
the care of children knows of instances in his own
practice of primary tuberculosis from exposure to
tuberculous adults in the home. With a few of my own
child patients infected in this way the outcome was
tragic. In others the tuberculin reaction was positive
without clinical evidence of pulmonary lesions during
childhood.

A large number of children in whom the tuberculin
reaction was positive before 7 years of age were fol-
lowed for 11 years by Ch’ui, Myers and Stewart. 2
Nine times more of these children developed the rein-
fection type of disease than did those of a control group
in whom the tuberculin test was negative at the same
age. This is conclusive evidence of the potential danger
to the future health of a child when the tuberculous
infection is acquired early. It shows that a positive
tuberculin reaction in childhood is undesirable and may
be a more serious matter than a positive Wassermann
reaction.

The fact is, practically all childhood tuberculosis is
contracted from association with adults who have the
disease in an open form. I agree emphatically with
Dietrich 3 that to prevent the contact of tuberculous
persons with children is as worthy a project as was
that to eliminate tuberculous dairy cattle from the pro-
duction of milk. By proper foresight and appropriate
action this can be done.

At the time when C. H. Smith 1 made the attempt to
attack the problem of the tuberculous servant he
encountered many difficulties which are still present,

although possibly to a less degree. The public is now
more fully aware than in the past of the danger to chil-
dren from contact with open tuberculosis. This and
the campaign of education regarding syphilis have
made parents willing and anxious to keep diseases of a
communicable nature out of their homes and away from
their children.

Prevention of contact between children and tuber-
culous nursemaids or other domestic helpers will be
less frequent when parents are so convinced of the
necessity of employing only healthy servants that they
will demand proof of their servants’ health. Too fre-
quently a great deal of resistance has to be broken
down and prejudices overcome before servants can be
induced to submit to this procedure. Domestics having
to do with the care of young children must be per-
suaded that it is to their advantage to have periodic
medical examinations so that they will secure them as
a matter of course. When “health references” are
universally asked for and a health card is essential to
get a job, a great step forward will have been made.
Physicians interested in child health should influence
their patients to take this wise precaution for the sake
of the children.

The danger to children from a tuberculous school
teacher is illustrated dramatically by the case of a
teacher in Minnesota reported by the Jordans. 4 This
teacher, with unrecognized far advanced tuberculosis,
in addition to teaching chemistry instructed the band
and orchestra. Often he would blow into a child’s
instrument, showing him how to execute a difficult
passage. The child then returned it to his own lips,
with a definite sputum transfer. It was found that
33p3 per cent of the boys of the band reacted positively
to the Mantoux test while the pupils of the school as
a whole were 15.72 per cent positive, a 100 per cent
greater incidence among his pupils.

The teachers and janitors in this school were 49 per
cent positive to the Mantoux test. Five of the 173
examined had reinfection adult type pulmonary tuber-
culosis.

In a tuberculosis survey in Macon County, 111., 5 of
705 school teachers given x-ray examinations 315 were
found to be infected and nine were actively tuberculous.
Lindberg concludes with the statement that “while
the school teacher has not more tuberculosis than the
average adult, next to the family she provides the
greatest opportunity for close prolonged contact with
the school child. To require the teacher to provide a
health certificate, including chest films, would serve to
remove this reservoir of infection.”

As a result of tuberculin tests and x-ray examina-
tions of more than 6,066 school teachers in a survey
in several parts of the country, 2.15 per cent were
found to have tuberculosis in a stage requiring treat-
ment. On this basis Lees 0 concludes that among the
871,607 teachers in our elementary and secondary
schools 18,739 tuberculous teachers were in active
service in 1936. This statement was confirmed by
Myers. 7

L. S. Jordan 8 maintains that the prevention of infec-
tion is the primary step in the control of tuberculosis.

— 1 — " 4. Jordan, L. S., and Jordan, K. B.; Minnesota Med. 1G: 555

Read before the region I meeting of the American Academy of (Sept.) ,1933. _ ,

Pediatrics, New York, June 1, 1939. 5. Lindbcrg, D. O. N ; The School Teacher as a Source of Tuber*

1. Smith, C IL: Health v Servants Only in a Healthy Home, New culosis Infection, Illinois M. J. CS: 350 (Oct.) 1935.

York Tubcrc. A. Bull. 3: 1 (Sept.-Oct.) 1922. 6. Lees, H. D.: Tuberculosis Among Teachers, Bull. Nat. Tubcrc. A.,

2. Ch’ui , P. T. Y.; Myers. J. A., and Stewart, C. A.: The Fate of June 1936. ^

Children with Primary* Tuberculosis, J. A. M. A. US: 1306 (April 8) Educators and Tuberculosis, J, Nat. Educ. A.,

1939. January 1939. *

3. Dietrich, Henry: Tuberculosis in. Infancy and Childhood, Arch. S. Jordan, L. S.: The Teacher, Journal Lancet 5G; 187 (April)

Pcdiat. 42:197 (March) 1930. 1936.

1874

CHILDHOOD TUBERCULOSIS— HALL

Jour. A. M. A.
Nov. 18, 191S

“Find the source” was his slogan. He found the
sputum positive in eight of 786 teachers tested. He
reported further that of sixty-four pupils exposed to a
teacher with far advanced pulmonary tuberculosis 42.6
per cent were positive to the Mantoux test, while of
161 other pupils of the same school and age group
11.2 per cent were positive. This is definite evidence
of the increased incidence of infection resulting from
contact with a teacher having open tuberculosis.

The approach, methods employed and results of a
tuberculosis survey of teachers and janitors in the
schools of Minneapolis sets an example which can well
lie followed by any community which has not already
established a satisfactory system of its own. This is
described by Harrington, Myers and Levine 9 in
reporting the examination of 3,600 Minneapolis school
employees. Sixty-eight showed x-ray evidence of dis-
ease necessitating further observation. Six were found
to have tubercle bacilli in their sputum.

In 1930 Dietrich 3 reported three families in which
four children developed tuberculosis (two of them
died) following contact in their homes with tuberculous
nursemaids. He also told of a kindergarten teacher
with active pulmonary phthisis whose association with
her 5 year old pupils resulted in the primary tuber-
culous infection of several of them. Dietrich found at
that time that there were laws in five states requiring
teachers to be free from tuberculosis and no laws in
respect to the health of nursemaids and governesses.
He recommended health examinations for all nurse-
maids, governesses and kindergarten teachers and issu-
ance of cards to all healthy applicants.

Rogers 10 in 1934 summarized all aspects of the care
of teacher health in this country as follows : About
two thirds of the largest cities required a certificate of
health from teachers before appointment. The smaller
the community, the fewer had such a regulation. At
that date, in twenty states, examination before employ-
ment was required by law. Nowhere was a tuberculin
reaction or lung x-ray examination mentioned as a
requisite part of the examination. In few, if any
places was repetition of examinations at stated intervals
part of the health program for teachers. When free
medical consultation service was offered, teachers sel-
dom made use of it, probably because of fear that the
result of an examination might react to their disad-

vantage.

One cannot help concluding that, for school teachers
to be proved healthy and free from transmissible dis-
ease, medical examination must be compulsory and
repeated at regular intervals. These examinations
should include a tuberculin test and x-ray examination
of the lungs and should be made by a physician who
is uninfluenced by any personal considerations which
might affect his report. In 1934 Philadelphia was the
only city with a teacher health program approaching
this ideal. Recently New York City has required thor-
ough examination of new teachers with periodic reex-
amination.

The American Academy of Pediatrics has endorsed
the principle of healthy adults in contact with children.
A campaign is in progress to bring to the attention of
doctors, parents, servants, trained nurses and teachers
facts relative to this aspect of child health. Through its

9. Harrington, F. E.; Myers. J. A., and Levine Ida: Tuberculosis
Among Employees of the .Minneapolis Schools, J. A. M. Acad. 104. 1869-

1 S 1 0 . 'angers, 5 J. 1 ??:" The Welfare of the Teacher, Bull. 4, U. S. Depart-
ment of Interior, 193-4.

Committee on Contact Infections, with the assistance
and cooperation of many child health minded organiza-
tions, the program of education is under way. Peclia-
tricians and family physicians can accomplish a great
deal by advocating that parents, other members of the
family, seivants, nursemaids and trained nurses, because
of their intimate contact with children, should have
periodic health examinations.

County and other medical societies throughout the
country are sponsoring a standardized examination
designed to detect any contagious condition. The exami-
nation will include an x-ray examination of the lungs,
at least for all who are tuberculin positive. The
examination will be available at a low rate of charge.
In most instances the radiologists are cooperating by
charging a minimum fee for the chest film.

The American Academy of Pediatrics advocates
that examinations be undergone voluntarily, through
an appeal to reason, rather than from compulsion.
What provision is made for obtaining examinations will
depend on the conditions existing in each locality. It is
desirable that examinations of all who are employed
be made by practicing physicians. In communities
where the wage scales of domestics do not permit the
payment of a fee sufficient to compensate a doctor for
the time required for an adequate examination and for
an x-ray examination, the applicants will be examined
in clinics for a nominal fee or no charge.

As part of this program for examination of domestic
servants in Knoxville, Tenn., Dr. Oliver W. Hill 11
reports that, in 1938, 571 persons with syphilis, sixty-
seven with active tuberculosis and five typhoid carriers
were picked up and put out of circulation.

Finding persons with insufficiently or untreated
syphilis is an important feature of this project. It is
thought that the benefit from this will be greater to
the individual needing treatment than to the children
with whom they are associated. The communicability
of this disease to children through kissing is possible,
though infrequent, when compared with tuberculosis,
in which the contagious stage lasts for a much longer
period. Smith 12 was able to collect but 125 cases of
acquired syphilis in children under 11 years of age.

There can be no question that this program will he
advantageous to the health of children by protecting
many' of them from unnecessary illness. In addition,
the individuals examined may have much to gain
through the discovery of conditions needing medica
attention. ,

The practicing physician is the person to take the
lead by advocating this health protection. The success
of the program depends to a great extent on his recom-
mendation. The physician can go even further m
setting an example by himself having a physical exami-
nation and an x-ray examination of the lungs.

CONCLUSIONS

1. Tuberculosis in children is acquired almost exclu

sively from contact with infected adults in their homes
and in school. ,

2. School teachers should be proved to be free

communicable tuberculosis. In very few commuiii i
in this country is this being done. ..

3. Domestic servants and nurses should have pe
medical examinations and be required to furms n
“health reference” of freedom from transmissible o

Hill O W.: Personal communication to tic author. grpE,

; Smith. F R-. Jr.: Acquired , Syphilis in Ch.ldren, Am- J-
>r. & Ven. Dis. 23: 163-185 (March) 1939.

Volume 113
Number 21

VITAMIN K — T AG E-HAN SEN ^

1875

4. Parents, relatives and pediatricians should also be
examined at intervals.

5. Cooperation with the program of the American
Academy of Pediatrics for healthy adults in contact
with children will result in fewer cases of childhood
tuberchlosis infection.

421 Huguenot Street.

Clinical Notes, Suggestions and
New Instruments

RAPID RECOVERY FROM TYPE XIII LOBAR PNEU-
MONIA TREATED WITH RABBIT SERUM

OF A PATIENT WITH ADDISON'S DISEASE UNDER TREATMENT
WITH DESOXYCORTICOSTERONE

Ford K. Hick, M.D., and Broda O. Barnes, M.D.

Chicaco

This report is made to change a conception of prognosis
in Addison’s disease complicated by infection. Undoubtedly,
many physicians have seen patients with Addison's disease
survive infections. Usually such subjects are treated as though
they were in crisis. This man had been controlled with
desoxycorticosterone and had returned to work when seized
with lobar pneumonia. He was continued on the same dose
of the synthetic hormone plus 5 cc. of adrenal cortex extract 1
daily and made a rapid, complete recovery.

We feel that this result further confirms the efficiency of
the substitution therapy with desoxycorticosterone in Addison’s
disease and that infection should not upset these patients too
much, provided a specific treatment is available for the infection.

REPORT OF CASE

A white man of 38, a salesman, entered Henrotin Hospital
May 8, 1939, with the complaint of weakness, dizziness, loss
of appetite and loss in weight. He had been well until the
fall of 1938, when he began to grow weaker and to eat poorly.
His symptoms were considerably aggravated by influenza in
February 1939, when he was away from work one month
because of weakness. Dizziness came on standing up suddenly,
on moving about or with exercise. On a few occasions he had
fallen. Lying down always put an end to the dizziness. His
weight had gone from 148 to 130 pounds (67 to 59 Kg.) on
entrance since November 1938. There was a considerable
aversion to food, and nausea was frequent this spring. He
had not vomited or had severe abdominal pain.

The past history was irrelevant except that he had been
sick for a few weeks with pneumonia at the age of 20.

The patient was a slender man, not acutely ill, with con-
siderable brown pigmentation about his head, which was bald,
and the neck, arms and sides of the body, especially the lateral
aspect of each hip. His strength was fair in the arms and
legs.

The blood pressure was found to be 60 systolic, 40 diastolic
standing up and 78 systolic, 50 diastolic while sitting up. While
lying down the lowest figure was 86 systolic, 56 diastolic. The
laboratory work-up showed no abnormality save that the serum
sodium was 133 milliequivalents per liter, compared to the
normal of 140 or more.

Treatment was started with 10 cc. of adrenal cortex extract
and 4 Gm. of salt daily. There was marked subjective improve-
ment) His weight began to increase as his appetite returned.
After six days on this treatment he was placed on 5 mg. of
desoxycorticosterone subcutaneously each day, on which his
weight came up to 138 and his blood pressure stabilized at
about 120 systolic, SO diastolic, and he returned to work.

June 23 he had a slight nasal discharge and fulness in the
head. The blood pressure was 114 systolic, 80 diastolic, while
standing. Next morning at 2 o’clock he had a chill and vomited
twice. On returning to the hospital at 5 a. m. he was acutely ill.

From the University of Illinois College of Medicine ami Henrotin
Hospital.

1. The substance used was Wilson Laboratories "Cortin."

The temperature was 104.4 F., pulse rate 100, respiratory rate
30 and blood pressure 146 systolic, 90 diastolic. The accessory
muscles of respiration were in use. There were questionable
harsh breath sounds over the left lower lobe posteriorly. He was
given 1,000 cc. of 5 per cent dextrose in physiologic solution
of sodium chloride.

The sputum contained type XIII pneumococci and antiserum
was started at 1 p. m., 200,000 units of rabbit serum being
given undiluted by 8 p. m. The white count was 7,200, the
blood culture negative.

June 25 the peak temperature was 99.4 F., the blood pressure
120 systolic, 72 diastolic. The patient felt well but coughed up
a little bright red sputum. He had no more fever but showed
dulness and rales over the left lower lobe for two days. An
x-ray examination confirmed the diagnosis of lobar pneumonia.
Retyping the sputum showed the same organism.

The management of Addison’s disease during the pneumonia
was 1 Gm. of salt daily, a general diet along with desoxycorti-
costerone 5 mg. daily subcutaneously, and 5 cc. of adrenal cortex
extract for four days. The maintenance dose of 5 mg. of
desoxycorticosterone daily is again adequate. The patient
returned to general activity June 29.

1853 West Polk Street.

SUMMARY of some clinical studies on

VITAMIN K

Erik Tage-Hansen, Copenhagen, Denmark

In continuation of the work of Dam and Glavind 1 I have in
the past year carried out a series of investigations on patients
with diseases in which lowered prothrombin might be expected.
The determination of prothrombin was made by the method
described by these authors. It was found to work satisfac-
torily. In fourteen of the cases in which lowered prothrombin
(high R-values) were found, the different ways of administer-
ing vitamin K were also studied.

Dam and Glavind 1 reported the treatment of five cases of
obstructive jaundice with K-avitaminosis by intramuscular
injections of an emulsion of vitamin K in water and found it
possible to restore the blood coagulation to the normal value
within a week.

Since then I have studied the effect of vitamin K when given
perorally, intramuscularly and intravenously.

For peroral use gelatin or starch capsules containing the
concentrate together with desoxycholic acid were prepared. In
accordance with the studies of Butt, Snell and Osterberg, 2
normal coagulation was obtained within two days with doses
of from 100,000 to 200,000 Dam units of vitamin K plus 2 Gm.
of desoxycholic acid. Some days later the coagulation defect
began to set in again.

By ingestion of an emulsion of the vitamin in sodium des-
oxycholate solution by duodenal or stomach tube the same
effect was obtained.

For injection purposes, concentrates having a strength of
more than 1 million units per gram were used.

Intramuscular injection on two successive days of a watery
emulsion of such a preparation representing 150,000 units -of
vitamin IC resulted in normal coagulation three days after the
first injection, an observation which is in accordance with the
results reported by Dam and Glavind.

Intramuscular injection of an oil solution of the vitamin in
a one day or in a three to five day period led to restoration
of normal blood coagulation after one to two weeks, from
150,000 to 400,000 units in all being used for each patient. In
some cases in which surgery was not employed, it could be
shown that the effect lasted for at least three weeks.

*• warn, mnm, ano i yiavroo, jonaiincs: Vitamin K i den niennes
kd.se Pathdogn Ugesk. f. !*ger 100: 2-1S-2S0 (March 10) 1938; Vitamir
K in Human Pathology Lancet 1:720 (March 20) 1938; The Clottim
Power of Human and Mammalian Blood in Relation to Vitamin K Act-
roed. Scandmav. 9G: 108-128, 1938.

2. Butt, H. R.; Snell, A. M., and Osterhcrp, A. E.: Further Obscrva
lions on the Use of \ itamm K m the Prevention and Control of th<
Hemorrhagic Diathesis m Cases of Jaundice, Proc. Staff Meet., May<
Chn. 13: s$3'/64 (Nov. 30) 1938.

1876

PNEUMONIA— EDWARDS ET AL.

Jour, A. M. A.
Nov. IS, 1939

Intravenous injection of emulsions— from 15,000 to 30,000
units in one dose— yielded normal blood coagulation within
eighteen hours, but as in the case of peroral introduction the
effect persisted for only a few days.

The foregoing results are in accordance with corresponding
experiments on animals.

Similar results have been obtained with all three forms of
administration against the hypoprothrombinemia of newborn and
older infants suffering from icterus gravis neonatorum and cer-
tain related diseases. 3

In urgent cases it is a great advantage that two rapidly
acting forms of application are now available *. intravenous
injection and ingestion together with bile, of which the first
is the most efficient.

The intramuscular injection of oil solutions is remarkable
for the long duration of the effect.

The proper treatment of each case is rendered possible by
taking advantage of the different modes of application, prefer-
ably by a suitable combination of them.

Biochemical Institute, University.

Special Clinical Article

TYPE SPECIFIC POLYSACCHARIDE SKIN
TEST IN SERUM THERAPY OF
PNEUMONIA

CLINICAL LECTURE AT ST. LOUIS SESSION

JOSEPH C. EDWARDS, M.D.

CHARLES L. HOAGLAND, M.D.

AND

LAWRENCE D. THOMPSON, M.D.

ST. LOUIS

The application of the intracutaneous test with type
specific pneumococcic polysaccharide as a guide in
serum therapy rests on a basis as sound theoretically
as that of the Schick test in the measurement of dermal
resistance to diphtheria toxin. In the case of the pneu-
mococcus polysaccharide a positive reaction indicates
resistance to the pneumococcus, while in the Schick
test a positive reaction is indicative of a lack of such
resistance. In either case, however, dermal reactivity
is used as a criterion of the immune status of the whole
organism.

That pneumococci are not alike was an observation
made in 1897 by Bezangon and Griffon, 1 who reported
serologic differences among morphologically indistin-
guishable pneumococci. Briefly, the intact pneumo-
coccus cell may be considered to exist as a body, or

appropriate concentrations of alcohol or acetone fol-
lowing in general the precipitation reaction of all com-
plex soluble carbohydrates. -

It was the significant discovery of this capsular
material, or the so-called soluble specific substance by
Docliez and Avery in 1917 2 that has led to a niore or
less exact understanding of the qualitative differences
existing among the thirty varying types of pneumococci.

The intensive studies of Heidelberger, Avery, Rabat
and Goebel 3 have given more exact information con-
cerning the structure of certain of these type specific
polysaccharides and their relation to specificity. The
capsular material of the common groups, at least of
types II, III and VIII, appears to be composed of dex-
trose and glucusonide units (aldobionicacid) in a carbo-
hydrate chain. Type I contains, as a basic group, a
trisaccharide with the two uronic acid molecules and
an amino sugar. 4 Until recently it was believed that
the uronic acid group was common to all pneumococci
and formed a basic antigenic unit. The structure of type
XIV, however, does not conform to this concept, in
that it is composed of hexosamine units with no demon-
strable trace of uronic acid. 3 In the case of II, III
and VIII the difference appears to be chiefly one of
stereochemistry, or the arrangement of the basic unit
in space.

These polysaccharides when coupled with a more
or less common pneumococcus protein form complete
antigens. The orientation of the antigenic action in the
production of antibody, however, is a function of the
carbohydrate group comprising the capsule. Although
in most animals the material depends on the protein
portion for its complete antigenic action, it will, in
its chemically pure form, react by precipitation with
homologous antipneumococcus serums in dilutions as
high as 1 to 4,000,000. Felton has studied its value
as a vaccine. 6

For use in skin testing only chemically pure cap-
sular material can be employed. Much of the earlier
work is equivocal, owing to the fact that impure
carbohydrate substances were used. The pneumococcus
contains, in addition to its type specific capsular poly-
saccharide, a so-called somatic, or C, fraction, which
is nonspecific and may give a latent reaction directed
against the nonspecific, or somatic, antibody. In addi-
tion, the somatic substance contains yeast nucleic acids
and nucleoproteins which are severe skin irritants and
often contaminate improperly prepared capsular mate-
rial. A report of the more detailed technic employed
by one of us (C. L. H.) in the isolation of the pure
carbohydrate fractions will be published later. White,
Robinson and Barnes discussed the various methods

soma, of bacterial protein, surrounded by a discrete
capsule consisting of a carbohydrate substance of rela-
tively complex structure. When released from the
intact pneumococcus cell, this material is water soluble
and may be precipitated from autolyzed cultures by

3. Dam. Henrik; Tage-Hansen, Erik, and Plum, P.: K-Avitaminose
Bos Spfcdc B0rn som Aarsag til HiemorrBagisk Diathese, "Ugesk. f. lager

1 ° From 6 the^Depa^rtment' of Internal Medicine, Washington University
School of Medicine. .

The work was made possible by grants to the Washington University
School of Medicine from Eli Lilly & Co., Indianapolis.

Read in the General Scientific Meetings at the Ninetieth Annual
Session of the American Medical Association, St. Louis, May 13, 1939.

The visiting and resident staffs and the laboratory personnel of St.
Louis City Hospital. Barnes Hospital, St. Louis County Hospital. Jewish
Hospital St. Luke's Hospital and St- Alary’s Hospital and the Department
of Health of the City of St. Louis cooperated in this study. Eli Lilly &
Co supplied antipneumoeoccus rabbit serum and certain of the pneumo-
coccus cultures from which Dr. C. L. Hoagland extracted the polysac-

Cl ’ 'I'.^Bezangon. p _ an j Griffon. V.: Pouvoir agglutinatif du serum d3ns
les infections experimentaies ct humaines a pneumocoques, Compt. rend.
Soc. de biol. -19: 551, 1897.

thus far employed. 1

2. Dochez, A. R., and Avery, O. T. : Soluble Substance ot Fnenmo-

coccus Origin in the Blood and Urine During Lobar Pneumonia, P
Soc. Expcr. Biol. & Med. 14: 126, 1917. gnluble Specific

3. Heidelberger, Afichael, and Avery, O. T.: ™ e 7 , S J9U.

Substance of Pneumococcus, J. Exper. Med. 88.73 i U J7
Heidelberger, Alichael, and Rabat, Elym A.: T'Y'AV. \ 1 (H ; Hetdel*
ferial Agglutination: I. A Alethod, ibid. CO: 643 (Nov.) L„bstance of
berger, Michael, and Goebel. W. F.: The Soluble Spwfo| u “ s W fee
Pneumococcus: V. On the Chemical Nature of the Aldobiomc Ac

the Specific Polysaccharide of Type ill Pneumococcu .J* . ‘ Chcmo
74:613 (Sept.) 1927. Avery, O. T„ and Goebel, \V.r..
Immunological Studies on the Soluble Specific S’*** 3 ” w?SKcbaride «f
coccus: I. The Isolation and Properties of the Acetyl J 0
Pneumococcus Type I, J. Expcr. Med. 58: /31 (Dec.) ws Medical

4. Marrack, J. R.: The Chemistry of Antigens

Research Council, Special Report Senes, No. 230, London, 1
Stationery Office, 1938. p. 97. , r ;r . Capsu !;ir

5. Hoagland, C. L.; Beeson, P. B., and Goebel, A. 1- • R( j at ; mt ,fcip to
Polysaccharide of the Type NIV Pneumococcus an (gept. 16) 19 1 ?-
tbe Specific Substances of Human Blood, SnenceSS.zoi If pneumococci :

6. Felton, L. D.: Studies on Immunizing Subsume ,1 xoccm IWr^e-

VII. Response in Human Beings to Ant: igenic Pm :u®« * 5933.

charides, Types I.and XL Pub. Health Rep 53: ISaS ; Bicf ogy '

7. White, Benjamin; Robinson, E. S., and Barnw . L.

Pneumococcus, New York, Commonwealth Fund, Dmsion o
1938, p. 473.

Volume 113
Number 21

PNEUMONIA— EDWARDS ET AL.

1877

The rationale of the skin test itself rests on the
observations of Mackenzie and Woo 8 in 1925 of an
allergic condition in the skin of guinea pigs following
immunization by killed pneumococci. That the mecha-
nism might be used as a guide in serum therapy was
suggested in 1933 by Francis, 0 who observed that 100
per cent of patients with type I pneumonia developed
at the time of crisis an urticarial wheal following the
intracutaneous inoculation of a dilute aqueous solution
of type I capsular polysaccharide. In an earlier com-
munication Tilleft and Francis 10 had observed that
the skin reaction to capsular polysaccharide appeared
in many patients after treatment with homologous anti-
pneumococcus serums and that when such reaction
occurred the prognosis was excellent. The fact that
the reaction appeared quickly, sometimes within thirty
minutes after serum administration, made it a desir-
able method of ascertaining when an adequate amount
of serum had been administered without waiting for
the drop in temperature and the clinical improvement
which formerly were the only guides to adequate serum
therapy.

It has been established by the work of Freund 11 and
others that the skin is the last organ to become sen-
sitized after the parenteral administration of immune
serums. This knowledge is particularly applicable to
the use of the skin test in the control of serum dosage,
since a positive reaction must indicate complete organic
saturation with antibody, a therapeutic ideal. That the
skin test is also applicable to patients treated with horse
serum as well as with rabbit serum has been established
by MacLeod, Hoagland and Beeson 12 and Finland
and Sutliff. 13

CLINICAL STUDY

A total of 1 14 patients were treated with type specific
antipneumococcus rabbit serum 14 in several hospitals.
Both serum and polysaccharide were available for
types I, II, V, VII, VIII and XIV. In addition, we
had polysaccharide for types III, IV and VI. It was
confirmed by clinical trial that all were free of the C
substance.

In an effort to make the study uniform, all the
patients were examined by one of us, who viewed
the roentgenograms, supervised the administration of
serum and performed the polysaccharide skin tests
before, during and after serum administration. Each
serum was monovalent and was given intravenously
by a method to be described in another report.

Technic of the Skin Test . — In each case 0.05 cc. of
a dilution of 1 : 10,000 type, specific polysaccharide in
physiologic solution of sodium chloride is injected
intracutaneously on the flexor surface of the forearm,
and the edges of the wheal so raised are sharply dotted
with ink to enable one to detect the slightest alteration

8. Mackenzie, G. M., and Woo, S. T.: The Production and Signifi-
cance of Cutaneous Allergy to Pneumococcus Protein, T. Exper. Med. 41:
65 (Jan.) 1925.

9. Francis, Thomas, Jr.: The Value of the Skin Test with Type
Specific Capsular Polysaccharide in the Serum Treatment of Type I Pneu-
mococcus Pneumonia, J. Exper, Med. 57:617 (April) 1933.

10. Tillett, \V. S., and Francis, Thomas, Jr.: Cutaneous Reactions to
the Polysaccharides and Proteins of Pneumococcus in Lobar Pneumonia,
J. Exper. Med. 50: 687 (Nov.) 1929.

11. Freund, Jules: Distribution of Immune Agglutinins in the Serum
and Organs of Rabbits, J. Immunol. 14: 101 (Aug.) 1927.

12. Macleod, C. M.; Hoagland, C. L., and Beeson, P. B.: The Use of
the Skin Test with the Type Specific Polysaccharides in the Control of
Serum Dosage in Pneumococcal Pneumonia, J. Clin. Investigation 17:
739 (Nov.) 1938.

13. Finland, Maxwell, and Sutliff, W. D.: Specific Cutaneous Reactions
and Circulating Antibodies in the Course of Lobar Pneumonia: I. Cases
Receiving no Serum Therapy, J. Exper. Med. 54: 637 (Nov.) 1931; II.
Cases Treated with Antipneumococcic Sera, ibid. 54: 653 (Nov.) 1931.

14. Refined, unconcentrated, supplied by Eli Lilly & Co.; hereafter
referred to as “serum.”

in contour or elevation after fifteen minutes. This is
usually injected at the time of the tests for sensitivity
to serum but may be delayed until after the intravenous
test dose. If the rest of the serum is given in one or
two doses within the next hour or so, there will usually
be enough polysaccharide at the site of the previous
test to react when sufficient serum has been given. It
was our custom to repeat the test after each serum
injection, although most of our serum was given as a
large single dose one hour after the test dose.

If an urticaria-like wheal appears at the site of injec-
tion within twenty minutes, and especially if pseudo-
pods form and the circumference of the wheal extends,
the reaction is considered positive. A flare often
accompanies the wheal formation but is not to be used
as an index of positivity unless the control reaction is
absolutely negative. It can be seen from the tables
that the result is rarely positive until after serum has
been given. Occasionally from five to eight days after
onset, at or near the spontaneous crisis, the reaction
becomes positive, indicating the presence of sufficient
antibodies. Although not all patients have sufficient
excess of antibodies to produce a positive result at the
time of normal crisis, the majority will show it a day
or so before or after normal crisis.

The test is repeated within three hours after the last
serum lias been given, and if the reaction is positive
in the uncomplicated cases no more serum is needed.
In the presence of complications such as bacteremia,
more serum is needed even though the result is positive.
A good rule to follow is to give more serum if there is
doubt as' to whether the reaction is positive or negative.
An unequivocally positive reaction is always obtained
after sufficient serum has been given, the only possible
exception occurring when a patient is dying and has
lost the reactivity of the skin.

Sterile stock solutions of the various capsular carbo-
hydrates in 1 : 1,000 concentration in physiologic solu-
tion of sodium chloride keep indefinitely. For hospital
use the 1 : 10,000 dilution keeps well at 40 to 60 C. all
year, and from this dilution 0.1 cc. may be taken into
a tuberculin syringe in order to inject 0.05 cc. intra-
cutaneously. A similar amount of sterile physiologic
solution of sodium chloride is injected as a control.

Scheme of Dosage . — Since few patients with fully
developed pneumonia require less than 60,000 units of
antiserum, this amount or more may be given as an
initial dose, after which the absence of a positive reac-
tion to the intracutaneous polysaccharide test is an
indication for giving additional doses of 20,000 to
40,000 units at two hour intervals until the reaction
becomes positive. Thus this test enables one in a sense
to titrate with antibody, the type specific capsular
carbohydrate being the indicator and a positive skin
reaction denoting the end point.

It is difficult to establish clinically the point at which
adequate serum has been given. A fall in the patient’s
temperature is an uncertain index, as it may follow
temporarily the administration of any, serum or foreign
protein. If one waits for a secondary rise in tempera-
ture valuable time is lost, and a one or two day pneu-
monia may be converted into a two or three day disease
with the attendant statistical increase in mortality.

With the use of the skin test, the delay between the
first and the second dose is a matter of only two or
three hours. Frequently the reaction becomes positive
while the first dose of serum is being given, thus
enabling one to save the unopened vials containing the

1878

Jour.- A. M. A.
Nov.- 18, 1939

PNEUMONIA— EDWARDS ET AL.

balance of the clinically estimated dose. In this way
the test obviates the necessity for overtreatment. It has
been customary in the past to overtreat as the lesser of
two evils. In fact an amount in excess of the clinically
calculated dose was formerly given in order to be safe.
Overdosage offers no clinical advantage and subjects
the patient to needless expense. Since the saving
effected by the use of this test in our series amounted
with but few exceptions to 20,000 to 100,000 units per

Table 1. — Incidence of Positive and Negative Polysaccharide
Skin Test Before Scrum Therapy

Number Number
with with

Positive Negative

Number Test Test Number
Type of of Before Before of

Pneumonia Patients Serum Serum Deaths

1 52 2 50 2

II 14 0 14 1

V IS* It 12 2

VII 14 0 14 0

VIII '19 1 IS 0

XIV 2 0 2 0

Totals 114 4 no 6

* Two type V patients treated before polysaccharide was ready for
use are not included.

t The only one of the five who died that had a positive test before
scrum.

patient, it is apparent that where serum is supplied to
indigent patients by the state the use of the test has
immense economic value.

In the presence of complications such as empyema,
the temperature, pulse and respiration are no longer
valued criteria of adequate therapy. Clinically the
patient appears to need more serum, and frequently
the presence of empyema may not be suspected. A posi-
tive skin reaction in such an instance indicates that
the patient can be benefited not by additional specific
therapy but only by procedures which will remove the
focus of infection.

The presence of a positive skin reaction in the
absence of clinical improvement after serum has been
given may be the first sign of incipient pus or bac-
teremia.

It must be emphasized that in the rare cases, per-
haps with bacteremia or endocarditis, the reaction
may be negative even though type specific antibody is
demonstrable in the blood and when the infection may
be advancing. In such cases the skin test cannot be
used as a criterion for serum dosage.

RESULTS

From table 1 it can be seen that of a total of 114
patients with pneumonia 110 had negative reactions
to the polysaccharide skin test before serum therapy.
Of these, 105 showed a positive reaction after serum.
Of the four patients who showed a negative result
after serum, three subsequently died although they
received more than enough serum (300,000 to 400,000
units) to cause a strongly positive skin reaction in the
average patient with the same number of lobes involved.

Duration of Positive Reactivity to Skin Test . — In the
few cases in which there was a history of hives, it was
noted that the control with physiologic solution of
sodium chloride did not cause a reaction. When skin
tests were performed during the days of serum sick-
ness, the results were in no instance interpreted as
positive unless they were also positive after the recovery
from serum disease.

From table 3 one can see that the patients who
recovered displayed great variability in the duration of
.positive reactivity to the skin test after serum therapy.
The duration did not vary directly with the dosage of
serum or with the period from onset of the disease to
the time serum was given. If, however, serum is given
late in the course, the concentration of antibodies sup-
plied by the patient himself may be increasing. The
average duration was about ten days after serum was
given. There seemed to be no relation between length
of the positive phase of the polysaccharide test and
serum sickness. The patients with complications tended
to have a longer phase of reactivity than did those
without complications.

Type 1 Pneumonia . — Of the fifty-two patients tested
before and several times after serum therapy, only two
had a positive result before serum was given. Of those
with a negative result before serum all but one reacted
positively after serum. This patient was given 60,000
units in the thirty-sixth hour of his pneumonia. The
injection was followed within twenty-four hours by a
crisis but without appearance of a positive reaction.
Of the two patients who died, one had a positive reac-
tion before serum therapy on the fifth day of disease
and the blood culture became sterile after the total of
360,000 units had been given. Death occurred nine
days later. At autopsy, consolidation of the entire right
lung with an acute aortic endocarditis was demonstrated.
The other patient’s reaction remained negative before
and after serum in the presence of fatal bacteremia.

Type II Pneumonia . — Fourteen patients were tested
and all showed a negative reaction before and a posi-
tive reaction after serum was given. The only patient
who died was admitted eight days after onset, was
delirious and had bacteremia. Although patients with
bacteremia late in the disease usually have sufficient
antibodies to produce a positive reaction before serum
is given, this patient did not, which of itself may be a
bad prognostic sign. Blood taken before and twice
after serum was given failed to show any agglutination
with type II smooth organisms and only slight aggluti-

Table 2. — Results of Skin Tests After Scrum Therapy in
Patients Shouting a Negative Test Before Treatment

Results of Tests of Results of Tests ot
Patients Who Patients Who

Number Recovered ’Pled

Pneumonia Patients Positive Negative Positive Negative

1 50 4S 1 1 1

II 34 IS .. 1 "

V 12 19

VII 44 14

VIII IS 18

XIV 2 2 ••

Totals 110 105 1 2

sation to a rough type II strain after serum was given,
"he result of the polysaccharide test was also negative-
^irge amounts of serum may fail to cause a pos_i ! _' c
eaction in such cases. Lack of tissue or skin react ivi }
lay be a factor when antibodies are present but
esult of the skin test is negative.

Type V Pneumonia.— Twelve of thirteen P ai1 ?^
ad a negative reaction before serum was given,
f the two patients who died, who had a positive r ’
on before scrum therapy on admission, three vv
iter onset of the disease, had bacteremia with emp; ctf ■ •
i spite of a normal temperature for thrc ^ a P‘.
?gative blood culture after being given 300, W

Volume 113
Number 21

PNEUMONIA— EDWARDS ET AL.

18 79

of type V serum, he died on the ninth hospital day.
Autopsy revealed an acute pneumococcus aortic vege-
tation. The other patient who died had negative reac-
tions both before and after treatment with 340,000
units of serum. Bacteremia disappeared with seeming
clinical improvement for several days. On the ninth
hospital day death suddenly occurred from circulatory
failure.

Type VII Pneumonia . — All fourteen patients had
negative reactions before and all had positive reactions
after serum therapy, with recovery.

Type VIII Pneumonia . — Of nineteen patients,
eighteen had negative reactions and one a positive
reaction before administration of serum.

Type XIV Pneumonia . — Two patients had negative
reactions before and positive reactions after serum was
given. Both recovered.

Pneumonia of Types III, IV and VI . — Several
patients were tested at intervals and after the crisis,
which occurred either spontaneous!}' or with the aid

Table 3. — Duration oj Positive Skin Test*

Reaction

Reaction

Negative

Positive

Alter

Units ot

on

Units of

Positive

Serum,

Patient’s

Serum,

Dnys

Phase

Thousands

Discharge

Thousands

3

1

GO

1

110

5

2

7

3

ICO, 80, 100

2

120, 210

9

3

100, 80

7

100

n

1

2G0

13

3

220, 170

15

o

100, 100

17

1

SO

2

100, 100

10

4

GO, 200

27

..

1

1G0

31

1

220

1

220

Total cases

12

23

* la thirtv-four of the thirty-five cases reactions ivere negative before
serum was given.

of sulfapyridine. In general, the patients treated with
sulfapyridine had a negative reaction before the fifth
day of the pneumonia, even those whose temperature
fell on the first or second day. Very few had a positive
reaction after the sixth to tenth day from the onset of
the pneumonia, the time at which antibodies naturally
occur in high concentration. Of the few patients seen
at the time of spontaneous crisis, several had positive
reactions to the polysaccharide test and recovered with-
out specific therapy.

PNEUMONIA OF A SINGLE TYPE

A 21 year old man was admitted on the third day of type I
pneumonia with a rectal temperature of 104 F., pulse rate of
100 and respiratory rate of 32 per minute. Slight cyanosis and
delirium were present. The lower lobe of the right lung was
consolidated. Clinically, it was estimated that at least 140,000
units of serum would be necessary and we prepared to give
160,000 units. The type I polysaccharide test, however, pro-
duced a positive reaction by the time 100,000 units of serum
had been given. Crisis followed in twelve hours. Several such
instances could be cited of patients in the older age group.

M. B., aged 70 years, was admitted on the seventh day of
type VIII pneumonia with a temperature of 103 F., pulse rate
of 100 and respiratory rate of 24. There were no signs of
approaching crisis. The white cell count was 30,400, with a
marked shift of segmented leukocytes. Consolidation of the
right middle lobe was evidenced by physical signs and a roent-
genogram. Types I and VIII polysaccharide skin tests yielded
negative results. Eighty thousand units of type VIII serum
caused a crisis in sixteen hours, and the reaction to the. type

VIII skin test was positive. The next day it was 3 plus;
it became negative one week later. The patient recovered
uneventfully.

J. B., aged 72 years, the husband of M, B., was admitted
four days after his wife oh the second day of his disease,
which partially involved the right upper lobe, beginning at the
hilus. This was also due to the type VIII pneumococcus. The
temperature was 302.6 F., pulse rate 115 and respiratory rate 26.
The type VIII polysaccharide test did not produce positive
results until after 100,000 units of serum had been given. Crisis
occurred within twelve hours. The reactions remained positive
for the duration of the hospital stay of ten days.

V. P., aged 28 years, was admitted on the eighth day of
type II pneumonia and had 100,000 units of type II serum;
the reaction did not become positive until another 40,000 units
had been given. Crisis occurred in twenty-four hours and
recovery ensued. In this case one would have estimated that
an additional 40,000 units, at least, was necessary.

L. C., aged 21 years, was given 100,000 units of type I serum
on the fourth day of pneumonia of type I in the left lower
lobe. The polysaccharide test produced a negative reaction
before and a positive reaction one hour after the serum therapy.
In twelve hours, however, the reaction was negative although
the temperature was normal. Subsequent tests gave negative
results for the next seven days, after which the reaction 'became
positive again, on the eleventh day from onset of the pneu-
monia, remaining positive for the next three days of the hos-
pital stay. Ill ore serum was not given when the reaction became
negative because clinically the patient was well on the road to
recovery, with normal temperature and respirations and with
but slight elevation of pulse rate. Had the temperature become
elevated above 101 F. (rectal) with a negative reaction, in the
absence of other causes for the temperature, more serum would
have been indicated.

If the temperature remains elevated, the reaction
positive and the disease unaffected by the usual amount
of serum, the sputum should be retyped. Thus it is best
to combine clinical judgment with all tests. Apparently
enough serum was given to control the infection but
not enough to diffuse into the skin and react with the
polysaccharide. If bacteremia had been present, more
serum would have been indicated as soon as this was
determined, in spite of a positive or negative reaction
to the skin test with type specific polysaccharide.

PNEUMONIA OF MORE THAN ONE TYPE

That the polysaccharide test is of value in the dif-
ferential treatment of pneumonia due to more than one
type is shown by the following eases :

A 26 year old woman entered on the second day after onset
of pneumonia with a chill, cough and rusty sputum. Types III
and VIII pneumococcus were directly found in the sputum by
the modified Neufeld technic. Early consolidation of the right
lower lobe was present. Since the type VIII organisms were
present in greater number per oil immersion field than the
type III, 80,000 units of type VIII serum was given and crisis
occurred in twelve hours. The reaction was negative for types
III and VIII before and positive for type VIII after serum
therapy.

A patient with type 1 pneumococcic pneumonia, recovering
spontaneously, was admitted on the tenth day with a tempera-
ture of 104 F. after two days of normal temperature. Careful
physical and rocntgenographic examination revealed a paren-
cht trial process in the right middle lobe. The original process
had been in the left lower lobe. A skin test with type I poly-
saccharide yielded unequivocally positive results, showing the
presence of a homologous antibody and reactive dermis. Tiie
presence of empvema was not suggested by physical and roent-
genograplnc signs. No sputum was available, whereupon a lung
puncture was performed; type VIII pneumococcus was isolated
directly from the new area of involvement. There was prompt
defers escence following the administration of type VIII anti-
pneumococcus serum; on recovery the patient reacted to both
type I and type VIII polysaccharides.

1880

COUNCIL ON PHYSICAL THERAPY

Jour. A. ft. A.
Nov. 18, 1919

T. H. had a typical onset with chills and rusty sputum three
days before entry. Type VII pneumococcus was isolated directly
from the sputum and 100,000 units of type VII horse serum
was given. Two days later the temperature was still elevated,
being 104.6 F., the pulse rate was 122 and the respiratory
rate 32. Since the reaction to the type VII polysaccharide test
was positive we were assured that enough serum had been
given. No evidence of empyema or bacteremia was found.
Accordingly the sputum was retyped, and this time type I
pneumococcus was found in abundance with a few type VII
organisms. Type I skin test was negative and 160,000 units
of the homologous serum was given before the skin reaction
became positive for type I, this being the fifth day of the dis-
ease. Within twenty-four hours the temperature was normal.
Reaction to the type VII polysaccharide test became negative
eleven days after serum was given, when the reaction to the
type I test was still positive. Recovery was uneventful.

In seven instances of pneumonia with more than one
type of pneumococcus in the sputum, the skin test
enabled us to know that adequate amounts of serum
had been given for one of the types in each case and
that serum was the logical cause of the crisis which
occurred within at least forty-eight hours and before
the seventh day of the disease. In two of these cases,
lung puncture was done to determine the actual cause
of the pneumonia, which proved to be pneumococcus of
the same type as that for which serum was given. This
was necessary when the multiple types in sputum were
of the more common variety. Sulfapyridine can also be
used to advantage in such cases.

FOUR SPECIAL CASES

All patients were treated without selection as soon
as the organism could be typed. Four patients who
were moribund on admission were treated with serum
in order to determine what little benefit might accrue.
In all but one of these cases, which will be described,
the type specific polysaccharide test was found to give
negative results before and after therapy with large
amounts of serum. It appears that in the presence of
terminal shock the skin is no longer reactive. The
reaction was positive before and after serum adminis-
tration in one moribund patient admitted twenty-one
days after onset of type V pneumonia involving the
entire left lung, with an encapsulated empyema and
type V pneumococcus in the blood culture. The blood
culture was sterile after 300,000 units of serum had
been given. The temperature was almost normal for
three days after serum therapy, but the patient died
on the ninth hospital day. Sulfapyridine was given
the day after the second rise in temperature and con-
tinued for five days. Aortic valvular pneumococcic
endocarditis was seen at autopsy in addition to the
lesions described. The other three patients died within
twelve hours of admission but none of them had a
serum reaction. There were no great variations in
blood pressure and pulse.

SUMMARY

In 114 cases of lobar pneumonia caused by type I,
II, V, VII, VIII or XIV pneumococcus, type specific
antipneumococcus rabbit serum was used. The reaction
of the patient to intracutaneous tests with the type
specific polysaccharide from the capsule of a homolo-
gous type of pneumococcus was determined before,
during and after the administration of the serum.

One hundred and ten of the patients had a negative
reaction to the test, indicating a low content of circu-
lating antibody, before serum was given. The test
proved to be a valuable aid in the more accurate esti-

mation and control of the optimum dose of serum
necessary for the successful treatment of the patient.

In thirty-five cases, daily skin tests with the poly-
saccharide were performed until the patient was dis-
charged from the hospital. In twelve of these cases
the reaction became negative before the patients were
discharged (seven to nine days), and in twenty-three
it remained positive (nine to nineteen days).

In some cases without complications, a positive reac-
tion to the skin test at the time of admission on the
sixth or seventh day of the pneumonia enabled us to
withhold treatment with the assurance of the presence
of sufficient antibodies to cause a crisis with favorable
outcome. Not all patients with spontaneous crises,’
however, have the excess of free antibodies necessary
to cause a positive reaction to the test. Some patients
with myocardial damage or cardiac decompensation
need serum even though they show a positive reaction.

A persistently negative, skin reaction appears to have
some value from a prognostic standpoint. In most
cases in which a positive reaction did not occur after the
administration of large amounts of serum the disease
terminated fatally. In such cases the blood agglutinins
were often found in high titer. A skin formerly reac-
tive to polysaccharide may lose its reactivity, even in
the presence of free circulating antibody, when the
patient is moribund. A positive reaction .in a patient
with bacteremia does not mean that no more serum is
needed. Dermal injection of pneumococcus polysaccha-
rides into human beings may induce subsequent reac-
tivity of the dermal cells, and this fact is to be borne
in mind in studies of skin sensitivity when repeated
intradermal injections of these agents are involved. 10

The polysaccharide skin test is a valuable, though
not infallible, means of measuring the serum required
for treatment in a given case of pneumococcic pneu-
monia.

Council on Physical Therapy

The Council on Physical Therapy has authorized publicatioX

OF THE FOLLOWING REPORTS. HOWARD A. CARTER, SECRETARY.

AUGUSTANA MODEL SAFETY GAS OXYGEN
APPARATUS ACCEPTABLE

Manufacturer: Safety Gas Machine Company, 1163 Sedgwick
Street, Chicago.

This unit is designed for the administration of inhalation
anesthesia. It utilizes D cylinders of oxygen, carbon dioxide,
nitrous oxide and ethylene, with provision conveniently maae
for one extra tank of each gas to be attached to the appara us.
In addition, there is an extra yoke provided for the admmistr -
tion of cyclopropane. To each of the sets of yokes (exc p
those for cyclopropane) to which the cylinders are connectc
attached a competent reducing valve. The cyclopropane }
has a pressure gage attached with which the °P er i t ° - (s
estimate the amount of gas remaining in the cylinder. Die 1
arc so designed that different gases cannot leak from
cylinder to another unless the cylinders are connected
machine in a way other than specified. j )C

There is a central mixing chamber into which E^cs iw J
jdmitted for delivery either singly or in various combi a X ■

A. gas is admitted to the mixing chamber through a J
; ight-Ieed in an individual water manometer. Ail mano
displace against a common head of water The flow of
J may be regulated by individual need c valves thvsjj
iesired proportions within reasonable limits roaj W
rhere is a by-pass valve as a quick source of WT £
fhe manometers are apparently each graduated in g

Volume 113
Number 21

COUNCIL ON PHARMACY AND CHEMISTRY

1881

There is an ether vaporizer attached, which permits the addi-
tion of ether vapor to the delivered gas mixture. It is so
arranged that the gases may be passed in varying proportions
through the ether container by regulation of the valve.

The remainder of the apparatus consists of a typical so-called
“circle filter” carbon dioxide absorption unit. ' The canister con-
taining the soda lime may be shut off from the circuit at will.

An exhalation valve enables the operator to utilize the so-called
"open,” “semiopen,” or “semiclosed” technics of anesthetic
administration. The valves are apparently of a rubber fabric
material. The rubber tubing and breathing bag appear to be
durable. The size of the bags, type of face masks and soda
lime mesh are optional.

The apparatus is supported adequately on a pedestal equipped
with rubber-tired casters. Even though somewhat large, it is
easily wheeled about.

The unit was submitted to a qualified physician, who studied
its therapeutic efficiency and applicability. The following was
concluded from his report:

There is some resistance to respiration, as in all types of
so-called “circle-filter” anesthetic apparatus. This is of the
order of 2 to 4 cm. ‘of water with ordinary
breathing. While this resistance is of little
import in a healthy subject, in the case of a
debilitated patient undergoing a long opera-
tion it is sometimes of considerable impor-
tance. It is common to all models of this
type of apparatus of all manufacturers.

When the carbon dioxide absorber is in
the breathing circuit, it efficiently removes
carbon dioxide. This was proved by actual
chemical gas analysis. It was found that
4-8 mesh soda lime produced somewhat less
resistance than an 8-14 mesh to breathing and
&afety S Gas a ' Oxygen was just as efficient in its removal of carbon
Apparatus. dioxide.

A comparatively small breathing bag al-
lows for more flexibility, in that anesthetic mixtures can be
changed more rapidly and smaller quantities of gas or vapor
are necessary.

The investigators commented that they saw no serious objec-
tions to the use of this apparatus. They qualified this statement
to this extent : Any skilled anesthetist can give good anesthesia
with any piece of apparatus within certain limits. In the last
analysis, it is the anesthetist rather than the apparatus that
gives the anesthesia.

The Council makes no comment expressed or implied regard-
ing any explosion hazard. It is extremely difficult to determine
conditions for such safety.

In view of the foregoing report, the Council on Physical
Therapy voted to accept the Augustana Model Safety Gas-
Oxygen Apparatus for inclusion in the Council's list of accepted
devices.

DUAL-SPECTRUM ULTRAVIOLET LAMP,
MODEL 300, ACCEPTABLE

Manufacturer : Bristow and Company, 2831 West Pico Boule-
vard, Los Angeles.

The Dual-Spectrum Ultraviolet Lamp, Model 300, is a thera-
peutic lamp designed exclusively for the use of the physician.
Evidence was provided to show that 82 per cent of the radiation
is between 2,000 and 2,600 angstroms, 16 per cent between 2,600
and 3,000 angstroms and 2 per cent between 3,000 and 3,200
angstroms. The firm claims that, by the use of special glass
tubing in addition to quartz tubing, approximately 50 per cent
more energy is provided between the bands 2,600 and 3,000
angstroms than is customary with quartz construction.

The lamp consists of a base containing three transformers;
a tubular stand supporting the lamp, a time clock, cable attach-
ment, switches and an orificial unit (Council accepted August
1938) ; and a reflector containing the burner. The weight of
the unit is 47 pounds, the outside diameter of the reflector is
36_ cm., and the supporting column is adjustable to different
heights. An air .cushion in the column serves as a shock
absorber. The reflector is adjustable horizontally and vertically
and may be rotated in both axes.

The reflector, with a bakelite back and an aluminum shell,
supports two types of tubing in the burner. One is of quartz
and another of a special composition glass which is coiled side
by side with the quartz tubing in a flat hexagonal pattern.
These tubes contain mercury and a mixture of inert gases and
are energized by two transformers made for 50 to 60 cycle
current, with 115 volts on the primary and 1,800 volts on the
secondary at 90 M.A. Together they consume 180 watts. The
orificial transformer has the same specifications on the primary
side with 2,000 volts on the secondary at 9 M.A.

The firm submitted evidence regarding the radiation (includ-
ing two spectrograms), power consumption and other physical
data. The lamp was reported to produce the intensity of ultra-
violet light in microwatts per square centimeter shown in
table 1.

Table 1. — Intensity of Ultraviolet

Quartz Light Special Glass

Both

At

4 inches .....

5,300

2,300

6,200

At

24 inches

510

320

640

According to the report of physiologic tests carried out on
abdominal untanned skin at 24 inch spacing, the erythema time
on this lamp is as given in table 2.

Table 2. — Calculated Minimum Perceptible Erythema Time

Seconds

Quartz light 75

Special glass light.... 105

Both 52

The lamp was examined by the Council, and the claims were
found to be acceptable from a physical standpoint, and the lamp
was determined to be adequate for clinical service.

In view of the foregoing report, the Council on Physical
Therapy voted to accept the Dual-Spectrum Ultraviolet Lamp,
Model 300, for inclusion in its list of accepted devices.

Council on Pharmacy and Chemistry

NEW AND NONOFFICIAL REMEDIES

The Fon.own.-o additional articles have been accepted as CON-
FORMING TO THE RULES OF THE COUNCIL ON PHARMACY AND CHEMISTRY

of tiie American Medical Association for admission to New and
Nonofficial Remedies. A copy op the rules on which the Council
BASES ITS ACTION WILL BE SENT ON APPLICATION.

Paul Nicholas Leech, Secretary.

^ee New and Nonofficial Remedies,

1939, p. 256).

The following dosage form has been accepted:

Asochloramid Saline Mixture Tablet s, 3.5 Brains (for preparing 2
ounces o t a 1 : 3,300 aqueous solution): Each tablet contains azochloramid
0.28 gram, sodium chloride 7.60 grains, disodium phosphate 0.54 grain and
monopotassmm phosphate 0.08 grain.

BACTERIAL VACCINE MADE FROM THE
TYPHOID BACILLUS AND THE PARATYPHOID
“A” AND “B” BACILLI (See New and Nonofficial Reme-
dies, 1939, p. 443).

Tiie Gilliland Laboratories, Inc., Marietta, Pa.

i ypnoia-raratypnotd Bacterial l aceme Immunising , — Also marketed in

innnZnt VW/'TT I in ?.f?°^ C0 ?S inin ^J n cach cahic centimeter
I .OOOmdlion kdkdtypho'd bac.il., SOO million killed paratyphoid A bacilli
and 500 million killed paratyphoid B bacilli.

Aiv x IMENINGOCOCCIC SERUM (Sec New and Non-
official Remedies, 1939, p. 403).

The National Drug Company, Philadelphia.

Antimeningococcic Serum, Refined and > -- • - >„

packages of two 10 cc. double-end ampule-vi „ ‘2

inirasp.nal and intravenous needles; in packag

intravenous needle and one 10 cc. double-end amnule-vial with

the C patient. ' S ,ncim3e<i "' ,th « ch P^kage to determine the sensitivity P of

1882

EDITORIALS

THE JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION

535 North Dearborn Street - - - Chicago, III.

Cable Address .... "Medic. Chicago”

Subscription price ..... Eight dollars per annum in advance

Please send in promptly notice of change of address, giving
both old and new; always state whether the change is temporary
or permanent. Such notice should mention all journals received
from this office. Important information regarding contributions
will be found on second advertising page following reading matter.

SATURDAY, NOVEMBER 18, 1939

EVOLUTION OF OUR KNOWLEDGE
OF TUBERCULOSIS

Subtle, evasive, paradoxical, intricate and complex
are terms that apply to the microscopic parasite which
a recent writer 1 characterizes as “A Bug Full of
Tricks.” The early history of devastation wrought by
this armored enemy of mankind is still preserved in
the distorted joints and spinal columns of prehistoric
skeletons and Egyptian mummies. The recent history
is accumulating much faster than is the record of many
other parasites that revolve about the microscopic or
chemical and immunologic analysis.

The code of Hammurabi, written at least 2,000 years
B. C., indicates some knowledge then of tuberculosis.
Greek writers described the clinical features of tuber-
culous disease in the fifth century B. C. In the second
century Aretaeus not only accurately described the
clinical features but suggested routine treatment. In
spite of their keen observations, Hippocrates and Galen
recognized the hopelessness of a problem that appeared
entirely occult. Galen probably never suspected that
his own illness was a manifestation of phthisis, for
bizarre beliefs befogged the issue. Fracastorius in 1546
expressed the belief that phthisis was due to invisible
germs. Paracelsus in 1567 wrote about miners’
phthisis. Franciscus Sylvius in 1650 suggested the
connection between scrofula and phthisis and that
tubercles precede phthisis. The first postmortem report
of miliary tuberculosis was given by Manget in 1700,
about which time Morgagni refused to perform necrop-
sies on the victims of phthisis because of his fear of
contagion.

The tuberculosis death rate reached its highest point
about the middle of the eighteenth century, coincident
with rapidly increasing facilities for the acquisition of
knowledge. Auenbrugger made an epochal contribution
in describing immediate percussion in 1761. Late in
the eighteenth century Whytt described tuberculous
meningitis, and Pott tuberculous destruction of the

1 . Moorman, Lewis J.: A Bug Full of Tricks, J. Oklahoma M. A.
S2:204 (June) 1939.

Jour. A. M. A,
Nov. 18, 1939

spine. In 1816 Petit described laryngeal tuberculosis,
and Portal suggested a connection between consump-
tion and engorgement of lymphatics. It is said that
William Stark, who was studying the pathology of
phthisis in London under the renowned John Hunter,
died of tuberculosis as the result of a wound received
in the morgue. Baillie, the successor of Stark, also
developed an infection of the hand after performing
a necropsy and died of tuberculosis, but not until his
years of study had clarified the knowledge of the
tubercle.

At the turn of the nineteenth century Willan dis-
cussed the relation of erythema nodosum to tubercu-
losis. Bichat advanced from the organ pathology of
Morgagni to tissue pathology within the organ. Bayle
presented in his volume “Pulmonary Phthisis” clinical
observations checked by more than 900 necropsies.
Corvisart popularized percussion early in the nineteenth
century. Later Piorry’s method of percussion and
Laennec’s new method of auscultation had a profound
influence on the progress of physical diagnosis. Laen-
nec appropriated all previous scientific advances and
with remarkable genius drew up a minute history of
near!}' 400 cases of phthisis before he was 22 years
of age. He recorded virtually all that is now taught
about the physical diagnosis of diseases of the thorax. He
published in 1918 nearly 800 pages on auscultation and
diseases of the chest. The advances of the nineteenth
century' would not have developed so rapidly without
the invention of the stethoscope by Laennec, who
himself died of pulmonary' tuberculosis. Contempo-
rary with Laennec, the great clinician Louis, who also
suffered from tuberculosis, correlated the symptoms
and pathology in the light of the necropsy, and through
his teachings and pupils — Oliver Wendell Holmes,
George C. Shattuck, William Pepper, Gerhard, Stille,
Power, Swett and Clark — he was largely responsible
for the establishment of clinical medicine, with special
interest in physical examination, throughout the world.
Virchow, contemporary with Louis, advanced from
tissue pathology' to cellular pathology and joined the
dualist Schonlein, who coined the word “tuberculosis.

At the University of Vienna, Skoda’s (1805-1881)
skill in diagnosis by means of percussion and ausculta-
tion led to the establishment of a special department
on chest diseases to which students came from all parts
of the world. Skoda’s work was brilliantly' coniplc
mented by his great contemporary Rokitansky, who >s
said to have performed more than 30,000 postmortem
examinations.

A great scientific awakening was imminent by the
middle of the nineteenth century. Villemin demon-
strated in 1865 in a series of masterly experiments
the specific nature of tuberculosis by means of inoct
lation. Gerlach in 1S70 proved that milk from
tuberculous cows may convey the disease. Medici
began to move into a new era, which was to

Volume 113
Number 21

EDITORIALS

1S83

the development of modern laboratory' methods. The
tubercle bacillus was seemingly preparing a way for
its own discovery and for the surrender of many of
the secrets of its occult powers. The first pathologic
laboratory was established by Virchow in Berlin in
1856 and the first hygienic laboratory by Pettenkofer
in 1878. In 1882 Koch discovered the tubercle bacillus.
Just before Koch’s discovery Trudeau, Dettrveiler and
others became pioneers in the sanatorium management
of patients, and in a short while artificial pneumothorax,
another revolutionary method of treatment, was to be
introduced by Forlanini.

Four thousand years has been surveyed for this brief
statement of evolution of knowledge of this disease.
Still from year to year more and more is being written.
As the unsolved problems related to the tubercle bacil-
lus remain infinite, so tuberculosis remains the greatest
killer of man during the most useful period of his life.

POSTSCARLATINAL NEPHRITIS
Some years ago Burky 1 2 announced a discovery which
many immunologists credited with opening up “so
many new broad and inviting possibilities that it is
fairly bewildering.” 3 He found that lens proteins are
nonantigenic when injected into homologous animal
species. If the lens substance is mixed with staphylo-
coccus filtrate, however, its latent antigenicity is in
some way activated or supplemented, so that it becomes
an effective sensitizing or immunizing agent. Rabbits
injected with toxin “synergized” or “potentiated” lens
protein not only develop antilens precipitins of high titer
(e. g. 1 : 50,000) but also develop degenerative lesions
in their own crystalline lens. These lesions duplicate
the picture found in human cases of endophthalmitis
phaco-anaphylactica. Extending his work to other tis-
sue products, Burky found that in rabbits high titer
antibodies could be produced by combining staphylo-
coccus toxin with homologous muscle proteins.

Since the publication of Burky’s discovery, many
attempts have been made to apply his synergic technic
to the production of improved vaccines and antiserums.
A few attempts have been made to apply it to the
etiology of senescence or degenerative disease. The
latest is its application to. the etiology of post scarla-
tinal nephritis.

Lindemanu 3 showed that a condition closely simulat-
ing glomerular nephritis can be produced in laboratory
animals by intravenous injection of heterologous anti-
kiclnev serum. Animals injected with such cytotoxic
serums develop albuminuria, hematuria, cvlindruria,
oliguria and occasionally anuria. In all these tests, how-
ever. the nephrotoxic serum was produced in a foreign
animal species. All attempts to develop a nephrotoxic
serum by injecting rabbits with homologous kidney

material have thus far been unsuccessful. Kidney pro-
teins, apparently, are nonantigenic in the body of the
animal of origin.

Applying the Burky technic, however, Schwentker
and Comploier, 4 of the Baltimore City Health Depart-
ment, injected rabbits with rabbit kidney emulsions
plus streptococcus or staphylococcus toxin. High titer
nephrotoxic serums were produced by both technics.
Specific absorption tests showed that the antiserums
thus produced contain at least two nephrotoxic
antibodies. First there was a relatively high titer
complement deviating antibody', specific for kidney
parenchyma. This is accompanied by a relatively low
titer antibody', which reacts with both kidney' and brain
emulsions. This second antibody is interpreted by the
Baltimore clinicians as presumably specific for the con-
nective tissue elements common to brain and kidney.

Having shown that toxin' reinforced emulsions of
homologous kidney are antigenic in rabbits, the Bal-
timore clinicians attempted to determine whether or not
specific nephrotoxic antibodies are developed in the
human body during the course of streptococcic infec-
tions. Complement fixation tests were therefore made
with the serums of forty patients in various stages of
scarlet fever, with twenty-nine control tests on patients
without any sign of streptococcic infection. Thirty-
seven (92 per cent) of the scarlet fever patients gave
positive nephrotoxic serum reactions, as contrasted with
but three (10 per cent) of the control patients. These
results indicate that most persons suffering from scarlet
fever develop circulating antibodies against their own
kidney tissues, a reaction rarely seen in normal persons
and then presumably due to unrecognized staphylococcic
or streptococcic infection.

From these data Schwentker and Comploier conclude
that streptococcus toxin damages some of the kidney
tissue during the primary' infection in scarlet fever.
This damage may' be clinically insignificant. The
denatured kidney proteins thus formed, however, are
released, “activated” or “potentiated” to “complete”
antigens, stimulating the production of antibodies
specific for kidney tissue. These antibodies may be of
sufficiently' high titer to give rise to acute hemorrhagic
nephritis. A similar immunologic vicious circle had
been previously proposed by Schwentker 5 to explain
the etiology of postinfectious encephalomyelitis. The
clinical and pathologic picture of encephalomyelitis is
readily produced in monkeys by repeated injections
with partially denatured brain emulsions. If the
Schwentker theory' of the etiology of postscarlatinal
nephritis is confirmed, the development of a logical
method of interrupting or preventing the nephrotoxic
immunologic vicious circle should not be beyond
ingenuity.

4. Schwentker, F. F., and Comploier, F. C.: T. Exper. Med 70*
233 (Sept.) 1939.

5. Schwentker, F. F., and Rivers, T. JL: J. Exper. Med. CO: 559,
1934; G1-.CS9, 1935.

1. Burley, E. L.: J. Alienor 5:466 (July) 1934.

2. Cooke, R. A.: J. Allergy 5: 473 (July) 1934.

3. Lindemanu, W. ; Ann. Inst. Pasteur 14: 49, 1900.

1884

CURRENT COMMENT

Jour. A. M. A.
Nov. is, 1919

COMBINED (ACTIVE-PASSIVE) DIPH-
THERIA PROPHYLAXIS

Fifteen years ago Ramon and Lafaille 1 suggested a
new method of prophylaxis against diphtheria. By this
- improved method the transient passive immunity caused
by injecting antitoxic serum is supplemented by a semi-
permanent active immunity caused by the simultaneous
injection of diphtheria toxoid. A number of European
investigators confirmed the theoretical possibility of
such combined immunization in laboratory animals.
Gundel and Konig, 2 for example, found that by a
proper selection of dosage and type of antiserum and
of toxoid a relatively permanent active immunity could
be superimposed on the transient passive immunity in
rabbits. This combined immunity was sufficient to
protect laboratory animals from diphtheria toxin over
a long period. The only question undetermined by their
.work was whether or not a similar duplex immuniza-
tion was possible or feasible in man.

Now the clinical feasibility of this combined technic
is denied by Paschlau 3 and by Frey and Schmid, 4 of
the Red Cross Hospital, Vienna. They injected 2,000
units of antidiphtheritic horse serum, cow serum or
sheep serum intramuscularly into each of twenty chil-
dren, followed by single or multiple subcutaneous injec-
tion with diphtheria toxoid. Alum toxoid was used in
most of the tests. The degree of combined active-passive
immunity was estimated in these children by periodic
titrations of the blood serum.

As a typical example of their data, the antitoxin titer
rose to 1.75 units per cubic centimeter of the patient’s
blood by the third day after the duplex injection. This
titer then fell to 0.4, 0.2 and 0.1 unit respectively by the
end of seven, fourteen and twenty-one days. On the
twenty-eighth day only a trace of the passively trans-
ferred antitoxin was detectable, which trace completely
disappeared by the forty-fifth day. Active immunity
was not demonstrable. Control patients injected with
toxoid alone developed relatively high antitoxic titers.

Under the conditions of their test, therefore, the
toxoid was not only an ineffective immunizing agent
but apparently had the deleterious effect of hastening
the elimination or destruction of the transferred anti-
toxin. Their general conclusion is that combined active-
passive immunization is not feasible in human medicine,
the two types of immunization being incompatible with
each other. This conclusion was dramatically confirmed
by one of their patients, who contracted diphtheria
during the course of their attempted duplex immuniza-
tion. Whether or not a combined active-passive immu-
nity is possible or feasible in specific infections other
than diphtheria was not tested by the Austrian clin-
icians.

1. Ramon, Gaston, and Lafaille, Andre: Compt. rend. Soc de bioI ;
93 : 582 (Aug. 14) 1925. Ramon, Gaston: Ann. Inst. Pasteur

9,9 2? Gundel 1 . 9 3L, and Koniff. F.: Ztschr. f. Immunitatsforsch. u. exper.

" ,he ” P p«chlauf G5ntlier: ^ Klin. Wchnschr. 18:7 (Jan. 7), 60 (Jan. 14)

*4 Frey , Leopold, and Schmkl. Eddebard: Ztscbr. f. Immunitatsforsch.
typer. Therap. 93:4S6 (June) 1939.

Current Comment

THE CHRISTMAS SEAL

Two hundred thousand persons are alive in the
United States today who would have been dead of
tuberculosis if last year had been 1904. Since that year,
which marked the inception of the National Tubercu-
losis Association, the mortality rate from this disease
has been cut down from 201 deaths per hundred thou-
sand of population to 49 in 1938. People are now being
urged to buy Christmas Seals, which help to finance the
work of this association and its 2,500 affiliated organiza-
tions in all parts of the eountty. A part of the money
derived from the sale of these seals goes into a fund
which maintains a rehabilitation program for tubercu-
lous persons in sanatoriums. But the real problem in
fighting tuberculosis involves education: Those who
have tuberculosis in its incipient stages can be cured if
they' are aware of their disease. In order to find these
early cases, the people must be educated to look for it.
In spite of the improvement of diagnostic methods, only
13 per cent of patients admitted to sanatoriums are
found to be in the early stages of the disease, thus
showing that there are far too many with unrecognized
cases in the community infecting their families and
neighbors. Only by finding every single case can the
disease be eliminated. Early examination, skilful diag-
nosis and prompt treatment are the factors that make
tuberculosis curable and preventable. Persons with
questionable cases should be promptly examined.

TESTIMONIALS OF THE DEPARTED FOR
VALENTINE’S MEAT JUICE
An early report of the Council on Pharmacy and
Chemistry (1909) pointed out that Valentine’s Meat
Juice was being promoted with fallacious claims that it
is highly nutritious and is valuable in the treatment o
pneumonia, diphtheria and typhoid. Such claims arc
no longer made. Recently physicians have received a
letter referring to an accompanying booklet containing
the “experience of Physicians who have, themselves,
suffered from Gastric and Intestinal troubles and fount
Valentine’s Meat-Juice of much comfort and satis
faction.” Of the testimonials (twenty-one in number)
eleven were from abroad. Of those supposed to have
been given in the United States, it is interesting to no e
the following testimony of Dr. C. :

“Having had a very long and- exhausting attack of
Fever, lasting from June until the following December,
ENTINE’S MEAT-JUICE was the only article of nouns!' 1 ™"

I could take and the only one I required. Yet long be
my illness I had prescribed it in my practice in ever) ^
of medical and surgical diseases coming under the care •
busy practitioner. I have never yet met with a cas -•
Infantile life to Old Age that VALENTINE’S MEAT JUIU
could not be given with the greatest advantage.’

According to the records of the A. M. A. Director).
Dr. C. died ten years ago. The next testimony
physician in America is Dr. M„ who died m
Dr. S. died in 1930. Dr. G., according to our recor r ,
graduated in 1S85, but the American Medical Direct
fas' lost a II contact with him. Dr. K. died m

Volume 113
Number 21

MEDICAL NEWS

1885

Dr. S. died in 1913; Dr. P. died in 1936. The Ameri-
can Medical Directory has no record of Dr. C. R. T.
but it does have a record of Dr. E. R. T., in the same
town, who died in 1919. Of Dr. T. L. P. it has no
record; there is a doctor from the same town with a
similar name who died in 1915. Dr. L. is not a member
or Fellow of the American Medical Association but is
apparently still living. In other words, only one doctor
of the entire group of American physicians whose tes-
timonials are offered by the Valentine’s Meat Juice
Company in the year 1939 is alive. The title of the
booklet is “Report From Members of the Medical Pro-
fession Who Have Themselves Taken Valentine’s
Meat-Juice When 111 With Gastric or Intestinal Trou-
ble.” And now they are no longer ill; they are dead.
But their testimonials linger on !

Medical News

(Physicians will confer a favor by sending for

THIS DEPARTMENT ITEMS OF NEWS OF MORE OR LESS
GENERAL INTEREST! SUCH AS RELATE TO SOCIETY ACTIV-
ITIES, NEW HOSPITALS, EDUCATION AND PUBLIC HEALTH.)

ALABAMA

Society News. — The Etowah County Medical Society was
addressed in Gadsden recently by Drs. James O. Finney
and Amos C. Gipson on "Complications of Peptic Ulcers” and
“Immunization and Treatment of Acute Infectious Diseases"

respectively, At a meeting of the Calhoun County Medical

Society, Anniston, recently the speakers were Drs. James
A. Ward on “Obesity Associated with Endocrine Disturbances”
and Hugh M. C. Linder on “Empyema Thoracis with Special
Reference to the Chronic Stage.” Both are from Birmingham.

Dr. John Ralph Morgan, Birmingham, discussed “The

Treatment of Burns” before the Walker County Medical Society
October 13 in Jasper.

ARIZONA

New Office for State Society. — The Arizona State Medi-
cal Association has opened offices at 202 Security Building,
Phoenix, and employed Mrs. Kitty Ives Coleman as executive
secretary. For the past three and a half years the association
has had a part time assistant in a combined office with the
Maricopa County Medical Society and library. The president
of the association held a conference of presidents and secre-
taries of the county medical societies at Phoenix October 22
to discuss the program of the association for the current year.

ARKANSAS

Society News. — The Ouachita County Medical Society was
addressed in Camden recently by Drs. James E. Knighton
Jr. on “Some Problems in Cardiology” ; James C. Willis Jr.
and Willis J. Taylor, "Partial Gastrectomy," and Oscar O.
Jones, “Treatment of Bursitis.” All are from Shreveport.

University News. — The general offices of the University
of Arkansas School of Medicine, Little Rock, were moved
recently to the former home of the late Dr. Carle E. Bentley,
which is adjacent to the school. This property was acquired
through purchase several months ago, newspapers report.
Space in the medical school occupied by offices since its
construction will be converted into additional quarters for the
library.

CALIFORNIA

Alumni Day. — The University of California Medical School
will observe its alumni day November 24. The program will
consist of clinics and fracture and medical ward rounds at San
Francisco Hospital. During the operations, the preoperative
and postoperative care and surgical methods will be discussed
by a member of the staff. There will be also a program of
entertainment, according to an announcement from the univer-
sity.

DISTRICT OF COLUMBIA

Personal. — Robert E. Bondy, director of disaster relief of
the American Red Cross, has been appointed director of public

welfare of the District. Rear Admiral Perceval S. Rossiter,

U. S. N., retired, formerly surgeon general of the navy, became
September 19 chief of staff at Gallinger Hospital.

The Davidson Lecture.— Dr. AValter Freeman, professor
of neurology at George Washington University School of Medi-
cine, recently presented the Davidson' Lecture before the Medi-
cal Society of the District of Columbia. His subject was
"The Surgery of Mental Disorder.” The lecture is given
biennially and is named for Dr. Edward Young Davidson.
The lecturer is chosen through essays submitted on a com-
petitive basis.

Portrait of Dr. White. — A portrait of the late Dr. Wil-
liam Alanson White, for many years superintendent of St.
Elizabeths Hospital and professor of psychiatry at George
Washington University School of Medicine, was presented to
the university in behalf of the medical faculty at the opening
exercises of the school September 25. Dr. Charles S. White
made the presentation and Mrs. Joshua Evans Jr. accepted it
for the university in behalf of the board of trustees.

FLORIDA .

Personal. — Dr. Luis Garcia will be director of a new
tuberculosis hospital which was to be opened about October 10
on the site of the former Pine Health tuberculosis preven-
torium, Tampa newspapers reported. The hospital was made
possible by the cooperation of the city and county with the aid
of charitable organizations. Dr. Garcia has been in charge of
the Tampa tuberculosis clinic since it was opened about two

years ago. Dr. William McQueen, Sarasota, has been

appointed superintendent of the Sarasota Hospital.

District Meetings. — The third annual meeting of the South-
east Medical District of the Florida Medical Association was
held at West Palm Beach October 12, with headquarters at
the Palm Beach Yacht Club. The speakers included Drs.
Eugene C. Chamberlain, Fort Lauderdale, on “Isolated Myo-
carditis”; Hillard W. Willis, Miami, “Nephritis in Children”;
George D. Lilly, Miami, “Surgical Treatment of Essential
Hypertension,” and Carlos A. P. Lamar, Miami, “Clinical
Endocrinology of the Male, with Especial Reference to the

Male Climacteric.” The North Central Medical District

Society held its third annual meeting in Ocala October 26 at
the Marion _ Hotel. Dr. Carl S. Lytle, Dunnellon, president
of the Marion County Medical Society, gave the address of
welcome. Among other speakers were Drs. Ralph E. Russell,
Ocala, on “Hygiene of the Eyes”; Laurie J. Arnold Jr., Lake
City, “Cervical Ribs”; Richard C. Cumming, Ocala, “A Young
Doctor Looks at Socialized Medicine,” and Walter E. Mur-
phree, Raiford, syphilis.

ILLINOIS

Personal. — Dr. Otto L. Bettag, White Haven, Pa., has been
appointed superintendent of the Livingston County Sanatorium,
Pontiac, succeeding Dr. Julius B. Stokes, resigned.

Outbreak of Typhoid. — Twelve cases of typhoid with one
death occurred at DePue, Bureau County, during September,
according to the Illinois Health Messenger. The outbreak was
ascribed to a raw milk supply used by all the patients. When
the supply was cut off as a control measure the epidemic ended,
the Messenger said.

Chicago

Dr. DeLee Observes Seventieth Birthday. — Dr. Joseph
B. DeLee, professor emeritus of obstetrics and gynecology, the
School of Medicine of the Division of Biological Sciences,
University of Chicago, observed his seventieth birthday Octo-
ber 29 at a party planned to benefit the Chicago Maternity
Center, which he_ founded. He was presented with cuff links
forged from a pair of forceps which he used in his early days
of practice. They were the gift of the staff of the center and
were presented by Dr. Beatrice E. Tucker, who directs the
institution.

Obstetric Service in the Home.— A plan is under way
to provide home obstetric service to indigent patients in Polk
County. The program is to be financed by funds from the
state department of health and cooperating groups are the state
department of health, State University of Iowa College of
Medicine, Polk County board of supervisors, the city health
department, public health nursing association, Polk County
emergency Relief Administration, Broadlawns Hospital, the
intern committee, the superintendents of the private hospitals

1886

MEDICAL NEWS

and the Polk County Medical Society. The objectives are to
afford obstetric service in the homes of indigent patients; to
enable the college of medicine to participate in such a service
and use the opportunities for teaching; to afford an opportunity
for interns connected with the various accredited Des Moines
private hospitals to participate in the service and to reduce
the number of obstetric patients in Broadlawns Hospital, mak-
ing the beds available to the more complicated and serious
types of cases in which hospitalization is imperative. The
home service will operate through the outpatient department
at Broadlawns and patients will be investigated and arrange-
ments made by the social service department, according to the
Bulletin of the Des Moines Academy of Medicine and the
Polk County Medical Society.

KANSAS

Changes in Health Officers. — Dr. Cyril V. Black, ■ Pratt,
has been appointed health officer of Pratt, filling the unexpired

term of the late Dr. Charles E. Phillips. Dr. Edwin O.

Squire has been appointed health officer for the Coffeyville
board of health.

Library and Museum of Medical History.— Space has
been provided in the Hixon Laboratory of the University of
Kansas School' cf Medicine, Kansas City, for a new library
and museum of medical history. Dr. Logan Clendening, who
has been conducting a course in medical history at the univer-
sity for many years, gave his collection of medical curiosities
and his historical library as a nucleus for the new department.
The building housing the laboratory was financed by the Hixon
Foundation, the PWA and gifts from Mrs. Clendening, it was
stated.

KENTUCKY

Poliomyelitis in Mountain Counties. — Fifty-five cases of
poliomyelitis have been reported in Floyd County and addi-
tional cases in adjoining counties, newspapers reported Novem-
ber 2. Most of the cases were in rural areas. The state
health department and the Kentucky Crippled Children's Com-
mission are investigating the epidemic with a view to prevent-
ing spread of the disease and instituting treatment for those
stricken. Ten cases were reported in Pike County, eight in
Johnson and three in Lawrence.

LOUISIANA

Society News. — At the October meeting of the Tri-Parish
Medical Association, comprised of the parishes of East and West
Carroll, Tensas and .Madison, Dr. William K. Purks, Vicks-
burg, Miss., spoke on allergy. The Eighth District Medical

Society was addressed in Alexandria October 11 by Drs. Con-
ley H. Sanford, Memphis, Tenn., on “Kidney Diseases and
Hypertension” ; Donovan C. Browne, New Orleans, “Func-
tional Colitis,” and Edwin J. Kepler, Rochester, Minn.,
"Obesity — An Endocrine Problem.”

Postgraduate Instruction. — Members of the staff of Loui-
siana State University Medical Center, New Orleans, are
cooperating in a series of postgraduate courses being given
by the division of maternal welfare of the state board of health,
the federal government and the state medical society. In Octo-
ber Drs. Rupert E. Arnell and William F. Guerriero, clinical
professor of obstetrics and gynecology and instructor in obstet-
rics and gynecology respectively, gave postgraduate instruction
to practicing physicians in northern Louisiana. Other mem-
bers of the staff later will conduct similar courses in various
subjects.

MASSACHUSETTS

Public Health Meeting. — The annual meeting of the
Massachusetts Public Health Association xvas held in Boston
October 26. The program was divided into sections with a
symposium making up the board of health section; the speakers
were Dr. John E. Gordon, Arthur D. Weston, C.E., and
Sophie C. Nelson, R.N. In the laboratory section the speakers
were Donald L. Augustine, Sc.D., on “Trichinosis”; William
C. Boyd, Ph.D., “Uses of Blood Grouping,” and Dr. Frank
E. Barton, Boston, “Use of Placental Blood for Transfusions.
The child health section devoted its session to a discussion of
“The Child: The Influence of Economic Factors.”

Society News.— At a special meeting of the New England
Heart Association in Boston October 30 Dr. Harry E, Unger-
leider and Mr. James D. Ewing, Equitable Life Assurance
Societv New York, discussed “Insurance Frauds and Disability -
Problems in Heart Disease.”— The New England Patho-
logical Society was addressed in Boston October 19 by Drs.

Jove. A. 31. A.
Nov. 18, 1939

Lome M. Gray, Toronto, Ont., “Fat Embolism”; Charles E
Dunlap on “Effect of Radiation on the Blood” and Shields
Warren, “Significance of Chronic Mastitis as a Precancerous

Lesion.” Dr. Vincent Gerard Ryan, who holds a fellowship

m the Austen Riggs Foundation under a grant from the John
and Mary R. Markle Foundation, discussed certain aspects of
cases falling in the neurotic-psychotic borderline before the
medical advisory board of the foundation at its annual meeting
in Stockbridge October 21. Dr. Austen Fox Riggs presided
at the meeting. The paper was discussed bv Drs Adolf
Meyer, Baltimore; Charles Macfie Campbell and' Stanley Cobb,
Boston; Earl D. Bond and Kenneth E. Appel, Philadelphia,
and Arthur H. Ruggles, Providence, R. I., among others.

MICHIGAN

Society News. — Dr. Carl V. Weller, Ann Arbor, gave an
address befSre the Ingham County Medical Society October 17
entitled “Shifting Points of View in Regard to Cancer." —
Dr. Harold Henderson, Detroit, addressed the Jackson County
Medical Society in Jackson October 17. His subject was “The

Middle Aged Woman.” Dr. Francis Bruce Fralick, Ann

Arbor, discussed “Ophthalmology and Its Relation to General
Health” before the Kalamazoo Academy of Medicine, Kala-
mazoo, October 17.

Highland Park Physicians’ Club. — The fourteenth annual
clinic of t be Highland Park Physicians’ Club was held Novem-
ber IS at the Highland Park General Hospital. The program
opened with a clinical pathologic conference by Dr. Edgar H.
Norris, professor of pathology, Wayne University College of
Medicine, Detroit. Others on the program xx’ere:

Dr. Sumner L. S. Koch, Chicago, Infections of the Hand.

Dr. Edward J. Stieglitz, Garret Park. j\Id., Treatment of Hypertensive
Disease from an Internist's Viewpoint.

Dr. Alfred XV. Adson, Rochester, Minn., Treatment of Essential Hyper-
tension by Extensive Sympathectomy.

Dr. Edward L. Cornell, Chicago, Analgesia and Anesthesia in Obstetrics.

Dr. Allen Graham, Cleveland. Diagnostic Criteria of Cancer. *

Dr. Temple S. Fay, Philadelphia, Temperature Factors in Cancer and
Embrjonal Cell Growth.

Medical Service for the Low Income Group.— Michigan
Medical Sendee, a nonprofit corporation for group medical
care organized under special enabling legislation sponsored hi'
the Michigan State Medical Society, is now ready to assist the
low income group in Michigan to obtain the services of doctors
of medicine in return for small monthly subscription payments.
The plan will be administered by a board of directors consist:
iug of from eleven to thirty-five representatives of the Pj lb ™
and the medical profession. Local advisory committees will h®
established by the medical profession so that professional judg-
ment will guide the relations with physicians concerning par-
ticipation, fees and the rendering of services. According to
the November state medical journal, the articles of incorpora-
tion of Michigan Medical Service have been certified by lc
attorney' general and the necessary' working capital has been
advanced by' the Michigan State Medical Society. The p an
will go into effect in the near future and its operation ">
be under the direct supervision of the state insurance depa
ment. All employed persons under the age of 65 w b 0 .J? n . •
enrolled in groups of twenty-five or more will be eligible
membership.

MINNESOTA

Study of Motor Accidents.— The Minnesota State Medi-
cal Association has appointed four physicians to co n «u«
studv of motor vehicle accidents. Drs. Kano Ikeda, bu * >
Maurice B. Visscher, Minneapolis; Dale D. Turnadiu, -•
neapolis, and Edward W. Ostergren, St. Paul.

Society News. — Included among the speakers before
Hennepin County Medical Society, Minneapolis, ’

ivas Dr. Horace M. Korns, Iowa City, on Arterial H}P« £

iion.” The Scott-Carver Medical Society was addr -

Dctobcr 10 in Shakopee by Drs. Arthur C. Kcrkhof aiul U- •
X'orman Nelson, both of Minneapolis, on New aspect
Endoscopy” and “Problems of Pernicious Anemia respective i

Minnesota Medical Foundation. — The establishmeii
he Minnesota -Medical Foundation at the University o . ];J
lesota, Minneapolis, was announced at a dinner -

ommemorating the fiftieth anniversary of the founding .
chool of medicine. The foundation has been set up ^

if the university to establish scholarships Protessor Jt i P . ((J

ureships, research and aid to worthy students. nmver

he Minneapolis Tribune, the foundation will Mia e Me P ^
o receive gifts, endowments, the rights to patent.,
roperty to carry out its aims. Funds derived from jW,
ources will be used exclusively to assist university •

teifj/'

1888

MEDICAL NEWS

Jour. A. M. A.
Nov. 18, 1939

OKLAHOMA

Regional Meeting.— The Southeastern Oklahoma Medical
Association held a meeting in Poteau October 24. The follow-
ing speakers were on the program :

Dr. Orville M. Woodson, Poteau, Nephroptosis.

Dr. Sidney J. Wolfermann, Fort Smith, Ark., Diagnosis of Location
of Intestinal Obstruction.

Dr. Leonard S. Willour, McAlester, Fractures of the Pelvis and Upper
End of the Femur.

Dr. Coyne H. Campbell, Oklahoma City, Hysteria.

Dr. Charles T. Chamberlain, Fort Smith, Vitamin Deficiency Diseases.

Dr. Paul Neeson Rolle, Poteau, Artificial Feeding of Infants.

Annual Railway Physicians’ Meeting.— The thirty-eighth
annual meeting of the Frisco System Medical Association was
held at Tulsa, October 23-24. Among the speakers were:

Dr. William G. Norman, Cherryvale, Kan., Economic Problems of
Modern Medical Practice.

Dr. Harry B. Davis, Kansas City, Mo., Ocular Conditions Encountered
by the Railroad Surgeon.

Dr. Edward H. Cary, Dallas, Texas, The Use of Old Tuberculin in
the Diseases of the Eye.

Dr. William S. Horn, Fort Worth, Texas, Chronic Brucellosis as a
Major Cause of Neurasthenia.

Dr. Robert M. Howard, Oklahoma City, Toxic Goiter.

Dr. Cyrus E. Burford, St. Louis, Injuries by External Force to Kidney,
Bladder and Urethra.

PENNSYLVANIA

State to Distribute Serum and Sulfapyridine for Pneu-
monia. — The state department of health recently designated
pneumonia control centers throughout the state from which
sulfapyridine and a certain amount of serum are to be dis-
tributed free at the request of physicians for patients who are
not in a position to purchase them. The centers are also
equipped to give rapid and accurate bacteriologic diagnosis.
Clinical reports on the results of therapy on forms supplied by
the state health department are required from each physician
who uses sulfapyridine or serum supplied by the department.

Society News. — Dr. Henry J. John, Cleveland, addressed
the Washington County Medical Society, Washington, Novem-
ber 8 on diabetes. Dr. Charles. Howard Marcy, Pittsburgh,

addressed the Fayette County Medical Society, Uniontown,

November 2 on pulmonary hemorrhage. Dr. Henry L.

Bockus, Philadelphia, addressed the Delaware County Medical
Society, Chester, November 9 on chronic gastritis. Dr. Kath-

arine O’Shea Elsom, Philadelphia, addressed the Dauphin
County Medical Society, Harrisburg, October 10 on “Nutri-
tional Disturbances Incident to Vitamin B Deficiency.”

Dr. Henry K. Mohler, Philadelphia, addressed the Harrisburg
Academy of Medicine October 17 on “Therapeutic Uses of
Sulfanilamide and Its Associated Compounds.”

TENNESSEE

Clinical Congress in Chattanooga. — The Chattanooga and
Hamilton County Medical Society held its annual clinical con-
gress October 26 at Newell Sanitarium and Erlanger Hospital.
Dr. Julius C. Brooks was in charge of surgical clinics, and
Dr. James D. L. McPheeters in charge of medical clinics.
Guest speakers at a banquet in the evening were Drs. James
E. Paullin, Atlanta, Ga., on “Treatment of Congestive Heart
Failure” and William H. Stewart and Charles W. Breimer,
New York, on “Cineroentgenography of Today.”

Society News. — Dr. Robert R. Brown addressed the Nash-
ville Academy of Medicine and the Davidson County Medical
Society October 31 on “Internal Derangements of the Knee
Joints” and Dr. William C. Dixon November 7 on “Treatment
of Uterine Prolapse.”- Drs. Jefferson A. Hanna and Wil-

liam C. Chaney, Memphis, among others, addressed the Dyer,
Lake and Crockett Counties Medical Society October 4 on
“The Present Conception of Vitamin Therapy” and “More
Recent Advances in the Treatment of Migraine” respectively.
Dr. Stewart Lawwill, Chattanooga, addressed the Chatta-
nooga and Hamilton County Medical Society November 2 on
“Intracapsular Cataract Extraction.”

TEXAS

UTAH

State Medical Election. — Dr. Alfred C. Callister, Salt
Lake City, was chosen president-elect of the Utah State Medi-
cal Association at the meeting of the house of delegates durin»
the Rocky Mountain Medical Conference in Salt Lake City in
September. Dr. George M. Fister, Ogden, became president
and the following vice presidents were elected: Drs. Edwin
M. Nehe.r, Salt Lake City; Wilford J. Reichmann, St. George,
and David E. Ostler, Richfield. The 1940 meeting will be in
Ogden.

VERMONT

Dispensary Enlarged. — The Burlington Free Dispensary,
operated jointly by the University of Vermont College of
Medicine and the city of Burlington, marked the twenty-fifth
anniversary of its founding by opening new and enlarged quar-
ters, The university' rented and remodeled a building and will
pay the rent and maintenance, while the city contributes $5,000
for expenses and a part of the salary of the director. The
dispensary is the teaching outpatient clinic for the medical
school. The new facilities include a laboratory and diagnostic
appliances. In addition it is planned to add new clinics in
psychiatry and venereal disease. The dispensary occupies two
floors of its new building, one floor is leased to relief agencies
and the upper floor has rooms for students who are on twenty-
four hour duty. Dr. Jesse A. Rust Jr. is city physician and
director of the dispensary.

VIRGINIA

Special Society Elections. — Several societies of specialists
held their annual meetings in Richmond during the recent
annual meeting of the Medical Society of Virginia. The Vir-
ginia Urological Society elected the following officers: Drs.
Albert A. Creecy, Newport News, president; Samuel Beverly
Cary% Roanoke, vice president, and Linwood D. Keyscr,
Roanoke, secretary. New officers of the Virginia Radiological
Society are Drs. Fred M. Hodges, Richmond, president;
Daniel D. Talley' Jr., Richmond, vice president, and Vincent
W. Archer, Charlottesville, secretary. The Virginia Pediatric
Society elected Drs. Samuel A. Anderson Jr., Richmond, presi-
dent; James V. Bickford Jr., Norfolk, vice president, and
John M. Bishop, Roanoke, secretary, reelected. Dr. Harry
Hudnall Ware Jr., Richmond, was elected president of the
Virginia Obstetrical and Gynecological Society and Dr. Henry
C. Spalding, Richmond, secretary.

WISCONSIN

Fiftieth Anniversary of County Medical Society.— The
Douglas County' Medical Society celebrated its fiftieth anni-
versary at a meeting in Superior October 4 with Dr. John
Baird, the only surviving charter member, as the guest o
honor. Dr. Fred G. Johnson, Iron River, councilor of the
eleventh district, and several colleagues paid tribute to
Dr. Baird, and the society' presented to him a gold medal i
recognition of his services to the society, the community an
the medical profession. A volume on the history of the socie ).
prepared by Mrs. Loran W. Beebe, Superior, was presente
by the woman’s auxiliary.

Society News. — Dr. Conde F. Conroy', Milwaukee, addresse
the Brown-Kewaunee-Door County Medical Society, Grcc
Bay, October 19 on management of varicose veins.— -u-
Alexander R. MacLean and John L. Emmett, Rochester, . 11 ■;
addressed the Eau Claire-Dunn-Pepin Counties Medical hoc: i
October 30 in Eau Claire on “Vascular Headache and Urinary

Retention” respectively. Speakers at a meeting of the ur.

County Medical Society, Lancaster, October 25_ were Vts.

C. Pickard, Dubuque, Iowa, on “The Ear, Nose and
in General Practice”; Horace Kent Tenney Jr., Mach- .
“Vomiting in the Newborn”; Walter C. Alvarez, R° - ’

Minn., “Treatment of Indigestion,” and Marcos Ferna -i ’
Milwaukee, “Cancer— Its Prevention and Control. - wr : .
iam J. Bleckwenn. Madison, addressed the Green La
Waushara Countv Medical Society, Princeton, October -i
‘The Use of Barbiturates in General Practice.

South Texas Postgraduate Meeting.— The eighth annual
Postgraduate Medical Assembly of South Texas will be held
in Houston December 5-7 at the Rice Hotel. The lecturers
will be Drs. George G. Ornstein, Eliot Bishop, Herbert K
Traut, James W. White and Rupert Franklin Carter, New
York- Henry H. Turner, Oklahoma City-; Frank R. Ober,
Boston; Grady E. Clay and Edgar G. Ballenger Atlanta Ga.;
Perrv G Goldsmith, Toronto, Canada; Harold I. Lillie, Roch-
ester Minn ; Archibald L. Hoyne, Chicago; Hans H. F.
Reese Madison, Wis., and Isaac A. Bigger, Richmond, Va.

WYOMING

State Medical Election.-Dr Peter M. Sehujik, ShcndaU;
-as named president-elect of the Wyoming S jtatc W
ocietv at the recent annual meeting of the hous Lake

uring the Rocky Mountain Medical I Conference ■ *» Sal^^
ity in September. Dr. Roscoe H. Reel e, C. - P ■ reclK ted
ice president and Dr. Marshal! C. kciib, jj ' j, ccar iic

‘cretary. Dr. John H. Goodnouph, Rock Springs, w
resident. Next year’s meeting will he m Sheridan.

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FOREIGN LETTERS

Joan. A. jr. A
Nov. ]S, 19JS

Foreign Letters

PARIS

(From Our Regular Correspondent)

Oct. 11, 1939.

American Hospital of Paris

The American Hospital with its 500 beds, its fine equipment
and its staff of physicians and selected nurses has just been
placed by Dr. Gros, its superintendent, at the disposal of French
war victims. Hospital services have been transferred to
Etretat on the coast of Normandie, where 1,500 wounded or
sick can be accommodated. On the other hand, a certain
number of French hospitals have been closed, either because
of the difficulty of evacuation in case of bombardment or
because of the considerable reduction in the number of inhab-
itants of Paris in consequence of mass migrations.

Treatment of Craniocerebral War Wounds

The Academie de chirurgie held its opening fall session
September 20. Gosset sent a cordial welcome with the best
wishes of the members to all French and allied surgeons. He
proposed a work plan and expressed the hope that the inter-
allied medical conferences conducted during the World War
at Val de Grace at the initiative of Mr. Lloyd George would
be revived because of their great usefulness. The principal
papers of this meeting were devoted to craniocerebral wounds
and their treatment and were read by Thierry de Martel, the
distinguished surgeon of the American Hospital of Paris, and
Clovis Vincent, professor of neurosurgery in the medical faculty
of Paris. Vincent arrived at cerebral surgery by way of
neurology and de Martel by way of general surgery. De
Martel modestly acknowledges his indebtedness to Cushing and
Mackenzie. The two papers differed on certain points but
were in general agreement. For .that reason they are reviewed
together. A neurosurgical operation in itself constitutes a
craniocerebral trauma. The physiopathologic sequels are the
same and the technics of attack on the cerebral tissue are
analogous. However, there is a considerable difference in the
traumatic agents and likewise important differences between
war wounds and ordinary traumas, such, for example, as are
due to automobile accidents.

In an automobile accident, a head weighing 17.6 pounds
(8 Kg.), considered as a projectile and launched at the rate
of 72 kilometers an hour, on striking an object effects an
impact equivalent to 160 kilogrammeters. The surface area
involved is wide. In a war wound, however, caused for exam-
ple by a bullet of 15 Gm. projected at 450 meters per second,
the bullet attains an impact effect of 150 kilogrammeters.
However, the surface involved is small. In the former case
manifold lesions may be observed as well as significant con-
cussion effects; in the latter, the lesions are concentrated and
deeper; often the damage done on the surface is negligible
compared with that to the nervous tissue. Today, with the
progress that has been made in surgery of the cerebral tissues,
one ought to bring about healing in many more cranial wounds
and, above all, prevent better than was formerly possible the
horrible effects which overshadowed the prognosis of those
surgically cured. For that reason, speed is of utmost impor-
tance. The wounded should be brought to the surgeon before
the appearance of edemas destructive to the brain, especially
near the pray columns and the bulb. Early intervention pre-
vents in the great majority of cases the principal risks of
traumas and interventions, namely, hematomas, cerebral her-
nias or fistulas of the cerebrospinal fluid, excessive loss of
bony substance and disastrous cicatrizations which affect the
skin, bone and cerebral tissue and induce epilepsies and mental
disorders. These benefits cannot be realized unless the surgeon

is competent and well supplied with the necessary equipment;
head equipment, mechanical trephines, Cushing-Mackenzie dips,
electrocoagulation apparatus of high frequency, low voltage
and of weak intensity, wax to close osseous orifices, refractors,
aspirators, irrigators for warm solutions, and black silk which
resists decomposition. Anesthesia will be local preferably.
Epileptic crises will be forestalled or managed with barbi-
turates, chlorol and bromides intravenously administered. Sys-
tematic roentgenography will reveal the presence of a projectile
and bony splinters. A shutter will be made in the cranium
according to the de Martel method, which enlarges the opera-
tive field. Its hinge will be made of muscular or aponeurotic
tissue. The dura mater ought to be attached to the crania!
periosteum or the deep wound portions by a fine catgut suture
and its hemostasis assured by means of clips or electrocoagu-
lation. Lesions of the cerebral tissue will then be clearly in
view. Contused portions will be removed by means of scissors.

The delicate matter of hemostasis with its inundation in the
absence of definite blood vessels will be managed by the aspi-
rator. It will show the bleeding points and indicate where
clips should be used or coagulation performed with low cur-
rent. At times, especially if a deeply embedded bullet is to
be removed, it will be necessary to make a complementary
cranial shutter. On completion of hemostasis suture is made.
Whenever possible, one ought to suture along the galea, because
it resists cerebral pressure better than the elastic skin of the
scalp. The most difficult part of this surgery seems to he
hemostasis of the sinuses. It is here that experience and sur-
gical skill will be important. According to Vincent, brain
surgery is a part of general surgery and can be easily learned.
There are in France quite a few capable brain surgeons, but
the number of wounded may require additional specialists.
Lenormant would like to see centers created for the treatment
of cranial wounds and for the instruction of physicians at the
front on indications for immediate action in lesions of the skull
and cerebral tissue.

French Scientific Societies
Some other societies have canceled their fall meeting and
among them are the Society of Dermatology and Syphilog-
raphy, which was to meet in Paris October 12-14, and the
cancer society' scheduled for October 8.

BERLIN

(From Our Regular Correspondent )

Sept. 20, 1939-

Mothers of Large Families in Germany
In the census of 1933, restricted to Germany before its terri-
torial conquests, were registered 3,577,000 married \mnicit,
exclusive of widows and divorcees, with four or more children,
which is 24.7 per cent of all married women. Of these, 1,14 ,
had four children and the remaining five or more. Of t ,c
latter, 735,000 had five children, 869,000 had six or scicn
children and 825,000 had eight or more. In the period between
the middle of 1933 and the beginning of 1939 the number o
married women with four children and more decrease! »
160,000 (those with four or five by 80,000; those with S,N '®^
seven by 30,000 and those with eight or more by 50,000). "

the other hand, the total number of married women durm-
the same period of time increased by about 1,563,000 to a tu
of 16,061,000. Widows and divorced women, not mclut c<
the figures given here, with four or more children were repor «
at the beginning of 1933 to total 1,600,000; with four or
children 750,000, with six or seven children 400,000 aw "
eight or more children 450,000.

Therapy by Fasting

The Frankfurter medizinische Gesellschaft recently con
ered.tfie question of fasting. H. H. Meyer first di- Cti ' . _ ,

basic principles underlying the therapeutics' of fasting.

Volume 113
Number 21

FOREIGN LETTERS

1891

the first days of fasting, he said, a brief diminution of nitrogen
excretion is followed by an increased excretory activity. Urea
elimination keeps pace with the level of the total nitrogen
excretion until the end of the first week of fasting. This is
followed by a decrease, as part of the nitrogen is contained
in the increased elimination of ammonia induced by acidosis.
Very little uric acid is excreted from the time fasting is begun.
Modifications of nitrogen elimination during the first week are
related to the carbohydrate level. No observations were made
that would indicate an increased retention of urea and uric
acid before fasting therapy was initiated. There is, however,
a great probability that intermediary metabolic products are
excreted in increased quantities, especially during the first
week. What the nature of these products is is not clear. A
part of them belongs to the group which can be detected in
the xanthoprotein test. Patients with high arterial blood
pressure and chronic constipation show an especially high
excretion of xanthoproteins. Control of oxygen eliminated
shows that after an incipient deterioration of oxidation, oxida-
tion improves more favorably than before fasting. In capillary
microscopy one can clearly observe a diminution of the abnor-
mally heightened capillary tonus. It invites the reflection that
the increased elimination of intermediary metabolic products,
which in turn participate in the decompensatory peripheral
processes, represents a contributing cause in its favorable effect
on circulatory diseases, especially in cases of high arterial blood
pressure.

Changes in the metabolism of carbohydrates and fats are
characterized by the sudden and marked development of acetone
during the fifth and tenth day of fasting. However, an increased
ketosis does not occur. Since the body manifestly adjusts itself
readily to a diminution of glycogen, the elimination of acetone
decreases again within a few days to an almost normal level.
Feeding with grape sugar frequently demonstrates, beginning
with the third week, a marked secondary hypoglycemia. The
acidity crisis contributes essentially to cause a change of the
organism, which change, in turn, mobilizes the defensive forces
of the organism. This can be clearly seen in the heightened
bactericidal power of the blood.

BELGIUM

(From Our Regular Correspondent)

Oct. 18, 1939.

Pensions for Aged Physicians
A most important corporate reform is under way, namely,
the establishment of a pension system for aged physicians. The
medical profession of Brussels cordially favors the idea that
the directors of the Federation of Belgian Physicians follow the
example set by the French, who have demonstrated what the
members of a profession still entitled to be called liberal can
accomplish without the support of the state. The plan is
approved by the French medical syndicates, which represent
four fifths of the physicians practicing in France and in the
colonics. Actuarial computations are in progress. Within two
years, no doubt, several thousands of aged physicians can retire
and be entitled to at least a partial pension. It would be unfair
to allot to them the full or normal pension in view of the fact
that no assessment has been levied on them. However, they
will receive about 8,000 francs if they make no contribution and
10,000 if they can contribute a small amount, equivalent to 5 per
cent of 1,000 francs. The younger members of the profession
will receive, at the time of retirement, from 25,000 to 29,000
francs. The highest premium will probably be 3,000 francs.
Certain other risks are also taken into account, such as half
pensions for widows, reimbursement for funeral expenses and
special grants for physical disability.

Socialized Medicine

Before the Societe medico-cbirurgicale of Brabant, M. Schwers
initiated a discussion on present tendencies in medical organiza-
tion, championing the private character of the physician’s status
and practice. He asserted that private practice should remain
the basis of all plans of organized medicine and that mass medi-
cine was not feasible either from the financial or from the
social point of view. The results would be disastrous. His
statement evoked much criticism ; although the assembly agreed
that it was undesirable to see medicine converted into a state
function, yet it was true that relations between medicine and
the state should exist and develop. On the problem of the
relation of medicine to the state, Massion presented the follow-
ing point of view : The state cannot practice medicine in the
current sense of the word. Freedom of choosing one’s physician
and the confidential character of his services must be rigorously
respected in medical practice as the foundation of the healing
art. The role of the state, however, is great. It must stimu-
late, direct and supplement, laboring to place medical service
within the reach of all. The physician, while refusing to allow
the fundamental character of his medical acts to be altered,
ought to work in cooperation with the state for a better public
health and a better medical service. An exclusively negative
attitude like that of Schwers was not tenable, he said. Medi-
cine cannot ignore the state, nor can the state divest itself of
an interest in the organization and solution of the pressing
problems of public health.

The New Tumor Center in Brussels
The Institute Jules Bordet, replacing the Centre des tumeurs
de l’hopital Brugmann, which had outgrown its usefulness, was
recently dedicated. The building is constructed on the two wing
plan. One wing, with eight stories, is intended for hospitaliza-
tion; the other, six stories high, is given over to rooms and
quarters for the examination of patients, for roentgenography
and diagnosis, for apparatus for radium therapy, for surgical
rooms and for laboratories and libraries. The eight story wing
contains an auditorium and museum, administrative offices and
consultation rooms for heads of departments, wards and rooms
for hospital service, and the kitchen and dining rooms for the
medical staff, nurses and relatives of the patients. The public
aid committee has assumed the task of the construction of the
building. The university has furnished the money for the
acquisition of a part of the land and the x-ray, the scientific
and the diagnostic equipment necessary for the treatment of
cancerous patients as well as for the study and instruction of
cancerology. Thanks to the National Funds for Combating
Cancer, the institute has 6.5 Gm. of radium.

Scientific control will be vested in the university and hospital
service in the Committee on Public Aid. The new center has
been named the Jules Bordet Institute as a tribute to an eminent
scientist of whom Belgium is proud.

Tuberculosis Among Workers in Tobacco Factories

Dr. Peremans reported (Arch, dc mid. sac. ct d'hyg. 1938,
number 8) the results of his investigations in the A'an der Elst
tobacco factory at Louvain. Only workers directly in contact
with tobacco were considered; these numbered 876, of whom
317 were men and 559 women. The average age was respec-
tively 37 and 26, and the average work duration respectively
eighteen and nine years. The workers examined were classified
as: (1) those who had no notable pulmonary lesion, (2) those
who had inactive pulmonary lesions and (3) those who had
active pulmonary lesions. Cardiac and bone anomalies were
also noted. Of the 317 men, twenty-four were found with
active and sixty-seven with inactive pulmonary tuberculosis,
twenty-four with cardiac lesions and five with bone anomalies.
The figures for the women were respectively' eleven, seventy',
fifteen and four. Of the thirty-five suspected male and female

1892

FOREIGN LETTERS

workers of the third group, thirty-four were given clinical tests
with the following results : Active open tuberculosis appeared
in two men and two women, active closed tuberculosis in eight
men and four women, inactive tuberculosis in twelve men and
five women and nontuberculous lesions in two men. The
summarized report on the 876 workers indicated the following
distribution: (1) sixteen cases (1.82 per cent) of pulmonary
tuberculosis in evolution in four of which (0.45 per cent) there
were open lesions, and (2) 154 cases (17 per cent) of inactive
pulmonary tuberculosis. A comparison of these figures with
those for other industries warrants the assumption that morbidity
due to tuberculosis is practically no higher among workers in
tobacco factories, on the average, than among workers in other
industries.

FINLAND

(From a Special Correspondent)

Oct. 24, 1939.

Goiter as a National Problem

Jobk. A. 31. .t
Nov. IS, 1939

tion of an unnamed statistician who has calculated that the
population will never exceed 4 millions. Be this as it may’
the attitude of women today toward the induction of abortion
must be different from what it was only a generation ago. In
the period under review, the ratio of febrile abortions in the
public hospitals in Helsingfors to the total number of preg-
nancies has increased sixty-six times, i. e. from 0.2 to 13.5 per
cent of all pregnancies. On the other hand, the ratio of afebrile
abortions has in the same period increased only sevenfold, i. e,
from 2.2 to 14.3 per cent. The calculation is also made that
though all ages are involved in this rising tide of abortions,
for the most part presumably induced, it is in the group below
the age of 30 that this rise is most marked. As is to be expected,
it is the unmarried woman whose pregnancies are most liable
to end in induced abortions. Indeed, at the present time, the
chances are that 67 per cent of the pregnancies of unmarried
women will end in abortions.

Vaccination Problems

While goiter has been given much prominence in certain
countries such as Switzerland, little is known in the outer world
of the goiter problems with which Finland has to cope. Even
in Finland itself there has hitherto been an inadequate apprecia-
tion of the nature and extent of these problems, and it is largely
owing to the studies of Dr. Johannes Wahlberg, conducted dur-
ing the past fifteen years, that a more or less comprehensive
survey of the situation has now been made.

The area in which goiter is endemic corresponds almost
exactly to that part which was dry mainland at the end of the
ice period, when much of what is now high and dry was under
the sea. In some parts, 10 per cent of the young men of military
age have been found to present enlargement of the thyroid
gland, and as the ratio of males to females suffering from goiter
is about 1 to 5, it will be realized how prevalent this ailment is
in the worst goiter districts. In the Pathological Institute in
Helsingfors about 300 cases have been investigated in the course
of a few years ; in his clinical work, Dr. Wahlberg has dealt
with 2,350 cases. The most characteristic feature of the endemic
in Finfand is the remarkably high frequency with which the
enlargement of the thyroid is adenomatous ; in the larger
thyroids, adenomatous enlargements are demonstrable on pal-
pation in about 90 per cent, and when the gland is subjected
to a histologic examination it is most rare not to find any
adenomatous changes.

There are still some doubts as to the wisdom of Finland
following the example of Switzerland in the matter of iodine
prophylaxis. May it not, it is asked, be wiser to wait and see
how the Swiss, who have been given prophylactic doses of iodine
throughout childhood, behave in adult life? Meanwhile, opera-
tive treatment in the most serious cases seems still to be the
most effective, most economical and most speedy remedy.

The Growing Frequency of Abortions

The changed outlook from the moral and social points of
view of the community in the matter of induced abortions has
lately been demonstrated in a statistical study by Dr. Aulis
Apajalahti of Helsingfors. His study deals with 21,007 cases
of abortion admitted to the public hospitals in Helsingfors in
the period 1901-1937. When the number of abortions was com-
pared with the number of women of child-bearing age in Hel-
singfors it was found that the ratio of the one to the other had
increased more than six times — from 1.9 to 12.5 per thousand.
While the frequency of abortions has gone up by leaps and
bounds, the birth rate has declined even more dramatically.
For example, in the period 190/-1909, the birth rate, expressed
in terms of the number of births per thousand women of child-
bearing age, was 80.2 In the period 1934-1936 the correspond-
ing figure was only 27.

Dr. Apajalahti notes that in 1936 the population of Finland
was 3,807,163, and he quotes the somewhat gloomy prognostica-

Until a few years ago Finland seemed to be immune to those
sequels to vaccination which have caused great uneasiness in
other European countries such as Holland and England. In
1932 the first cases of encephalitis following vaccination were
reported. These cases — there were only four — were, however,
enough to cause grave concern for the public health authorities
already embarrassed by widespread neglect of vaccination in the
country. After a careful consideration of every aspect of the
subject, the public health authorities succeeded in framing a
new vaccination law which came into force on Jan. 1, 1937.
This law reflected recent experiences with regard to diseases
of the central nervous system following vaccination, and pro-
vision was made for the wholesale vaccination of children before
they reached that age at which encephalitis is most likely to
follow vaccination. The law provides that children are to be
vaccinated before the end of the calendar year in which they
attain the age of 2 years. Neglect of this order is to be punish-
able. The effect of this law was a marked rise in 1937 in the
number of vaccinations, which reached 162,877, or 56 per cent of
all the children due to be vaccinated in that year. The corre-
sponding percentage for 1935 was only 22.8, and for 1936 it
was 33.9.

It was unfortunate that five new cases of acute disease of the
central nervous system following vaccination should occur ,n
1937, the first year of the operation of the new vaccination la"-
Dr. Lars Gronlund, who has issued a special report on these
five cases, has advanced a new theory as to the underlying causes
of postvaccinal encephalitis. His theory hinges on the obseria
tion that in one of his cases, that of a girl aged 5 years, t)P lca
myasthenia gravis had developed at the age of 2. Dr. Gron un
suggests that the myasthenia gravis may have been a hormone
deficiency or a vitamin-deficiency disease, which lowers ^
resistance of the central nervous system to the usually harm r
virus of vaccinia.

THE NETHERLANDS

(From Our Fcffiilar Correspondent)

Oct. 18, 1939-

Gout

Dr. Van Breemen presented a study- before the ^

fedicales de Bruxelles on the pathology of gout in the i’c '
sods. From the statistical point of view the disease 15 ‘
i this country-. However, the disease exhibits a P m '
iterest : If gout did not exist, the history- of the « or ''
rve a different aspect. Gout is no longer recognizer i
petitioner with the facility which formerly character;
agnosis. Now as formerly the pathogenesis of / out ' ’

' hundreds of investigations, is unknown. It* «■
ibitus, articular, deviations, uric acid content m '

phus and roentgen aspect have their value for d;ag

Volume 213
Number 21

MARRIAGES

1893

poses, but in different degrees. The speaker made observations
on different diagnostic facts. Various forms like rheumatoid
gout, chronic gout in women and the irregular type (atypical
Goldscheider type) were observed; they are more frequent in
the Netherlands than the classic type.

Religious Affiliation of University Students
University statistics furnish the following data on the religious
preferences of students enrolled in the different faculties and
departments :

No Helift-

Koman Other ious

Protes- Catho- Often- Relig- Connec- L'n-

tants

lies

Jews

tals

Ions

tions

know

Theology..

93

6.4

0.5

0.1

Law...,,.,

4S.1

20.7

3.9

0.4

2C.5

0.4

Law an cl letters..

45.1

12.6

1

5.2

1.3

34 .8

Medicine

48

17.3

3.3

0.2

0.3

SO.S

0.1

Mathematics and

natural sciences

4G.4

13.S

3.1

0.1

0.5

30

0.1

Mathematics and

letters..

44.1

17 .S

3.1

0.3

0.3

34.4

Philosophy and

letters

42.2

2G.C

3.9

02

0.4

2G.3

0.4

Veterinary studies
Social sciences

59.S

17

1.3

0.6

0.3

21

Amsterdam. ..

35.7

io.e

9.5

0-5

44

0.1

Rotterdam....

53.2

10.2

2.9

0.5

23

30.9

Tilburg

2.1

97.1

0.3

0.5

Delft

39.4

10.S

0.9

0.2

0.5

47.2

1

Wageningen...

6-U

13.3

0.9

1.2

1.1

29.1

Total

fS.3

17.1

2.9

0.4

1

30

0.3

The Netherlands.

40.8

30.3

1.3

15.0

AUSTRALIA

(From Our Regular Correspondent)

Oct. 11, 1939.

The Biochemical Changes in Stored Blood

An attempt to obtain a more precise knowledge of the bio-
chemical changes that take place in stored human blood has
recently been made by Marjorie Bick, working at the Walter
& Eliza Hall Institute, Melbourne. Seeking conditions under
which blood might be stored for longer periods than has hitherto
been possible, she has determined during storage the content of
dextrose, urea, creatinine, nonprotein nitrogen, reduced gluta-
thione and uric acid in whole blood and the ionic phosphate
content of the plasma.

It was found possible to keep the blood from fourteen to
seventeen days at 0 C. before any sign of hemolysis was
observed. The onset of hemolysis appeared to be associated
with two significant changes in biochemical composition, namely
an increase in both the nonprotcin nitrogen of the blood and
the ionic phosphate content of the plasma. The dextrose content
of the whole blood invariably decreased almost to zero before
hemolysis began, but the artificial maintenance of a high con-
centration of dextrose only delayed hemolysis for a short period.

The behavior of blood stored under anaerobic conditions was
also investigated.- The results show that anaerobic conditions
hasten the decrease of dextrose but are without effect on the
development of the other changes observed.

Cells washed free from plasma with buffered saline solution,
with or without the addition of dextrose, hemolvzed much more
readily than did erythrocytes suspended in their own plasma,
and the increase in nonprotein nitrogen was concurrently larger
and more rapid. \\ hen, however, cells were washed and stored
m buffered saline solution containing S per cent sucrose, their
stability was markedly increased and the changes in the con-
centrations of nitrogenous constituents were slower. As the
sucrose was dissolved in saline solution the erythrocytes were
not agglutinated to any extent, so that any effect due to mechani-
cal aggregation of the erythrocytes appeared to be excluded.

The very slight increase in the concentration ■ of phosphate
ions in stored plasma, compared with the high increase observed
in whole blood, indicates that the ionic phosphate content has
some connection with the hemolytic process.

The biochemical changes that take place do so almost entirely
in the erythrocytes, but the essential nature of the process
remains unknown.

Passive Immunity in Experimental Whooping Cough

Most investigators of prophylactic vaccination against whoop-
ing cough have stressed the need for some laboratory test to
detect the appearance and duration of immunity. E. A. North
and his colleagues working at the Commonwealth Serum
Laboratories and the Children’s Hospital in Melbourne have
recently described methods for the demonstration of an anti-
body protecting mice against infection with Haemophilus
pertussis when injected intranasally under anesthesia. This pro-
tective action, they state, is the result of the development of a
specific antibacterial antibody in the serum following natural
infection with Haemophilus pertussis or artificial immunization.
The protective antibody was not present in the serums of non-
immunized children who had not had whooping cough but
appeared following prophylactic immunization. It was present
in the serum of most adult contacts of patients with whooping
cough following symptoms suggestive of mild infection but was
not present in healthy young adults who had had no contact
with these patients.

These workers conclude, therefore, that this antibody, demon-
strable directly by the injection of mice, plays an important
part in the resistance of children immune to whooping cough
as the result of the natural disease or prophylactic vaccination.

Marriages

William Morgan Fox, Columbia, S. C., to Miss Peggy
Sugg Williams of Raleigh, N. C., in Durham, N. C., Sep-
tember 23.

Lewis Earl Fraser, Hiwassee Dam, N. C., to Miss Alice
Jean Keith of Memphis, Tenn., at Carthage, Miss., September 2.

Nicholas Aaron Wheeler Jr., Lafayette, Ala., to Miss
Caroline Carmichael in McDonough, Ga., October S.

Malcolm Douglas Harrison, Washington, D. C., to Miss
Sadye Belle Dailey of Blanche, N. C., October 7 .

Peter Darling Crynock, Morgantown, W. Va., to Miss
Louella Wilson of Fairmont, November 4.

ICermit Wendell Covell, Angola, Ind., to Miss Evelyn
Dickson at Asheville, N. C., November 2.

Mavis P. Kelsey, Rochester, Minn., to Miss Mary Randolph
Wilson of Beaumont, Texas, September 17.

Alex Chalmers Hope, Union, S. C., to Miss Virginia Nalle
Campbell of Charlotte, N. C., October 5.

Robert Mazet Jr., New York, to Miss Catherine Metz of
Springfield, 111., September 23.

Leon J. Anson, New York, to Miss Betty H. Bowers of
Johnstown, Pa., October 11.

James Everett Moore, Ashland, Ky,, to Miss Fern Harris
of Winchester, October 8.

Walter Nickel, Rochester, Minn., to Miss Mona O’Neil
of Minneapolis, recently.

William Fitzgerald, Chicago, to Miss Hilda Duffy of Syca-
more, III., September 12.

Joseph Marcovitch, Dwight, 111., to Miss Lillian Ganzer in
Brooklyn, September 6.

V', K . 9- Hammond to Mrs. Theresa A. McTurk, both of
Philadelphia, recently.

„ “ Miss sa «’
tai'SliSL La " 1 “ m ‘ M >- T ”*' »«' «'

Jack Hull, Indianapolis,
Ind., in September.

to Miss Princess Cogan of Peru,

1894

DEATHS

Jous. A. 3f. A.
Nov. 18, 1919

Deaths

Livingston Farrand ® Brewster, N. Y. ; College of Physi-
cians and Surgeons, Medical Department of Columbia College,
New York, 1891 ; president from 1921 to 1937 and since 1937
president emeritus of Cornell University; instructor of psychol-
ogy at his alma mater from 1893 to 1901, adjunct professor of
psychology from 1901 to 1903 and professor of anthropology,
1903-1904; president of the University of Colorado, Boulder,
from 1914 to 1919; treasurer of the American Public Health
Association from 1912 to 1914; from 1905 to 1914 was execu-
tive secretary of the National Association for the Study and
Prevention of Tuberculosis, now known as the National Tuber-
culosis Association, of which he was elected president in 1923;
member of the Colorado State Medical Society; in 1939 chair-
man of the advisory committee of the American Red Cross
and chairman of the central committee from 1919 to 1921 ;
director of tuberculosis work in France of the International
Health Board, Rockefeller Foundation, 1917-1918; Officer of
the Legion of Honor of France; member of the board of trus-
tees of the American Museum of Natural History; formerly
chairman of the board of trustees of the Carnegie Foundation
for the Advancement of Teaching, of the National Health
Council, New York State Public Health Council, the special
New York State Health Commission appointed in 1930 and
the advisory council of the Milbank Memorial Fund; received
degrees from numerous universities ; author of “Basis of Ameri-
can History” published in 1904; editor of the American Journal
of Public Health, 1912-1914; aged 72; member of the board
of governors of the New York Hospital, where he died, Novem-
ber 8, of bronchopneumonia and empyema.

Robert Sonnenschein ® Chicago; Rush Medical College,
Chicago, 1901 ; associate clinical professor of laryngology and
otology at his alma mater since 1933 ; formerly professor of
diseases of the ear, nose and throat at the Post Graduate Medi-
cal School; member of the American Academy of Ophthal-
mology and Otolaryngology, the American Laryngological
Association, the American Laryngological, Rhinological and
Otological Society and the American Otological Society; fel-
low of the American College of Surgeons; past president of
the Chicago Laryngological and Otological Society; member
of the medical advisory board of the third district in Illinois
during the World War; contributed a chapter on testing of
hearing in Jackson and Coates’s book “The Nose, Throat and
Ear and Their Diseases,” published in 1929, and a section on
surgery of the ear in “A Text Book of Surgery” by Christopher,
published in 1935; aged 60; since 1926 attending otolaryngologist
to the Michael Reese Hospital, where he died, November 8,
of paratyphoid infection and pneumonia.

Oscar H. Plant, Iowa City, Iowa; University of Texas
School of Medicine, Galveston, 1902; professor of pharma-
cology at the State University of Iowa College of Medicine;
instructor of physiology at the University of Texas, Galveston,
1901-1907, and assistant professor of physiology, 1907-1910;
instructor of pharmacology, University of Pennsylvania, Phila-
delphia, 1911-1913, assistant professor of pharmacology, 1914-
1918, and professor of pharmacology, 1918-1920 ; treasurer,
1929-1934, vice president 1935-1936, and president in 1939 of
the American Society for Pharmacology and Experimental
Therapeutics; in 1939 chairman of the executive committee of
the Federation of American Societies for Experimental Biology;
aged 64 ; died, October 2, of coronary sclerosis.

Charles Staples Mangum, Chapel Hill, N. C. ; Jefferson
Medical College of Philadelphia, 1894; member of the Medical
Society of the State of North' Carolina; since 1905 professor
of anatomy, from 1933 to 1937 dean, from 1900 to 1905 pro-
fessor of pharmacology and demonstrator of anatomy, and
formerly professor of physiology and • materia medica at the
University of North Carolina School of Medicine; member of
the American Association of Anatomists ; aged 69 ; died, Sep-
tember 29, in a hospital at Durham of cirrhosis of the liver.

Louis Laval Williams ® Medical Director, U..S. Public
Health Service, retired, Asheville, N. C. : Medical College of
South Carolina, Charleston, 1880; was appointed assistant
surgeon in the U. S. Public Health Service in 1885; for many
vears in charge of public health conditions at various immigrant
stations; in 1920 was nominated by President Wilson assistant
surgeon general at large; was retired m 19-4, \\as m
medical director in 1930 by an act of Congress; aged /9, died,
September 17, of cerebral thrombosis.

Earl Lenwood Parmenter ® Lieut. Colonel, U. S. Army,
retired, Mobile. Ala. ; . University Medical College of Kansas
City Mo 1907- veteran of the Spamsh-American and World

wars; was commissioned a major in the medical corps of the
U. S. Army in 1920, and was retired for disability in line of
duty Oct. 31, 1937, with rank of lieutenant; aged 59; died
August 27, in the Jackson Infirmary, Jackson, Miss., of cardio-
renal disease.

John Wilson Tappan ® Surgeon, U. S. Public Health
bervicc, El Paso, Texas ; University of Virginia Department of
Medicine, Charlottesville, 1898; entered the U. S. Public Health
Service March 20, 1917, and retired Nov. 1, 1933; formerly
CI jA and county health officer; fellow of the American College
of Physicians ; aged 71 ; died, September 2, in the William Beau-
mont General Hospital.

Curtis Dudley Pillsbury ® Lieutenant Colonel, M. C,
U. S. Army, Fort Crook, Neb.; University of Michigan
Homeopathic Medical School, Ann Arbor, 1914; served during
the World War; was commissioned a first lieutenant in the
medical corps in 1917, in 1919 a major and in 1937 a lieutenant
colonel ; aged 50 ; was killed, September 29, when his car was
struck by a truck.

George Arthur Neal © South West Harbor, Maine;
Baltimore Medical College, 1905; president and formerly secre-
tary of the Hancock County Medical Society; for many years a
member of the school board and at one time superintendent of
schools ; on the staff of the Mount Desert Island Hospital, Bar
Harbor ; aged 67 ; died, September 17, of angina pectoris.

John E. Douglas, Garrett, Ind. ; Chicago College of Medi-
cine and Surgery, 1913 ; member of the Indiana State Medical
Association ; assistant professor of clinical pathology at the
Baylor University College of Medicine, Dallas, Texas, and
pathologist of the hospital, 1 929-1930; aged 52; died, September
23, of coronary thrombosis and chronic myocarditis.

Walter S. Stevens ® Oklahoma City; National University
of Arts and Sciences Medical Department, St. Louis, 1912; at
one time superintendent of the Choctaw-Chickasaiv Sana-
torium, Talihina ; medical director of district number 5, Indian
Service; aged 54; died, September 11, in St. Anthony Hospital
of lymphatic leukemia.

Walter C. McFadden © Shelbyville, Ind.; Medical College
of Indiana, Indianapolis, 1902 ; past president of the Shelby
County Tuberculosis Association; formerly secretary of the
city board of health ; on the staff and at one time superintendent
of the W. S. Major Hospital; aged 60; died, September 31), ot
coronary occlusion.

James Dodd Dixon, Montreal, Que., Canada; McG ill Uni-
versity Faculty of Medicine, Montreal, 1902; member of tnc
board of health of Lachine ; fellow of the American College o
Surgeons; surgeon to the Lachine General and St. Joseph
Hospital; aged 60; died, September 27, in the Royal Victoria

Hospital.

Charles Lloyd Egbert, Hastings, Neb. ; College of Physi-
cians and Surgeons of Chicago, School of Medicine 0
University of Illinois, 1903; member of the Nebraska Mai
Medical Association; medical director and superintendent _
a hospital bearing his name ; aged 60 ; died, August 26, ot ie<
di seasc

Rudolph Duenweg, Terre Haute, Ind.; University
Louisville (Ky.) Medical Department, 1913 ; member of tnc
Indiana State Medical Association; fellow of the Amcri
College of Surgeons; on the staff of St. Anthony s Hosp t < ■
aged 48; died, September 24, at Culver, of coronary embohs •

Herbert Scott Pattee, Manchester, N. H.; University ot
Vermont College of Medicine, Burlington 1913, member
the New Hampshire Medical Society; served during -the
War; on the staffs of the Elliot and the Balch hospitals, ageu
52; died, August 26, in Tilton, of coronary thrombosis.

Cecil Boner O’Brien, Greencastle, Ind.; Indiana Uttivc
School of Medicine; Indianapolis, 1923; member of the ■ 1 d
State Medical Association; physician to . i he e®*t/mber 7. >«
service, DePamv University; aged 42; died, Septembe
the Robert W. Long Hospital, Indianapolis. ' f

Joseph Savage Alford ® Los Angeles; U'mxrsit)
Pennsylvania School of Medicine Philadclphw. 1908, nu em
of the Colorado State Medical Society; aged 55, aieo, i
tember 23, in the Veterans Administration Facility,

Calif., of coronary thrombosis. ,

Allen Romayne Long, Buffalo; Uiuve««tt of
School of Medicine, 1921 ; member of ‘he Medical &oo >
the State of New York; instructor of med.c.ne at h . d
nater; on the staff of the Deaconess Hospital, aged
August 25, of myocarditis. w . j c ff c rson

John Humes Bamfield ® Logansport Ind^ J^ber
Medical College of Philadelphia, 1886; for m-nj j

Volume 115
Number 21

DEATHS

1895

of the school board ; on the staff of St. Joseph Hospital ; aged
75; died, September 27, in the Methodist Hospital, Indianapolis,
of heart disease.

Capers Capehart Jones, Birmingham, Ala.; Philadelphia
University of Medicine and Surgery, 1870; member of the
Medical Association of the State of Alabama ; Confederate
veteran ; aged 93 ; died, September 7, of angina pectoris and
arteriosclerosis.

William E. Craig, Joplin, Mo.; University of _ Kansas City
Medical Department, 1884; member of the Missouri State
Medical Association; aged 76; on the staffs of the Freeman Hos-
pital and St. John’s Hospital, where he died, October 9, of
heart disease.

Thomas Alva Strain, Meridian, Miss.; Chicago College
of Medicine and Surgery, 1914; member of the Mississippi
State Medical Association ; served during the World War ;
aged 52; died, September 21, of hypertension and arteriosclerotic
heart disease.

Henry Dundor Kunkel ® Reading, Pa. ; University of
Pennsylvania School of Medicine, Philadelphia, 1929; on the
staff of the Reading Hospital ; aged 36 ; died, September 2, in
Berlin, Germany, of complications following an operation for
appendicitis.

Patrick H. Veach © Staunton, Ind. ; Medical College of
Indiana, Indianapolis, 1891 ; an Affiliate Fellow of the American
Medical Association; formerly county coroner and member of
the state legislature ; aged 77 ; died, September 4, of cerebral
hemorrhage.

James Benham Lucas, West Alexandria, Ohio; University
College of Medicine, Richmond, Va., 1899; member of the Ohio
State Medical Association; for many years member and presi-
dent of the local board of education ; aged 63 ; died, Sep-
tember 22.

Parish Stewart Smith, Conyers, Ga. ; Atlanta College of
Physicians and Surgeons, 1904; member of the_Medica! Associa-
tion of Georgia; aged 62; died, September 7, in the Emory
University Hospital of femoral hernia, acute appendicitis and
peritonitis.

Roy Winton Johnson, Indianapolis ; Northwestern Uni-
versity Medical School, Chicago, 1912; served during the
World War; surgical adviser to the Aetna Casualty and Surety-
Company; aged 57; died suddenly, September 4, of coronary
occlusion.

Henry D. Grady © Miami, Mo.; University of Missouri
School of Medicine, Columbia, 1880; Bellevue Hospital Medical
College, New York, 1881 ; an Affiliate Fellow of the American
Medical Association; aged 83; died, September 2, of pyo-
nephrosis.

Charles Russell Weaver ® Twin Falls, Idaho; Harvard
Medical School, Boston, 1925 ; served during the World War ;
formerly secretary of the Southside Medical Society ; aged 42 ;
died, September 7, in the Portland (Ore.) Medical Hospital of
uremia.

James Horace Stimson Jr., Galveston, Texas; University
of Tennessee College of Medicine, Memphis, 1938; on the staff
of the U. S. Marine Hospital ; aged 26 ; died, September 13, of
inhalation pneumonia and burns received in an explosion on a
launch,

Robert Milton Wolfe, South Norwalk, Conn.; Maryland
Medical College, Baltimore, 1901 ; member of the Connecticut
State Medical Society; at one time mayor; on the staff of the
Norwalk Hospital ; aged 62 ; died, September 26, in New York.

Walter Jones Adams © Norfolk, Va. ; Medical College of
Virginia, Richmond, 1895; an Affiliate Fellow of the American
Medical Association; at one time acting assistant surgeon in
the U. S. Public Health Service; aged 74; died, September 16.

Alfred Christopher Scaccia, Bound Brook, N. J. ; Uni-
versity of Louisville (Ivy.) School of Medicine, 1936; member
of the Medical Society of New Jersey; aged 29; died, Septem-
ber 18, in the Neurological Institute, New York.

Harry Preston Pratt, Chicago; National Homeopathic
Medical College, Chicago, 1892; Harvey Medical College,
Chicago, 1S96; Bennett College of Eclectic Medicine, Chicago,
1896; aged 79; died. September 14, of chronic myocarditis.

Joseph H. Bradfield, Atlanta, Ga. ; Atlanta Medical College,
1893 ; member of the Medical Association of Georgia ; formerly
superintendent of the Battle Hill Sanatorium ; aged 72 ; died,
September 6, of arteriosclerosis and chronic myocarditis.

Leon Izgur, Brooklyn ; Atlanta College of Physicians and
Surgeons, 1913; member of the Medical Society of the State of
New York ; formerly superintendent of the Greenpoint Hospital ;
aged 55; died, September 27, of coronary thrombosis.

Frederick William McKenney, Brookline, Mass.; Tufts
College Medical School, Boston, 1919; aged 45; on the staff of

St. Elizabeth's Hospital, Boston, where he died, September 11,
of peritonitis following an operation for appendicitis.

William F eland Hickle ® Kenedy, Texas; Hospital Col-
lege of Medicine, Louisville, Ky., 1904; formerly city and couuty
health officer ; member of the state parole board ; aged 66 ; died,
September 23, in the Beeville (Texas) Hospital.

Manfred C. McNew, Ada, Okla. ; Dallas (Texas) Medical
College, 1902; member of- the Oklahoma State Medical Associa-
tion; aged 69; died, September 1, in Breco’s Memorial Hospital
of an overdose of morphine, self administered.

Allen Malone Kilgore © Los Angeles; Rush Medical Col-
lege, Chicago, 1919 ; served during the World War ; aged 47 ;
died, September 25, in the Good Samaritan Hospital of
injuries received in an automobile accident.

Oscar Rodney Emerson © Newport, Maine; Medical
School of Maine, Portland, 1894; member of the board of
registration of medicine; aged 67; died, September 27, of
injuries received in an automobile accident.

Jefferson Davis Yates, Orange, Texas; Southern Medical
College, Atlanta, Ga., 1895 ; county health officer ; past president
of the Orange County Medical Society; aged 78; died, Septem-
ber 25, in a local hospital of typhus fever.

Peter Charles Dodenhoff © Detroit; Michigan College of
Medicine and Surgery, Detroit, 1901 ; for many years on the
staff of St. Mary’s Hospital ; aged 60 ; died, September 23, of
chronic myocarditis and arteriosclerosis.

Murray Emerson Reeder, Columbus, Ohio; Starling-Ohio
Medical College, Columbus, 1910; member of the Ohio State
Medical Association; served during the World War; aged 52;
died, September 16, of thrombosis.

George Britton Grim, Evansville, Ind.; Kentucky School
of Medicine, Louisville, 1895 ; member of the Indiana State
Medical Association ; aged 72 ; died, September 5, in the
Methodist Hospital, Indianapolis.

Merville H. Carter, Baltimore; College of Physicians and
Surgeons, Baltimore, 1878; formerly member of the board of
education ; aged 81 ; died, September 5, of cerebral hemorrhage,
arteriosclerosis and hypertension.

Stoddard Sprague Martin, Windsor, Vt. ; Hahnemann
Medical College and Hospital of Philadelphia, 1888; served dur-
ing the World War ; health officer ; aged 72 ; died, September 25,
of arteriosclerotic heart disease.

Leonard J. Lunsford, Montalba, Texas; Dallas (Texas)
Medical College, 1904; aged 63: died, September 10, in the
Missouri Pacific Lines Hospital, Palestine, of pneumonia follow-
ing injuries received in a fall.

William Powell Buck Jr., Kinder, La.; University of
Louisville (Ky.) School of Medicine, 1907 ; member of the
Louisiana State Medical Society ; aged 55 ; died, September 27,
of pulmonary tuberculosis.

John F. Cardwell, Grand Rapids, Mich.; Detroit College
of Medicine, 1900; member of the Michigan State Medical
Society ; aged 66 ; died, September 24, in the Sparrow Hospital,
Lansing, of heart disease.

James Edward Kelly, Jersey City, N. J.; Georgetown
University School of Medicine, Washington, D. C., 1925; aged
38; died, September 3, of coronary thrombosis and cardio-
vascular renal sclerosis.

John Lewis Rawls * Suffolk, Va.; Jefferson Medical
College of Philadelphia,' 1917; on the staff of the Lakeview
Hospital; aged 54; died, September 12, of injuries received in
an automobile accident.

William Martin Richards, New York; Bellevue Hospital
Medical College, New York, 1S98; served during the World
War; aged 66; died, September 11, in the Neurological Institute
of cerebral embolism.

Jesse Chrisman Horton, Los Angeles; College of Physi-
cians and Surgeons, Los Angeles, 1914; served during the
World War; aged 49; died, September 24, in the U. S. Naval
Hospital, San Diego.

Obed Yost, Miami Beach, Fla.; Western Reserve University
Medical Department, Cleveland, 1892; formerly medical referee
of the Equitable Life; aged 70; was drowned, September 27,
in Biscayne Bay.

Frank Paine Ramsey, East Jordan, Mich.; College of
Physicians and Surgeons of Chicago, School of Medicine of
the University of Illinois, 1899; aged 66; died, September 19
of carcinomatosis. ’

George S. Wright, Seattle; Yale University School of
Haven Conn 1884 ; aged 78; died, September
IS, in the Providence Hospital of injuries received when struck
by an automobile.

1896

DEATHS

Jour. A. M. A.
Nov. 18, 1939

Robert Lester Paxton, Lemont, 111. ; University of Illinois
College of Medicine, Chicago, 1930 ; member of the Illinois
State Medical Society ; aged 35 ; died, September 30, of poison,
self administered.

Charles Elston Phillips ffi Pratt, Kan. ; Kansas Medical
College, Medical Department of Washburn College, Topeka,
1905; county health officer; aged 62; died, September 11, of
angina pectoris.

Jenness Morrill, Falkland, N. C.; University of Maryland
School of Medicine, Baltimore, 1888; aged 74; died, September
9, of chronic endocarditis, mitral insufficiency and chronic inter-
stitial nephritis.

Morton McTyeire Moss, Bowling Green, Ky. ; Vanderbilt
University School of Medicine, Nashville, Tenn., 1894; served
during the World War ; aged 72 ; died, September 3, of Parkin-
son’s syndrome.

Frederick Irving Brown, Los Angeles; Rush Medical
College, Chicago, 1890; formerly instructor in otology at his
alma mater; served during the World War; aged 70; died,
September 19.

Robert L. Barclay, Kennard, Texas (licensed in Texas,
under the Act of 1907) ; aged 60 ; died, September 26, in the Jim
Smith Memorial Hospital, Crockett, of septicemia and
pneumonia.

Samuel Jackson Redman, Dexter, Maine; Medical School
of Maine, Portland, 1899; member of the Maine Medical Asso-
ciation; aged 70; died, September 28, of carcinoma of the
esophagus.

Marion Dennis Thompson ® Pamplico, S. C. ; Medical
College of the State of South Carolina, Charleston, 1933; aged
31 ; died, September 28, in the McLeod Infirmary, Florence, of
pneumonia.

William Herbert Aykroyd, Toronto, Out., Canada;
Queen’s University Faculty of Medicine, Kingston, 1903;
Manitoba Medical College, Winnipeg, Man., 1913; aged 70; died,
August 29.

John J. Stoll © Chicago; Rush Medical College, Chicago,
1885; an Affiliate Fellow of the American Medical Association;
aged 78; died, September 22, of uremia and chronic glomerular
nephritis.

Robert Eugene Taft © Cleveland; University of Wooster
Medical Department, Cleveland, 1898 ; aged 73 ; died, September
9, at Shaker Heights of coronary occlusion and diabetes
mellitus.

Thomas LeRoy Jefferson, West Palm Beach, Fla.;
Meharry Medical College, Nashville, Tenn., 1892; aged 72;
died, September 29, in the Pine Ridge Hospital of acute appen-
dicitis.

John McKendree Bailey, Hopewell, Va. ; Medical College
of Virginia, Richmond, 1924; member of the Medical Society of
Virginia; aged 40; died, September 22, of cirrhosis of the liver.

William Wells Brand, Portland, Ore; Ensworth Medical
College, St. Joseph, Mo., 1899; served during the World War;
aged 66; died, August 27, of arteriosclerosis and heart disease.

Patrick F. Burke, Allentown, Pa. ; Jefferson Medical Col-
lege of Philadelphia, 1894; aged 74; for many years on the
staff of the Sacred Heart Hospital, where he died, September 3.

Roscoe Eugene Glass, Tampa, Fla.; Medical College of
Virginia, Richmond, 1914; aged 52; died, September 25, in a
local hospital of injuries received in an automobile accident.

Madge Dickson Mateer, Tsingtao, China; Homeopathic
Hospital College, Cleveland, 1885; a retired medical missionary
of the Presbyterian Church; aged 79; died, September 12.

John R. Perry, Marion, Ky. ; Hospital College of Medicine,
Louisville, 1907; member of the Kentucky State Medical Asso-
ciation ; aged 55 ; died, September 26, of angina pectoris.

Benjamin F. Lyle, Cincinnati; Medical College of Ohio,
Cincinnati, 1SS2; formerly member of the board of education;
aged 7S; died in September, at the Bethesda Hospital.

Nash Collins, Delhi, La.; Kentucky School of Medicine,
Louisville. 1891; member of the Louisiana State Medical
Society; aged 69; died, September 12, of myocarditis.

Lelia B. Higgins © Wilton, Maine; Woman’s Medical
College of Pennsylvania, Philadelphia, 1893; aged 79; died,
August 1, of cerebral hemorrhage and myocarditis.

Clinton L. Montgomery, Blue Mound, 111.; Rush Medical
College, Chicago, 1S95; served during the World War; aged
72; died, September 20, of coronary thrombosis.

Harvey Weston Turnipseed, Tchula, Miss.; University of
.Nashville (Tenn.) Medical Department, 1900; aged 68' died
September 16, in the Baptist Hospital, Jackson.

Tristram Bethea Hamer, Carrollton, Texas; Vanderbilt
University School of Medicine, Nashville, Tenn., 1892; agedfiS;
died, September 6, of cardiorenal insufficiency.

Charles Cyrus Kehl © Seattle; University of Kansas
School of Medicine, Kansas City, 1920; aged 48; died, Sep-
tember 21, in St. Luke’s Hospital of nephritis.

Isabel M. Davenport, Orlando, Fla.; Woman’s Medical
College, Chicago, 1891; formerly a practitioner in Chicago;
aged 83; died, September 17, of heart disease.

Hiram C. Jones, Logan, W. Va. ; College of Physicians and
Surgeons, Baltimore, 1889; aged 78; died, September 28, in the
Huntington (W. Va.) Orthopedic Hospital.

Job Nelson Statum, Birmingham, Ala.; Southern Medical
College, Atlanta, 1888; served during the World War; aged
S3 ; died, September 24, in Kessler, W. Va.

B. E. Huckabee, Birmingham, Ala.; Meharry Medical
College, Nashville, Tenn., 1902; aged 75; died, September 1, of
cardiac hypertrophy and chronic nephritis.

Jonathan Manning Roberts, Chicago; Columbia University
College of Physicians and Surgeons, New York, 1896; aged 68;
died, September 6, of chronic myocarditis.

Lewis J. Daniels, Milwaukee; Rush Medical College,
Chicago, 1896; aged 65; died, September 20, at the Columbia
Hospital of arteriosclerotic heart disease.

William Donaldson McNamar, Jacksonville, Fla.; Western
Pennsylvania Medical College, Pittsburgh, 1892; aged 70; died,
September 18, of cerebral hemorrhage.

Isaac Clark Woodford Fling, Belpre, Ohio; University of
Louisville (Ky.) Medical Department, 1907; aged 62; died,
September 3, of coronary thrombosis.

William C. Mack, Indianapolis ; Howard University College
of Medicine, Washington, D. C., 1914; aged 53; died, Sep-
tember 29, of pulmonary tuberculosis.

Edward Arthur Sherlock, Los Angeles; Syracuse (N. Y.)
University College of Medicine, 192 1; aged 44; died in Sep-
tember of poison, self administered.

R. S. Pounds, Redan, Ga.; Georgia College of Eclectic
Medicine and Surgery, Atlanta, 1912; aged 50; died in Septem-
ber of a self-inflicted bullet wound.

Thomas W. Henderson, Augusta, Ark. (licensed in
Arkansas in 1907) ; aged 60; died, September 7, of chron
nephritis and cardiac hypertrophy. ,

George Cassell Nelson © La Harpe, 111.; St. Louis 0
lege of Physicians and Surgeons, 1910; aged 55; died,
tember 21, of coronary thrombosis.

Olaf Bentzen, Miami, Fla. ; Kongelige Frederiks Untversite
Medisinske Fakultet, Oslo, Norway, 1S93; aged 67; die , -
tember 16, in a local hospital. _ . ,

James W. Lambert, Valley Head, W. Va.; Univerat) ,
Louisville (Ky.) Medical Department, 1908; aged OS,
September 4, of thrombosis.

Arthur A. McCabe, Oklahoma City; College of jjiysicn
and Surgeons, Keokuk, Iowa, 1878; aged S3; died, P
23, of cerebral hemorrhage. _ _ Medical

Thomas J. Hackett, Houston, Texas ; ^^p^ibcr P, ol

College, Nashville, Tenn., 1913; aged 48; died,
acute glomerular nephritis. - r n \

Charles Henry Phillips Jr., St. Louis ; Meharry J
College, Nashville, Tenn, 1908; aged 57; died, Septembers,
hypertensive heart disease. _ ,- v )

Jacob Shrader Smith, Bellingham, IVash. ; Louis wllct^ ( |
Medical College, 1898; served during the V orld \ >

63; died, September 14. . t ;

Morris Schaner © Toledo, Ohio; University of - U " f C1 cut£
College of Medicine, 1916; aged 50; died, September 2b,

dilatation of the heart. _ VindcrbiO

James Eliott Blakemore, Van Burcn, Ark. , ' ‘ j
University School of Medicine, Nashville, Tenn, t° ->

76; died, September 14. A(c(! ;.

Mary Roush Krieger, Cincinnati ; American bocc - . p
cal College, Cincinnati, 1891 ; aged 91 ; died, Septc
the Bethesda Hospital. Tfnivrr‘i:V

Elmore Estes, Johnson City, Tenn.; Vanderbilt
School of Medicine, Nashville, 1911; aged 61; died, b P
28, in a local hospital.

Volume 113
Number 21

BUREAU OF INVESTIGATION

18 97

Bureau of Investigation

THE MME. ADELE FRAUD

The Interesting History of Adele Millar’s
Quackeries

On Jan. 24, 1939, the United States mails were closed to
Adele Millar, Adele Millar Prentiss and Francisca of Los
Angeles and San Francisco. The case illustrates once more
the futility of temporizing with quackery. The story that fol-
lows is based on (1) material in the files of the Bureau of
Investigation of the American Medical Association, (2) infor-
mation supplied by the Post Office Department and (3) facts
released by the Federal Trade Commission.

The first record that the Bureau of Investigation has of .
any one known as Adele Millar appears in a clipping from
the San Francisco Call of July 30, 1911. This was a column-
long story of the case of a girl who, according to her friends,
“was the unwitting victim of inexpert and bungling” work of
a “beauty specialist” concern. The girl— a suicide— the story
stated, was abnormally sensitive about her complexion. She
went to a physician who refused to do what she asked because
of the danger involved in the treatment she desired. She then
went, according to the newspaper report, to the Millar Insti-
tute, whose proprietor was an Adele Millar. The result of
the “treatment” she received so blotched and scarred the girl's
face that she disappeared; her body was found later “cast up
by the waves at Bolinas beach.”

The newspaper story further stated that, coincidentally with
the girl's disappearance, Adele Millar’s husband gave out that
his wife “had gone to Europe for an indefinite stay." ' The
paper, on investigating, reported that the facts were that this
Adele Millar had not left the state but was “sojourning incog-
nito at a chicken ranch on the Mountain View road one mile
from Petaluma.” The paper added: “Her [Adele Millar’s]
departure for ‘Europe’ occurred simultaneously with the
announcement of the girl’s disappearance.” The Bureau of
Investigation has no record that any action was taken in this
case.

The second record that the Bureau of Investigation has of
a person of this name was a report from the Board of Medical
Examiners of California stating that an Adele Millar was
arrested on July 21, 1927, charged with violation of the Medi-
cal Practice Act of California. She was arraigned in Division
6, Municipal Court of Los Angeles. She pleaded guilty and
was sentenced to pay a fine of §100 or serve fifty days in the
city jail. Sentence was suspended for two years on condition
that she would not violate the State Medical Practice Act
during that period.

The third record came about three years later, when Adele
Millar was again arrested and arraigned on April IS, 1930,
in the same court as before (Division 6, Municipal Court of
Los Angeles), charged once more with violation of the Medi-
cal Practice Act. Again she pleaded guilty and was sentenced
to serve sixty days in the city jail. But sentence was sus-
pended for 180 days on condition that she acquaint herself
with the law pertaining to her work!

The fourth record came about four years later, when a Post
Office fraud order was issued Jan. 4, 1934, closing the mails
to “Mme. Adele,” of Los Angeles, a trade name used by Adele
Millar. At this time she was selling a “Wonder Peel Paste”
which she had been advertising four years previously and
which contained caustics. Although she represented that her
paste was harmless, the Post Office report stated that “expert
medical evidence shows that the burning caused by its use
is extremely dangerous and complaints in evidence show two
actual instances in which death was narrowly averted as a
result of such burns.” In addition, Adele Millar sold “Beauty
Turtle Oil,” a “Developing Cream” and a so-called “Skin
Tightener” — the usual armamentarium of the beauty-specialist
quack. Because these were sold through the mails under
fraudulent claims, the fraud order was issued. The Post Office
also obtained an indictment against Adele Millar, charging her

with using the mails to defraud. She pleaded guilty and was
given a suspended sentence of two years 1

The ’fifth record is contained in a release issued by another
government agency, the Federal Trade Commission, on March
7, 1938 — about four years after the first fraud order was issued.
The release read in part:

“The Federal Trade Commission has issued a complaint charging Adele
Millar, 177 Post St., San Francisco, with misrepresenting the therapeutic
value and merit of Wonder Peel Paste, advertised as a treatment for skin
ailments and sold in interstate commerce. The respondent trades as Mme.
Adele and Chez Adele.*’

The conclusion of the Commission’s case was reported in a
release it issued on July 29, 1939, reading as follows :

“The Federal Trade Commission ordered Adele Millar, trading as Mme.
Adele and Chez Adele, San Francisco, to discontinue false representa-
tions in the sale and distribution of a cosmetic preparation designated
“Wonder Peel Paste,” or any other similar preparation.

“Under the order, the respondent is prohibited from representing that
her preparation will withdraw toxins from the skin, accelerate chemical

••-Every . wdmaki an# %ev«ry)'-'-jhknl^V : ii
•• A ■' APLula-GL&NDllIiAB :. TRBATS£EXTa-V'- I!
-*-* V FACLHT SURGERY ; 'Ji

■Tri-Facial Muse lb -arid "Tissue

RT

an

.r.tt

ag zss sags B , , ,i , .

I iDEI.E MTr.T.AR— .-M..

| ' WONDER ’ lT’.EI, PASTE. f.YOO

['■ B6":! MELROSE ...WE. HOily. r>404.

- - - ■ ■ UtllltiA rkwilm

Mr '/"S' • ..WONDER PASTE.; 'iV-*’ •-

* OVER-NIGHT’ HOME ' TREATMENT v' ;

. : FRECKLES, ’ WRINKLES, . PITS, - AGEING
•FACES.' ABSOLUTELY HARMLESS, $5.
'ADELE AOLLAiR, 5633>MELROSB -AVB.

tr . ‘ .A.. ' , ■* . ’■' * ** '- 1 * — "

^Advertisements (enlarged) from the Los Angeles Examiner, August

changes in the living skin cells, or supply materials to the skin to repair
waste tissues; that its use will prevent or remove freckles, liver spots or
wrinkles; that it will prevent or remove or have any beneficial effect in
aiding in the removal of, any blemishes or other conditions of the skin
which are due to or persist because of a systemic or metabolic disorder or
condition; that it will prevent pimples, blackheads, puffs, scars, pits, acne
or crepey neck, and that it has any beneficial effect in aiding in the
removal of pimples, blackheads, puffs, scars, pits, acne or crepey neck,
unless such representation is limited to those conditions which are of a
surface character only.

“The respondent, now known as Adele Millar Prentiss, is also ordered
to cease representing that her preparation has any beneficial effect on the
metabolism or nutrition of the tissues.”

The action of the Post Office Department referred to in the
first paragraph of this article, closing the mails to Adele Millar
Adele Millar Prentiss and Francisca, was due to her having
resumed, under these names, the mail-order sale of her Wonder
Peel Paste in defiance of the original fraud order issued against
her m 19o4. This necessitated the issuance of the supple-
mental fraud order of January 1939 against the later trade
names used by Adele Millar and brings the record of this

1898

CORRESPONDENCE

individual up to date. All of this must be very amusing to
the Adele Millar organization. Certainly it reveals the ina-
bility of the authorities concerned to inhibit her activities. The
long time which usually passes before the issuing of final orders
by federal organizations gives many a promotor opportunity to
reap the field before the storm breaks.

C orresp on den ce

“OBSTETRIC SHOCK”

To the Editor: — Dr. Virgil H. Moon has called my attention
to the fact that material from his book ("Shock and Related
Capillary Phenomena,” New York, Oxford University Press,
1938) was used in my article “Obstetric Shock: Its Causes,
Recognition and Management” (The Journal, September 23,
p. 1183) without due credit being given him. On comparison,
to my utter chagrin, I find that Dr. Moon’s statement is correct
and I am therefore anxious to make amends for this error.

After spending some six or seven months reviewing the general
subject of shock, including the few existing articles on obstetric
shock, I began to write a paper in the form of an editorial for
a chairman’s address. Such an article could consist only of a
review of the literature, with some practical considerations
gleaned from a personal experience of some ten years’ interest
in the subject. It was a most difficult job, owing largely to
the confused state of the vast literature on shock. Work piled
up; “time marched on,” and I deemed it necessary to obtain
the assistance of a ghost writer, to whom I gave all my notes
(a voluminous quantity), including an extensive bibliography
and a partly written address. In due time he returned the com-
pleted article. It did not occur to me to check meticulously
every statement as to authorship. I had full confidence that
credit would be given wherever necessary for material used.
It was not until I received Dr. Moon's letter that I appreciated
the fact that my ghost writer had taken many paragraphs in
toto from the final chapter of Dr. Moon's monograph, published
by the Oxford University Press.

For this error of omission I offer my sincere apology to
Dr. Moon and to the Oxford University Press.

Harvey B. Matthews, M.D., Brooklyn.

THE THECA INTERNA CONE: A TEST
FOR FOLLICULAR GROWTH
AND STIMULATION

To the Editor : — During the meeting of the American Medi-
cal Association in St. Louis and since then in meetings of
medical societies all over the country, a moving picture has
been shown which deals with a new gonadotropic substance
recovered from the serum of pregnant mares. In this picture
the development of the growing graafian follicle is shown. This
part includes the “Theca Interna Cone,” giving the name as
such but not that of the author.

The author’s name is of little importance as soon as the
discovery is generally acknowledged. Until this stage is
reached, the author’s name should be mentioned in moving
pictures, as is customary in other forms of medical publication.

My papers dealing with the growth of the graafian follicle
and the causes of its ascent to the ovarian surface cover a
period of sixteen years of histologic research. The pathologist
Prof. Ludwig Aschoff, whose assistant I was from 1921 to
1922, told me to find out why the follicle ruptures. He antici-
pated that, in addition to the endocrine stimulus, there was a
special anatomic mechanism, because other pathologic cystic
formations of the ovary almost never rupture even when they
reach the size of a man’s head.

In my first paper (Why Does the Follicle Rupture? Arch,
f. Gyttak. 119: ICS [Sept.] 1923) it was shown that the dis-

join. A. It. A
Nov. 18, l)i)

tance between the follicle and the ovarian surface in human
beings becomes smaller with the appearance and developing!
of the thecal layers. At the same time it was found that there
exists always an eccentric type of growing in follicles, while
pathologic cystomas have a concentric way of growing. A
one-sided thickness of the theca interna, rich in cells, toward
the ovarian surface is present, which in larger follicles is from
eight to ten times wider at the upper pole than at the 1 over
pole toward the hilus. The theca externa, on the other hand,
ricli in connective tissue fibers, stays thick around the lower
hemisphere and becomes thin at the upper hemisphere toward
the ovarian surface, thus keeping the follicle like a goblet
from expanding to any other side but the surface of the ovary.
The active growth of the theca interna , which is soft, owing
to its richness in fast multiplying cells, provides an area of
lower resistance in direction toward the cortex* and albuginea.

In a later study (Theca-Interna Cone, the Pathmaker of the
Follicle, ibid. 158:628, 1934) it was demonstrated in human
and cat ovaries that there was not only a blunt one-sided
thickness of the theca interna but a wedgelike theca interna
cone with a triangular outline which always points toward the
nearest part of the ovarian surface. This thecal cone pos-
sesses a tropism toward the surface like the sprout of any
seed and plows the path for the follicle by active infiltrating
growth through the stroma and the albuginea. The follicle
proper follows the line of least resistance thus provided, pas-
sively adopting frequently an elliptic or even a cone shape itself.

The theca interna cone can be demonstrated only in serial
sections, perpendicular to the ovarian surface, running through
the apex of the cone, as geometric considerations easily show.
This must have been the reason why it has not been found
before in an organ thoroughly examined by many authors for
more than a hundred years.

In order to make sure that the theca interna cone was part
of the normal histologic and physiologic picture of the ovary
it was necessary to prove its presence in as many mammalian
species and orders as possible. This was done together win
Erika von Moeliendorff (The Theca Interna Cone, a Typka
Structure in Growing Mammalian Follicles, ibid. 160:27 ,
1935). The theca cone could be verified in all mammalian
species the ovaries of which we were able to obtain (luring

and

dogs

the estrus and preestrus. In addition to Homo sapiens
cats, the thecal cone was found in horses, cows, sivmc,
and rabbits. _ .

The work was completed at the Mayo Foundation an 3
final report, based on more than 18,000 microscopic s 1 c -'
given before the staff of the Mayo Clinic (The Theca ’dern
Cone and Its Role in Ovulation, Furr t., Gyncc. & Obd-
299 [Sept.] 1938; abstr., /Tor. Staff Med., Mayo Ch». i -
443 [July 13] 1938). . . ... H

The theca interna cone is found only in growing 10
It disappears when degeneration sets in. It therefore can
used as a test for normal follicular growth and stimu a
Erwin O. Strassmann, M.D., Houston, Texas.

RABIES

To the Editor: — The report on “Rabies in Birmingham.
Alabama” (Drs. G. A. Denison and J. D. Dowltng,
Journal, July 29, p. 390) raises several questions that ca
further discussion. No one should find fault with t -
ments of fact in their report; but it is unfortunate tia
of the conclusions that they drew were published, becaus -
have already been seized on by enemies of public heaim
and orthodox medical practice to cast discredit .on cvc.
rabies control measures as Drs. Denison and Donlmg
selves advocate. , .i. r : r

The authors’ thesis is stated in the first paragraph
report : “We are especially concerned with those pr

Volume 113
K UMBER 21

CORRESPONDENCE

1899

which confront tile physician; namely, the value of antirabies
vaccine and indication for its administration.” Their intima-
tion that “failure to control the dog” is what calls for other
antirabies measures is one with which there is or should be
general agreement. The factors that they mention as leading
to the "indiscriminate administration of vaccine,” as given in
the third paragraph of their report, may also be largely accepted
as widely prevalent, though the indictment suggested by the
word “indiscriminate" is much too strong.

Since the thesis stresses the “problems which confront the
physician,” it seems strange that in the fourth paragraph of
the report the prospective patient is described as being in a
state of "such extreme mental anguish that nothing short of
vaccine treatment can prevent nervous collapse of the individ-
ual” ; and yet they go on to say that “the physician too often
fails to maintain a professional attitude and allows himself to
be influenced by the undue apprehension of the patient.” It
will surely be agreed that the public should be educated as
rapidly as possible so that “undue apprehension" will more and
more rarely occur, but this takes a long time, and the health
officer or practicing physician who is confronted with an indi-
vidual so extremely apprehensive as to be in danger of nervous
collapse ought seriously to question his own wisdom and “pro-
fessional attitude” if he refuses to give vaccine. Such persons
very often truly believe and violently feel that it is the duty
of the health department to give them the vaccine, and refusal
to give it leads to loud criticism freely voiced among friends
and neighbors. Facing such a situation, the health officer
would injure his department vastly more in the mind of the
public than be could possibly gain in any way by refusing the
treatment. What the influence of such an attitude on the part
of a practicing physician would he on his practice is left to
the physician to judge.

As to statistical data given in the report, no question is
raised; but one obvious conclusion regarding the effectiveness
of canine vaccination was not drawn. If the incidence of rabies
among all dogs belonging to white owners was 1.5 per cent,
while the incidence among vaccinated dogs (40 per cent of
the whole group) belonging to white owners was 0.5 per cent,
this would indicate that about 75 per cent of vaccinated dogs
were protected by the treatment.

The mortality of 0.06 per cent among 42,947 persons who
received antirabies vaccine may be compared with the average
mortality figure of 0.36 per cent given in League of Nations
data concerning persons treated after being bitten by known
rabid animals. The authors do not state the proportion of
the 42,947 persons who are known to have been bitten by rabid
dogs, but if it was only one in six their data would be as
good evidence for the use of antirabies vaccine as are the
League of Nations data.

It is difficult to see how the conclusion “The persistence
with which fatalities continue to be equally distributed among
the treated and untreated” can be drawn from the fact that
twenty-three of the forty-eight fatal cases had received sup-
posedly adequate treatment. Such a conclusion could logically
follow only if the number of untreated persons bitten by known
rabid animals was approximately equal to the number of treated
persons known to have been so bitten. No definite data are
given to substantiate any such assumption. Such data should
not be hard to collect if they exist, for while it is never pos-
sible to obtain reports of all dog bites it is always possible to
trace what happens to those people who refuse treatment after
it is found that they have been bitten by known rabid dogs,
which class after all is the criterion of susceptibility to rabies.

The argument based on the comparative number of deaths
among Negroes and white persons from some points of view
has some weight, but even here there are other variable factors
that have not been taken into consideration. For instance, the

statement that “Negroes undoubtedly are bitten and otherwise
exposed to rabies as often as the white persons” is an assump-
tion not susceptible of proof from the data given; the very
fact that “their animals are subject to the poorest of care”
would leave the Negroes’ dogs in most instances free to follow
the frequently observed tendency of a rabid dog to run away
from home and bite other dogs, while the well cared for dog
belonging to the white family would be much more likely to
be observed and handled in the early stages of the disease,
resulting in bites of the owner or members of his family. It
is in “caring for” his dog that the owner of a rabid animal is
most often bitten.

It is claimed, therefore, that the following quoted statement
is seriously open to question: “In the experiences cited there
is little relation between mortality from rabies and the adminis-
tration of antirabies vaccine, for (1) among the highly exposed
untreated (Negro) population fatalities are no greater than
among the highly exposed treated (white) population, and (2)
such rare fatalities as do occur are equally distributed among
the treated and the untreated.”

If the authors really believe this twofold assertion, it is difficult
to see why they advocate giving antirabies vaccine at all. It is
indeed surprising to read through the rest of their report and
find them recommending a rabies control program practically
identical with that in effect in other parts of the country where
rabies is a problem and to note that in Birmingham in 1938
the ratio of antirabies treatments to the number of known rabid
animals was 2.9. In Los Angeles County, another rabies focus,
this ratio was less than 2.0.

Some further Los Angeles County data on cases of human
rabies may be of interest. In this county it is not often that a
person refuses treatment after it is found that he has been bitten
by a rabid dog, and the force of pound men and quarantine
officers on the job do not fall far short of finding all dogs that
become rabid and tracing all persons bitten by them. In a
recent two year period there were five deaths from human rabies.
In three of the five cases treatment was neglected, one reason
being that two of the bites were not reported till the persons
became ill. One of the dogs concerned was a pup which was
killed by its owner after it had bitten his child. Another was
not known to have bitten any other person and was never found.
One bite was recognized soon after it occurred, but the person
bitten was intoxicated and careless and did not heed the health
department’s counsel to take antirabies vaccine. In the fourth
case the treatment could not be considered adequate in view of
the location and type of the bite. In the fifth an adequate dosage
of vaccine was given, but it was vaccine of local manufacture
and not generally approved.

In passing, it should be noted that as yet no standard method
of determining the potency of antirabies vaccine on the market
is in effect. This defect in procedure is one that should be
remedied, and until it is one may expect too frequent failures
of the vaccine to protect. Even when all possible tests are
made, however, we do not yet have a perfect vaccine for any
disease; but this is not considered a valid argument against
using vaccines.

All should certainly agree with the authors’ first sentence in
their conclusion : “The data presented are not of a type to
warrant definite conclusions." It is to be regretted that they
apparently came near reaching such conclusions, or at least
expressed themselves in such a way as to put unwarranted
weapons into the hands of people who delight in attacking health
officers and the public health program.

J. L. Pomeroy, ALD,

H. O. Swartout, M.D., Dr.P.H,

Los Angeles.

County Health Officer and Director of the Bureau
of Communicable Disease Control, respectively.

1900

QUERIES AND MINOR NOTES

Jour. A. St. A.
Nov. 18, 1939

Queries and Minor Notes

The answers here published have been prepared by competent

AUTHORITIES. TlIEY DO NOT, HOWEVER, REPRESENT THE OPINIONS OF
ANY OFFICIAL EODIES UNLESS SPECIFICALLY STATED IN THE REPLY.

Anonymous communications and queries on postal cards will not
be noticed. Every letter must contain the writer's name and
ADDRESS, BUT THESE WILL BE OMITTED ON REQUEST.

ALLERGY TO COLD

To the Editor : — A woman aged 53 had a hysterectomy and roentgen therapy
following a diagnosis of carcinoma of the cervix nine years ago. Physical
examination reveals obesity, apparently from a familial trend, and blood
pressure of 180 systolic and 110 diastolic but otherwise essentially normal
conditions. The urine is normal and the hemoglobin is 70 per cent. She
is highly nervous and requires phenobarbital to sleep. On Aug. 13, 1939,
she was washing cucumbers in cold water and developed, after about ten
minutes' exposure, a diffuse swelling of the hands accompanied by itching
and burning. This was relieved by the injection of 0.5 cc. of a solution
of epinephrine hydrochloride. On August 15, while standing outdoors in
a sleeveless dress in a cool wind, she felt an itching of the flexor surfaces
of the forearms and presently developed urticarial wheals in these areas.
At a later date the ingestion of an ice cream cone caused gross rapid
edema of the upper lip and tongue, as did contact with ice cubes in an
iced drink. The application of an ice bag for nosebleed caused, in
twenty minutes, edema of the eyelids and forehead to the extent that she
could not open her eyes. This edema responds to epinephrine and
ephedrine but the injection is followed by severe headache, presumably
due to the hypertension. There is no history, either personal or familial,
of allergy of any type prior to August 13. Could you offer me any sug-
gestions or literature as to the management of such a case during the
coming winter months? Her financial status would prevent the patient's
removal to a warmer climate. A . H FieM/ M . D R ando | ph , Minn .

Answer. — This is an undoubted case of hypersensitiveness to
cold. In addition, another type of allergy (such as food allergy)
may be present. Several methods have been employed in the
treatment of cold allergy. One consists simply of systematic
exposure to low temperatures in order to build up tolerance.
This may be accomplished by daily cold showers or baths fol-
lowed by a warm shower if the reaction is undesirable. A brisk
ice rub followed by treatment with a heat lamp is recommended
by some (Duke, W. W. : Physical Allergy as a Cause of Derma-
toses, Arch. Dermal. & Syplt. 13:176 [Feb.] 1926). Another
method of exposure to cold is advised by B. T. Horton and
G. M. Roth (Collapse While Swimming: The Most Dangerous
Consequence of Hypersensitiveness to Cold, Proc. Staff Med.,
Mayo Clin. 12:7 [Jan. 6] 1937). It consists of immersion of
a hand in water at 10 C. for one to two minutes twice daily
for three or four weeks. However, this method is probably
more useful in the type of cold hypersensitiveness in which con-
stitutional histamine-like effects are prominent.

In recent years considerable attention has been given to the
relationship of histamine to allergy and particularly to cold
hypersensitiveness. Treatment with histamine has been recom-
mended on the basis that the reaction phenomenon will be
exhausted. Thus, G. W. Bray (A Case of Physical Allergy :
A Localized and Generalized Allergic Type of Reaction to Cold,
J. Allergy 3:367 [May] 1932) cited a case of cold allergy in
a boy who was relieved by daily histamine injections beginning
with 0.1 mg. and increasing to 1 mg. It is felt, however, that
these doses are excessive. Horton and Roth recommended injec-
tions of histamine in doses of 0.1 mg. or less twice daily for
two to three weeks.

More recently (Roth, G. M., and Horton, B. T. : Hypersensi-
tiveness to Cold; Treatment with Histamine and Histaminase:
Report of Case, Proc. Staff Meet., Mayo Clin. 12:129 [March 3]
1937) histaminase has been used in the treatment of cold hyper-
sensitiveness. A dose of from S to 10 units three times daily,
taken by mouth, is the usual procedure. The function of the
histaminase is to detoxicate the excess of histamine formed in
the tissues.

TUBERCULIN TREATMENT FOR TUBERCUL1DS

To the Editor : — Will you please tell me the exact method of administering
old tuberculin in the treatment of rosaceo-like tubercutid (Lewandowsky)?
I wish to start with a 1:10,000,000 dilution. M.D,, New York,

Answer.— “Exact” is not an appropriate term for tuberculin
therapy, for each physician has his own technic and each patient
reacts in a different way and must be managed differently.
Most users of tuberculin therapy test the sensitivity of the
patient by the Mantoux intracutaneous test and begin treat-
ment with a subcutaneous injection of an amount slightly less
than that producing a reaction. Once or twice a week this
dose is repeated for a few times; then, if no reaction has been
caused, the amount of tuberculin is increased cautiously and

this dose is repeated several times. From 10 to 100 per cent
increase is made- depending on the physician’s judgment of the
patients tolerance.

The patient, if ambulatory, is instructed to take his tempera-
ture three times daily and to record it and any symptom that
he may notice. At the interview with his physician these data
are discussed and evaluated.

It is the present practice to use sterile physiologic solution
of sodium chloride for diluting tuberculin, without the addition
oi phenol. If sterile, the dilutions keep their strength for some
time. Great care must be used in cleansing the implements
in which tuberculin has been used, for a minute amount of
one of the stronger solutions can alter the dose of a weak
solution materially. Many workers keep special syringes and
needles. for the dilute solutions. These are cleansed and boiled
in distilled water.

H. S. Burnell-Jones (Tuberculin in the Treatment of Cuta-
neous Disorders, Brit. M. J. 1:1212 [June 15] 1935) advises
two doses a week for the first few weeks, then one a week,
increasing 10 per cent when there has been no reaction. He
depends on a general reaction, counting a rise of temperature
to 99 F. as such. He does not approve local reactions and in
order to avoid them he injects between the shoulders, where
the skin is less liable than that of the arm or leg to give local
reaction. He places great value on a rest period of from six
to eight weeks now and then during a course of treatment,
which he thinks gives the tissue cells a chance to recuperate
from the repeated stimulation of tuberculin.

Other measures to increase the patient’s resistance and to
facilitate local healing must not be neglected. In fact, many
authorities consider tuberculin an adjuvant to other therapeutic
measures rather than the chief factor. For the tuberculin
treatment the motto must be “Make haste slowly.”

BUTADIENE, 1SOPRENE AND PIPERYLENE
To the Editor : — Will you please inform me of ony possible dangers of bodi
acute and chronic forms to daily exposure to the following volatile
hydrocarbons: butadiene, isoprene, piperylene. The patient uses no masts
and has come in contact with concentrated vapors ot the goses lor
the past two years but to date has noticed only nouseo alter exposure.

Leon Miller, M.D., Philadelphia.

Answer. — At this time these chemicals are used principally
in the production of plastics, synthetic rubber and rubber-like
substances. The destructive distillation of natural rubber yields
some isoprene. Conversely, the polymerization of isoprene ma)
lead to a product resembling natural rubber. Butadiene, when
polymerized, may furnish "Buna” rubber, likewise resembling
natural rubber. All of these substances, as a result of lairiJ
simple chemical or physical manipulations, furnish a W®
variety of new compounds not all of which can be predicte ■
If isoprene is merely allowed to stand for a few weeks, ne
physical properties may arise. In the freshly prepared sta >
none of these three mentioned chemicals are highly toxic, fl-
are mild narcotics. All are irritants to the mucous membranes.
Such actions are acute. By way of chronic changes, ernpt)
sema may be produced. Larionov and his co-workers (An- '
skiy med. Autr. 30:440, 1934) found that the minimal letnai
dose of butadiene for mice through the inhalation of v a P ors
from 200 to 300 mg. per liter of air. For isoprene, the corre
sponding killing dose is 140 mg. At autopsy, pathologic c <
was limited to the respiratory tract; no changes were ‘
ciated with the heart, liver or kidneys. The physiologic : P <
erties of the polymers and compounds of these suDsta
are little known except in the case of chlorinated butaaic
(chloroprene). Von Oettingen and associates (J. Indtisi. n.j-
& Toxicol. 18:240 [April] 1936) reported toxic action
chloroprene when administered to laboratory animals. , . ,
subcutaneous series they stated : “The smallest dose j
could be administered was 0.001 cc. per gram and th s
100 per cent of the animals within three and one-halt to
and one-half hours.” By inhalation as little as OJ mg- >,
liter was injurious. The pathologic features d'jdoS j,

pulmonary irritation, pulmonary edema, cardiac "JP?”™, u .
dilated visceral blood vessels, gastro-enteritis, nephritis, c
neous irritation and loss of hair. These severe man
are to be associated with the introduction of the c j; cr

rather than with the butadiene nucleus itself, since the “ ^
cited data indicate a far lower toxicity for the u

EU \Vhile e ’it is possible to rate the substances mentioned in £-
query as of a comparatively low order of p *. the

not wholly inert and the guiding data are meage . J
time being, at least, exposure to high concentrations ol
should be avoided.

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1902

QUERIES AND MINOR NOTES

Jour. A. It. A
Nov. 18, 1939

Toluene is less dangerous than benzene, but this is due partly
to its higher boiling point. Butyl alcohol is more dangerous
than ethyl alcohol, although the ethyl alcohol may be denatured
with 5 per cent methyl alcohol. Full information does not exist
with regard to the toxicity of hydrogenated naphtha, and at
the present time it is customarily classed as of the same order
of toxicity as petroleum naphtha. Some claims have been made
that hydrogenated naphtha may contain up to IS per cent of
cyclic compounds. To the extent that this is true, hydrogenated
naphtha is to be respected more than naphtha. The acetates
represent the constituents of least toxicity but are capable never-
theless of inducing mild conjunctivitis, respiratory irritation
and similar abnormality. Thinners of almost any type are cap-
able of inducing dermatitis, either through direct irritation or
fat removal. It is always desirable that no workroom atmos-
phere contain high concentrations of the vapors of thinners.
In coating operations, exhaust systems are customarily desirable
or necessary, and in addition in some workplaces respirators or
helmets may be found in use.

SULFANILAMIDE, NICOTINIC ACID AND
METHYLENE BLUE

To the Editor : — My experience with the use of large doses of sulfanilamide
is confined principally to the treatment of gonorrhea. Some of my
patients have complained of shortness of breath on exertion (due to
methemoglobinemia?). Hartmann advises from 1 to 2 grain (0.065 to 0.13
Gm.) doses of methylene blue every fourth hour for the prevention of
methemoglobinemia. Not all observers agree that cyanosis and methemo-
globinemia arc associated; in addition, methylene blue tends to cause
nausea but may be given in enteric coated capsules. There are also a
few observers who do not believe that sodium bicarbonate is necessary.
Finally nicotinic acid seems to be of distinct value. At this rate I would
want to give my patients (a) sulfanilamide, (b) nicotinic acid, (c) sodium
bicarbonate and (d) methylene blue. If such a scheme is followed, would
it be desirable from the standpoint of possible incompatibility to space
these drugs, say, one drug every hour; or is there no incompatibility?

M.D., Pennsylvania.

Answer. — No evidence is available on which to base an
opinion as to whether or not incompatibility would develop
from the simultaneous administration of sulfanilamide, nicotinic
acid, sodium bicarbonate and methylene blue. In considering
the combination of sulfanilamide and methylene blue it might
be well to review the work which lias been done on relieving
cyanotic symptoms originating from sulfanilamide therapy by
methylene blue (/. Clin. Investigation 17:699 [Nov.] 1938;
18:179 [March] 1939). The rationality of adding nicotinic
acid and sodium bicarbonate at the same time is not experi-
mentally and clinically established. It would seem better that
the drugs, if indicated, be given concurrently.

DEATH OF EPILEPTIC PATIENT FROM LOCAL
ANESTHESIA

To the Editor; — A white man aged 32, in excellent physical condition with
the exception of existing epilepsy, was prepared for a hemorrhoidectomy.
The surgeon used what he considered 1J£ ounces of 2 per cent procaine
hydrochloride prepared by a graduate nurse. One cc. of a solution of
epinephrine hydrochloride was added to the procaine hydrochloride before
infiltration of the hemorrhoidal area. Just as the surgeon commenced
to remove the first hemorrhoid, the patient complained of nervousness,
developed a horizontal nystagmus, had five convulsions (clonic type) one
ofteT the other and died on the table. The cause was considered respira-
tory, the breath becoming progressively weaker in spite of the use of
artificial respiration. The patient was treated with phenobarbifaf, receiv-
ing one 1 Yx grain (0.1 Gm.) tablet daily, and had on an average from
two to five seizures a month but never status epilepticus. The head
and upper extremities were violaceous after death. Investigation revealed
that the nurse had made up 45 cc. of 2 per cent pontocaine hydrochloride
solution in place of 2 per cent procaine hydrochloride, and this was used
for infiltration. Would you consider the pontocaine hydrochloride the
primary cause of death? M.D.

Answer. — The symptoms preceding death are characteristic of
the effects of cocaine derivatives on the central nervous system.
They occur when the quantity of solution exceeds the limit of
safety, when the concentration of the drug is too high or when
an inadvertent intravenous injection has been made. In this
case, 45 cc. of a 2 per cent procaine hydrochloride solution
might well be too high a concentration to use for infiltration
anesthesia; if the solution injected was pontocaine hydrochloride
in the same concentration, this far exceeds the limit of safety,
as pontocaine hydrochloride is used in 1:1,000 to 1:500 dilu-
tions for infiltration. The correspondent docs not mention the
concentration of the pontocaine hydrochloride solution.

It is usually considered unwise to operate on epileptic patients
under local anesthesia, as they may develop convulsions on the
operating table unless they are well prcmedicated with barbit-

urates or bromides. As the convulsions due to an overdose a
the iocal anesthetic are due to cortical irritation, it is conceivable
that the brain of an epileptic patient may be more sensitive to
such intoxication than a normal brain; however, death here
occurred almost certainly as a result of too much of the anr-
thetic or because of an intravenous injection. The latter may
cause fatality in comparatively small doses.

XEROSTOMIA

To ihe Editor ; — A woman aged 65 who is generally much debilitated her
chronic gallbladder disease and is suffering greatly from xerostomia (dry
mouth). The tongue is quite red and beefy in appeoronce, the lips ore
cracked, and voice production or articulation is difficult owing io a dry-
ness felt in the esophagus and mouth. The blood picture is normal. I have
been giving large doses of liver (Reticulogen Lilly) intramuscularly, 1 cc.
weekly for four weeks, without any relief. Her general physical con-
dition is decidedly under par. There is moderate arteriosclerosis with a
mild hypertension. The nose and throat are otherwise negative. She
has both upper and lower dental plates. Stomach analysis shows anacidity.
Therapy other than liver has included brewers' yeast tablets, diluted
hydrochloric acid and moderate doses of digitalis for tachycardia. Any
information you can give as to relief of dry mouth will be greatly
appreciated. M.D., Westmoreland, Kon.

Answer. — Xerostomia, or deficient salivary secretion, is an
accompaniment of diabetes mellitus, diabetes insipidus, bella-
donna poisoning, severe fevers and nephritis. All dehydrated
states are affected to a certain extent. While the. condition
is rather rare, all too often no assignable cause is demon-
strable. In the absence of a specific cause, symptomatic treat-
ment is resorted to with indifferent results. Glycerin mouth
washes give some relief. Smalt doses of pilocarpine some-
times stimulate salivary secretion.

To discuss the possible causes of the fissured lips and the
red tongue, apart from xerostomia, would carry the discussion
from such local causes as eczema oris through a tremendous
number of conditions up to a general nutritional deficiency
such as pellagra or sprue. In the case cited, liver extract
will not do much in the presence of a normal blood picture.
Digitalis is usually ineffective in tachycardia that is not asso-
ciated witli heart failure. Anacidity is not uncommon at »K<-
65 and hydrochloric acid may give symptomatic relief. Brewers
yeast may be useful. .

A most careful search for a local or systemic cause should
be pursued. If such search proves fruitless local treatment,
unsatisfactory as it is, must be kept up.

GASTROINTESTINAL MELANOMAS

To the Editor : — Are melanomas ever primary in the gastrointestinal troc^
How commonly arc melanomas found in the gastrointestinal tract
commonly are melanomas a cause of intestinal obstruction.

M.D-, New York

Answer. — Melanomas can be primary in the gastrointestinal
tract. They occur almost exclusively in the rectum.. Acco '
ing to Ewing (Neoplastic Diseases, ed. 3, Philadelphia, w. •
Saunders Company, 1928, p. 935) they constitute about z
per cent of all melanomas. Of 266 malignant melano ■
reviewed by Affleck (Am. J. Cancer 27:120 [May] 1936), .

one such lesion was found in the mouth and in i the rcc -
respectively. Gerritzcn (Arch. }. It in. Chir. 178:400 [Dc -
1933) stated that seventy-two cases of primary melanoma
the rectum were reported up to 1934. Forty-eight °* ’

actually were primary mclanosarcomas of the rectal ,
membrane, whereas the remaining twenty-four consis ‘
primarv melanosarcoma of the anus arid melanocarc ••
This author added an additionai case of rectal melanosarc •
to those already reported. Such tumors are found c- ,
quently in the intestine and occasionally in the R allu ‘
bile ducts, esophagus and mouth. Of course, in the p •
of all melanomas situated in the last-mentioned sites, int : l ■
tion always arises as to whether they are primary or sec •_
manifestations. Melanomas are infrequently a cause
final obstruction, partly because of their coinparatne r. ^
md partlv because the majority of them arc S’luntcu ^
-ectum. In a case of multiple primary melanomas otin-
ntestine reported by Menne and Beeman (Am. j , c

S- Nutrition 3-.7S6 [Dec.] 1936) there was no
if obstruction prior to the operation. Maxwell (. I- '■ . ..

!:656 [Nov. 24] 1928) reported a case in which c r0 "f tcc re-
inal obstruction and intussusception were the remits oi -
larv melanomas of the small intestine. , r ,f e r-

An adequate bibliography may be compiled irom
necs to the literature in the textbook or in tlie .
he authors cited.

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1904

EXAMINATION AND LICENSURE

Jour. A. M. A.
Nov. IS, 1939

Medical Examinations and Licensure

COMING. EXAMINATIONS

STATE AND TERRITORIAL BOARDS

Examinations of state and territorial boards were published in Tiie
Journal, November 11, page 1833.

NATIONAL BOARD OF MEDICAL EXAMINERS

National Board of Medical Examiners: Parts I and II. Medical
centers having five or more candidates desiring to take the examination,
Feb. 12-14. Part III. Chicago, Jan. 16-18. New York, January 15-17.
Registration closes Dec. 9. Ex. Sec., Mr. Everett S. El wood, 225 S. 15th
Street, Philadelphia.

SPECIAL BOARDS

American Board of Anesthesiology: An Affiliate of the American
Board of Surgery. Written. Part I. Various places throughout the
United States and Canada, March 28. Oral. Part II. New York, June
10-11. Applications must be received 60 days prior to examination. Sec.,
Dr. Paul M. Wood, 745 Fifth Ave., New York.

American Board of Internal Medicine: Written. Various sec-
tions of the United States, Feb. 19. Formal application must be received
on or before Jan. 1. Sec., Dr. William S. Middleton, 1301 University
Ave., Madison, Wis.

American Board of Obstetrics and Gynecology: General oral and
pathologic examinations (Part II) for all candidates (Groups A and B)
will be conducted u\ Atlantic City, N. J., June 8-11. A£J>h'coiions for
admission to Group A, Part II examinations must be on file not later than
March 15. Sec., Dr. Paul Titus, 1015 Highland Bldg., Pittsburgh (6).

American Board of Ophthalmology: Written. Various cities of
the United States and Canada, March 2. (The only written examination
in 1940.) Oral. New York, June 8*10. Formal applications must be
received before Jan. 1. Sec., Dr. John Green, 6830 Waterman Ave.,
St. Louis.

American Board of Otolaryngology: New York, June 3-5. Sec.,
Dr. W. P. Wherry, 1500 Medical Arts Bldg., Omaha.

American Board of Pathology: Memphis, Nov. 22-23. Sec., Dr.
F. W. Hartman, Henry Ford Hospital, Detroit.

American Board of Pediatrics: New York, April 30 and May 1.
Kansas City, Mo., preceding the Region III meeting of the American
Academy of Pediatrics, Seattle, June 2. Sec., Dr. C. A. Aldrich, 723
Elm St., Winnetka, 111.

American Board of Psychiatry and Neurology: New York,
December 18-19. Sec., Dr. Walter Freeman, 1028 Connecticut Ave. N.W.,
Washington, D. C.

American Board of Radiology: Atlanta, Ga., Dec. 9-11. Sec.,
Dr. Byrl R. Kirklin, 102-110 Second Avenue S.W., Rochester, Minn.

Illinois June Report

Mr. Lucien A. File, acting superintendent, Illinois Department
of Registration and Education, reports the written examination
(graduates of foreign schools given also a practical test) held
at Chicago, June 20-22. The examination covered ten subjects
and included 100 questions. An average of 75 per cent was
required to pass. Three hundred and twenty-seven candidates
were examined, 319 of whom passed and eight failed. Twenty-
nine physicians were licensed by reciprocity and three physicians
were licensed by endorsement. The following schools were
represented :

School passed Grad.

College of Medical Evangelists (1939)

Chicago Medical School (1939)

76, 78, 78, 79, 79, 79, 80, 80, SO, 80, 80, 80, 82, 82,

82, 82, S2, 82, 82, 82, 83, 83, 83, S3, 83, 83, 83, 83,

84, 84. 84, 84, 85, 88

Loyola University School of Medicine (1938)

(1939) 75,* 77, 78, 79, 79, SO, 80, SO, 80, 80, 81, 81,

81, 81, 81, 81, 81, 81, 81, 81, 81, 81, 81, 81, SI, 81,

82, 82, 82, 82, 82, 82, 82, 82, 82, 83,* 83, 83, 83, 83,

83, 83, S3, 83, 83, S3, 83, 83, 83, 84, 84, 84, 84, 84,

84, 84, S4, S4, 85, 85, 86, 87, S7, 88

Northwestern Universitj- Medical School (1938)

85, (1939) 78, 79, 80, SO, 81, 81, SI, 82, 82, 82, 82,

82, 82, 83,* 83, S3, S3, 83, 84,* S4, 84, 84, 84, 84,

85,* 85, S5, 86, 86, 87

Rush Medical College (1937)

83 * 86, 87,* (1938) 79,* 80, 81, 82, 82, S3, 83, 83,

S3, S3, 84, S4, 84, 84, 84. 85, 85, 85, S5, 86

The School of Medicine of the Division of Biological

Sciences (1937)

(1938) SI, 83, 85, 86 . .

University of Illinois College of Medicine (1938)

(1939) 78, 79, 79, 80,* SO, 80, 80, SO, 80, 80, 81,

51, 81, 81, 81, SI, 81, 81, 81, 81, 82, 82, 82, 82, 82,

52, 82, 82, 82, 82, 82, 82, 82, 82, 82, 82, 82, 82, 82,

83, S3, 83, 83, 83, 83, 83, S3, 83, 83, S3, S3, S3, 83,

84 * 84 * 84,* 84, 84, S4, S4, S4, 84, S4, 84, 84, 84,

84, 84, S4, S4. S4, 84. S4. 84, 85,* 85, S5, 85, 85,

85, 85, 85, 85, 85, 85, 85, S5. S5, 85, S3, 86,* 86,* 86.*

S6, SG, 86. 86, 86, 86, SG, SG, 87, S7, S7, S7, $7, 87,

SS,* 88.* SS,* 88 „

Harvard Medical School (1937) Sa, (19 j8)

Tufts College Medical School (1938)

St. Louis University School of Medicine (1938) SL»,

University and Bellevue Hospital Medical College (1934)

Universitv of Rochester School of Medicine (1936)

Ohio State University College of Medjcmc:.. U93S)

Vanderbilt University School of Mcdicane. . (1937) 77,* (19 jS)

Marquette University School of Medicine ...(1939)

80, S2, S5

Per

Cent

80

75,

84,*

83,*

80,

80,

88 *

82

82

SO

84

SS*

83

82

79.

University of Wisconsin Medical School * (19181

University of Toronto Faculty of Medicine.. “ notn

(1938) 82, 83, 84, 86* K }

Medizinische Fakultat der Universitat Wien (191

(1919) 78, (1922) 82, (1924) 77, (1925) 75, (19^6)

80 (1928) 80, (1936) 79 ' *

Deutsche Universitat Medizinische Fakultat, Prag (1932)

Univerzita Komenskeho Fakulta Lekarska, Bratislava. . (1934)
Albert-Ludwigs-Universitat Medizinische Fakultat, Frei-
burg (19?^>)

Friedrich-Wilhelms-Universitat Medizinische Fakultat

Berlin ... ..... . . (1 917 ) 75, (1935)

vereinigten Friedrich-Universitat Medizinische Fakultat,

Halle-Wittenberg (1920) 78, (1925)

Universitat Heidelberg Medizinische Fakultat...*". .’.(1936)

Universitat Koln Medizinische Fakultat (1922)

Magyar Kiralyi Pazmany Petrus Tudomanyegyetem

Orvosi Fakultasa, Budapest (1928)

Regia Universita degli Studi di Firenze Facolta di Medi-

cina e Chirurgia (1936)

Regia Universita degli Studi di Roma Facolta di Medi-

cina e Chirurgia (1937)

Universitat Basel Medizinische Fakultat (1937)

Universitat Bern Medizinische Fakultat (1937)

Universite de Geneve Faculte de Medicine... (1934)

77,

83

SI/

79,

7 7

77

81

77

76

75

81

80

76
80
80
79

School failed

Jefferson Medical College of Philadelphia. __ .
Universite de Paris Faculte de Medicine

Year
Grad.

(1900)

_ .. (1937)

Friedrich-Wilhelms-Universitat Medizinische Fakultat, Rerlin (1936)

Schlesische-Friedrich-Wilhelms Universitat Medizinische Fakultat,

Breslau (1935)

Universitat Heidelberg Medizinische Fakultiit (1922), (1936)

Regia Universita degli Studi di Bologna Facolta di Medicina e

Chirurgia (1937)

Second Leningrad Medical Institute .(1922)

Reciprocity

with

Wisconsin

Kansas

Wisconsin

Iowa

Iowa

Kentucky

School LICENSED BY RECIPROCITY g“,[

Loyola University School of Medicine (1934), (1938)

Northwestern University Medical School (1931)

University of Illinois College of Medicine (1938)

College of Physicians and Surgeons, Keokuk (1897)

State University of Iowa College of Medicine. (1930), (1937)

University of Louisville School of Medicine (1938)

St. Louis University School of Medicine (1933), (1934),

(1936), (1938, 5) Missouri

Washington University School of Medicine (1938)

University of Michigan Medical School (1933)

University of Nebraska College of Medicine (1932)

University of Cincinnati College of Medicine (1931)

Western Reserve University School of Medicine (1935)/

(1936), (1938) Ohio •

University of Oklahoma School of Medicine (193/)

University of Tennessee College of Medicine (1935) Tenness

Baylor University College of Medicine (1937) Louisia

University of Texas School of Medicine (1932), (1937)

University of Wisconsin Medical School (1934)

Year Endorsement

g c k oo j licensed by endorsement Grad. of

Rush Medical College (1937),* (J937)N. B. M.

Yale University School of Medicine (1931)N.B. d.

* Licenses have not been issued.

Missouri

Michigan

Nebraska

Ohio

Kansas

Texas

Pcnna.

Wisconsin Reciprocity Report
Dr. E. C. Murphy, secretary, Wisconsin State Board of Medi
cal Examiners, reports eleven physicians licensed by reciproci )
on June 29 and September 14. The following schools " cr
represented: y „ r Reciprocity

g c k oo j LICENSED BY RECIPROCITY Grad. V/ith

College of Medical Evangelists ■•■■■■ ^Jlbnois

Rush Medical College 0937), ( 938 R'iJY

Northwestern University Medical School Illinois

University of Illinois College of Medicine.. low*

State University of Iowa College of Medicine /Ytm* Maine

University of Minnesota Medical School

(1938) Minnesota . Illinois

St. Louis University School of Medicine mqv?) perrna.

Temple University School of Medicine....... - Arizona

University of Pennsylvania School of Medicine I 1 ?- 53 -'

Colorado October Endorsement Report
Dr. Harvey W. Snyder, secretary, Colorado State Boar o
Medical Examiners, reports eleven physicians been:
endorsement at the meeting held at Denver, October
following schools were represented:

Year Endorse®™'

„ , , LICENSED BY ENDORSEMENT Grad- 01 _

School riowVC. B. M.Ef

College of Medical Evangelists. V.gjg, min" 1 !

Northwestern University Medical School r!o-> 7 ) Mi'" 5 '-" 1

Rush Medical College. .............. : (i9?6) Kau w *

University of Kansas School of Medicine... Lee: vert

Tulane University of Louisiana School of Medicine. . .11* A. j, j|. Lx.
Tufts College Medical School. . ., VlM-J) ’ Hf'?!

Volume 115
Dumber 21

BOOK NOTICES

1905

»

Book Notices

Training for Championship Athletics. By C. Ward Crampton. M.D.
Cloili Price, $2.50. Pp. 303, with T illustrations. New York & Ion-
don; Whittlesey House, McGraw-Hill Book Company, Inc., 1039.

As the title suggests, Dr. Crampton’s book is designed pri-
marily to attract and interest boys and young men. It should
do both. The author is well qualified by long experience as
an athlete, teacher of athletes and physician to athletes to write
of the making of athletes. He does it brightly and effectively,
with real analytic ability. So well is the job done that it
should make helpful reading for others than prospective ath-
letes, particularly coaches and physical education teachers. In
content the volume presents general material on training for
various athletic activities, growth, development and diet, much
of it made spicy and interesting by being directly connected
with prominent athletes such as Bob Feller and Glenn Cun-
ningham. The styles, habits and training methods of a num-
ber of such athletes are discussed in a way to stimulate and
intrigue the average boy. The latter part of the book is
devoted to more specific and detailed matters of diet and tech-
nic for various sports. Included are sprinting, mile running,
pitching, batting, basketball and fundamentals of football.
There are many helpful illustrations from photographs of great
athletes and the type is large enough to be easily readable.

Medicolegal Phases of Occupational Diseases: An Outline of Theory
and Practice. By C. 0. Snppington, A.B., M.D., Dr.P.H. Cloth. Price,
$2.75. Pp. 405, with 7 illustrations. Chicago: Industrial Health Book
Company, 1939.

Extension of workmen's compensation to include indemnifi-
cation for disability arising from occupational disease is of
comparatively recent origin. Nevertheless there are sound
indications already that this development has come to be a
major preoccupation in the field of medical jurisprudence.
Even a satisfactory definition of what constitutes an occupa-
tional disease is extraordinarily hard to reach. When one
adds to that fundamental difficulty the associated problems of
etiology, disability rating and adjudication, the whole picture
becomes one of fascinating complexity. In the construction
of a work on occupational disease compensation, therefore,
there is at once the necessity of picking out and emphasizing
those principles which have received the imprint of judicial
and authoritative interpretation. In these respects the author
has succeeded admirably. The subject matter, all closely con-
structed after the handbook style, is treated under four major
headings : industry, insurance, medicine and law. The first
section deals largely with lists and classifications of indus-
trial hazards. There are also chapters on detection and con-
trol from the engineering standpoint which will be of interest
to physicians not entirely aware of the considerable advances
being made along these lines. The section on insurance testi-
fies for the most part that successful principles for under-
writing this type of risk are by no means settled. Past
experience in compensating for industrial injuries, valuable as
it has been, will provide only a partial solution to the per-
plexing problems of disability arising out of occupational dis-
ease. The economic and social impacts of this movement,
especially the medical contribution and particularly past rela-
tionships which have existed between medicine and insurance
in the casualty fields, are evidently outside the scope of this
book. The chapters devoted to medical considerations concern
themselves with classifications of exposures according to cause
and part affected. Throughout this discussion the need for
thorough study of etiology is constantly underlined. Disability
estimation .largely follows Kessler’s previous work. There are
only brief references to medical treatment, which because of
its unsatisfactory character should occupy a secondary position
to preventive principles. The legal section receives the most
extensive consideration. There are tables on incidence col-
lected from the few states that publish data on closed occu-
pational disease claims. The controversial details of blanket
versus schedule coverage are presented as well as the merits
and disadvantages of court procedure, industrial commission

practice and the use of medical advisory boards. An appendix
contains digests of workmen’s compensation laws affecting
occupational diseases and also abstracts of court decisions
which will be interesting to physicians who have had contact
with legal procedure in sufficient degree to allow for proper
appraisal.

Urine: Examination and Clinical Interpretation. By C. E. Dukes,
M.Sc., M.D., D.P.H., Pathologist to St. Peter’s Hospital for Stone and
Other Diseases of tile Urinary Organs, London. Cloth. Price, $8. Pp.
403, with 110 illustrations. New York, Toronto & London: Oxford
Unirerslty Press, 1939.

As stated in the foreword, the author has attempted to col-
lect methods of laboratory procedure for investigations on the
urine useful in clinical practice. He has devoted much space
to the clinical interpretation of these laboratory results. This
experience has been gained as a result of ten years’ service
as clinical pathologist to a hospital majoring in the care of
patients with urinary tract diseases. The volume is well
printed on good paper, adequately indexed and contains excel-
lent photographs, some of which are presented as colored plates.
Many references to original articles are given and the volume
should serve as an excellent guide to laboratory workers.
Errors in proof reading are nil, although on page 21 hippuric
acid is referred to as a conjugated product of benzoic acid
and glycerin. However, this compound is described correctly
later. The book is stronger in the section devoted to micro-
scopic and bacteriologic technics than to the chemical procedures.

Many essential chemical procedures, at least so regarded in
the United States, have been omitted. Some of these omis-
sions might be cited. Better tests for the recognition of bile
salts utilizing the Pettenkofer reaction are available than those
given. In the determination of the pn value of urine, no men-
tion is made of the quinhydrone or glass electrode methods,
although the quinhydrone method is of quite common use since
the apparatus is economical, accurate in the range of urine,
and avoids the pitfalls of the colorimetric procedures in a solu-
tion such as urine, which may be at times highly colored. It
would seem that qualitative tests for the presence of urea in
urine are superlative and should not be emphasized. The
hypobromite method has been almost entirely replaced in this
country by the urease procedure. No mention is made of boric
acid as an absorbent for ammonia in the aeration procedure
for determining urea, although this absorbent is commonly
used and obviates the necessity of one standard solution. Only
the Benedict uric acid method is given and no reference is made
to the direct procedure. Similarly, the excellent method of Sul-
livan for recognition of cystine is omitted. This method serves
admirably for identifying cystinuria as well as the recognition
of cystine calculi.

The chapter devoted to hormone assay is a welcome addi-
tion to a modern reference work, hut here again there is a
lack of procedures . which are now recognized as useful clini-
cally. No test is described for the determination of the corpus
luteum hormone as it is excreted in the urine as pregnandiol
glucuronate. The Oesting chemical method for determining
androgen is not given nor is there any mention of the lacto-
genic hormone.

To workers in other countries it would seem that the metric
system of measurement should be followed completely. Body
weights would not then be referred to as so many stone, such
as is given in the section devoted to vitamin C. Chemical
tests for vitamins Bi and B: are not presented even though
this determination is at present on a quite quantitative basis.
The Koppanyi test for barbiturates in the section on recog-
nition of poisons is not included, although it would seem that
this method offers the best quantitative technic for the deter-
mination of this group of substances.

There is an extended chapter on urinary' calculi with excel-
lent illustrations and undue detail for one who is interested
in the laboratory _ angle solely. Usually the pathologist is
interested mainly in the type of calculus that is present in
order to give the clinician information on which to base thera-
peutic procedure. The determination of the type of calculus
is a simple accomplishment and can be done following the
procedure gi\en by the author. However, acetic acid is usually'

1906

BOOK NOTICES

Jo us. A. M. A
Nov. IS, 1935

the acid of choice in the differential acidification for the
recognition of calcium phosphate and calcium oxalate.

Essentially this volume offers much of value to the labora-
tory technician and to the general practitioner by presenting
in a simple manner laboratory urinary technic in a concise
form.

Die T uberkulose als Allgemein-Krankheit. Von Dr. G. Liebermeister,
Letter c/er Jnneren Abteihing des Stadtischen Krankenhauses Duran. Nr.
72, Tuberkulose-Bibliotliek, Beihefte zur Zeitschrift fur Tuberkulose.
Herausgegeben von Dr. Pranz ltedeker, Oberregicrungs- u. Obermedizinal-
rat, Berlin, und Dr. Karl Diehl, dirigierender Arzt, Sommerfeld. Paper.
Price, 12 marks. Pp. 108, with 23 illustrations. Leipzig : Johann
Ambrosius Barth, 1938.

This small volume will be of interest to the specialist in
tuberculosis but of less concern to the general practitioner and
specialist in other diseases, in spite of the fact emphasized by
the author, to which exception cannot be taken, that the gen-
eral manifestations of tuberculosis are such that internists,
pediatricians, surgeons and physicians in the specialties should
be familiar with them. Liebermeister’s book represents a mix-
ture of clear summarizing of accepted facts and an attempt to
explain them in a complicated way that will seem unnecessarily
confusing to all not versed in the varying terminology' built
around the phenomenon of allergy'. Clinicians with long
experience in tuberculosis, in turn, are apt to take frequent
exception to the rather glib explanations of variation in the
course of tuberculosis in terms of euergy, dysergy and nomergy
and to feel that commonly the course does not conform with
the diagrams in the text intended to illustrate stages of
the disease. Specialists in tuberculosis, however, will find the
author’s conceptions stimulating in directing attention to the
relations of allergy and illness.

Hygiene. By 3. It. Currie, M.A., M.D., D.r.H., Henry Meehan Pro-
fessor of Public Health, University of Glasgow, Glasgow. Cloth. Price,
?5. Pp. 324, with 34 illustrations. Baltimore : William Wood & Company,
1938.

This textbook on hygiene is described by the author as intended
for the use of students of medicine, priority being given to the
social aspect of hygiene. Although Currie states that he does
not elaborate the administrative and legal points of hygiene, one
third of tlie book describes rather fully the provisions in Great
Britain for medical and public health care, including maternal
and child welfare, school hygiene, mental hygiene and industrial
hygiene. One chapter is devoted to a discussion of social insur-
ance as it is employed in Great Britain. This discussion is
largely an enumeration of the laws which have been passed and
the benefits available to individual citizens without any opinions
being given with regard to the effectiveness of such legislation.
The remainder of the volume takes up various aspects of per-
sonal and environmental hygiene, such as food, ventilation,
lighting, water supply and waste disposal, and gives a rather
detailed treatment of the individual infectious diseases. This
book should serve the purpose for which it is written, that is, as
a textbook on hy'giene for medical students- in Great Britain.
Because much of the material is concerned with specific legis-
lation and practices in that country-, its chief value in the United
States will be as a reference book for those wishing to get infor-
mation on practices in Great Britain.

Les troubles tie la thermoregulation (coup do chaleur). Par L. Dcro-
bert. Paper. Price, 00 francs. Pp. 218, with 13 Illustrations. Paris:
yfasson & Cie, 1939.

This work is an experimental study the purpose of which
is to determine the pathology of the clinical group of symp-
toms known as heat stroke. Two thirds of the monograph
consists of a survey- of the literature that the author considers
has a bearing on the subject. Although there are twenty-five
pages of bibliography, the American work on the subject is
incomplete and most of the authors mentioned in the text
cannot be found in it. The author exposed dogs, rabbits and
guinea pigs to high humidity and temperatures ranging from
*10 to 45 C. (104 to 113 F-), studied the clinical effects and
examined them post mortem. The first group of animals died
in from thirty-five to seventy-five minutes. The second group
also exposed to high humidity and to lower temperatures, 32
to 35 C. (S9.6 to 95 F-), survived. The physical and clinical
changes were noted and they were later examined pathologi-
callv. The final group consisted of a case of heat stroke and

one. of severe burns in human beings. Descriptions with illus-
trations of the morphologic changes in the blood cells were
given and some measurements of the chemical constituents oi
the blood recorded. The author concludes that “elevated tem-
perature on one part of the body or on the whole body is
capable of causing benign symptoms (syncope and collapse) or
serious symptoms (properly known as heat stroke) the cause
of. which is disintegration of the albumins. . . . Although
this disintegration is important, the marked increase of ‘albu-
mos.es’ causes lesions as important as those found in anaphy-
lactic shock.. These ‘albumoses’ can cause the same lesions
in an organism previously sensitized even though it is not
specific, or in an organism in which the antitoxic barriers are
deficient. . .. . This produces a disintegration of the first
importance in which the polypeptides cause lesions of the
vegetative centers, which in their turn are responsible for
changes in the organ as a whole.” The evidence cited for
these conclusions is inconclusive. The relation of the metabo-
lism of water and the electroly-tes to shock might have been
discussed with advantage.

M One Thousand Autobiographical Sonneis. By Morrill Moore. Cloth.
Price, $5. Pp. 1,000. New York: Harcourt, Brace & Company, 1038.

This book is cleverly titled with the metric symbol for a
thousand, which happens also to be the author’s initials. It
contains 1,000 sonnets of 50,000 which he has written, though
he pledges himself that most of the rest will not be published.
These sonnets are in many different forms. A considerable
number present the traditional octet and sextet of the estab-
lished form for this poetic medium. Others are differently
divided, one for example consisting of couplet, triolet couplet
and triolet quatrain, with the second line of the latter broken
in two. There are others in two stanzas of seven lines, sonic
in three-five-three and three, and still others in five-two-two
and one. The rhythm is as causal and irregular as the stanza
divisions. Lines are frequently brpken in the middle. Rhymes
appear or are ignored, at the author’s pleasure. The sonnets
are said to be autobiographic, but the reader would have diffi-
culty recognizing this fact if his attention were not called to
it by the introductory statement. The work does show strongly
the influence of bis medical training and bis interest in psy-
chiatry, since many of his sonnets deal with medical matters,
as, for example, “There Was A Man”:

. . . He was born in Wurttemburg,

Came to America at twenty, never married,

Never missed operas, and always tarried
Before antique shop windows and before
Shops where meerschaum objects and where amber
Were displayed, and never spoke English well.

And got along very quietly till he fell
And broke his hip.

Pneumonia ended his life
In Bellevue neatly stretched between two sheets
By crevasses and canyons that were streets.

Other sonnets deal with the psychology of deafness, An'bn
lance Call,” and a satire on the gyrations of the. bald cn 1
“Too Late for Herpicide.” A whole division is ocvoUi
dreams and symbols and in this is included a tricky
in Code” and one composed almost exclusively of J u 1
names and other words. There is such endless variety o
and topic in this book that should make it provocatnc ^ ^
stimulating reading for one who can pick it . up and r f] ,
by snatches. In fact, the reviewer is not inclined to io
author to his promise of nonpublication of the rest of Ins "
or at least a portion of it.

Short Stature and Height Increase. By C. J. GcrIIng.

3. Pp. 159, with Illustrations. New York : Harvest Hou ,

The title is intriguing but may lead the man of s,10rt
> whom this book is addressed, to expect far more
uthor can deliver. The author does not prorn.se ni tW '^ ^

lapters to increase the height of the individual bat p ;

le various factors that may produce an illusion ot ^

right. The book is interestingly and simply .

resents the various factors responsible for growth, 1 ^

le mechanism of growth and all the {actors as S -j . , ,

cep, age and disease are discussed in their rcla -
-owth. The author then tells of the folly of using Uuri*
Ivertised self-prescribed drugs and devices to tiring ■

Volume 113
Number 21

BOOK NOTICES

190 7

increase in height. There is a brief but excellent discussion of
the little faith that should be placed on weight tables based on
age and height. The main thesis of the book is that posture is
the best and surest aid for those of short stature. It can bring
about an actual increase in height only so far as the person has
allowed himself to assume a slouch. The benefits of exercise
to increase the tone of the muscles responsible for good posture
may result in better health and a better appearance and with it a
better outlook on life. The chapter on stature aids is of interest
in that it discusses shoes and clothing and the part they play in
producing illusions of greater height. It is a book that the prac-
ticing physician may want to recommend to his patients whose
short statures are keeping them from a normal, cheerful outlook
on life.

Lite and Letters of Or. William Beaumont. By Jesse S. Mycr, A.B.,
M.D. With an introduction by Sir William Osier, Bt., M.D., F.B.S.
Second edition. Cloth, Price, $5. Pp. 327, with illustrations. St.
Louis: C. V. Mosby Company, 1930.

Here is a new printing of the famous book by Myer first
published in 1912. It still bears the introduction which Dr.
William Osier wrote at that time. The name of Beaumont is
almost supreme among workers in the field of physiology in
this country as our greatest pioneer. At the meeting of the
International Congress of Physiologists in Boston in 1929,
William Beaumont was figuratively canonized as the Patron
Saint of American Physiology. In a new introduction by
Dr. A. C. Ivy' there is an analysis of present day points of
view in relationship to Beaumont’s experiments. The present
volume contains a reproduction of the fine painting made by
Dean Cornwell in 1938 and is otherwise similar to the edition
published in 1912. This book is a “must” item for every
American physician interested in medical history.

Otolaryngology in General Practice. By Lyman G. Richards, M.D.,
Associate Professor of Otolaryngology, Tufts Medical Sciiooi, Boston.
With a foreword by D. Harold Wallter, M.D., Consultant in Otology,
Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. Cioth.
Price, $0. Pp. 332, with 72 illustrations. New York: Macmillan Com-
pany, 1939.

This textbook on otolaryngology for use by the general
practitioner accomplishes its purpose in an admirable way.
The author discusses the most common diseases and complaints
which the general practitioner is called on to take care of
in everyday practice. Tlte impression one gets on reading the
book is that here are the opinions of a person of experience,
unmarked by strong personal bias and characterized by a great
deal of good common sense. The author has not described in
great detail operations which the general practitioner has no
right to do and which he is not called on to do. The one
operation on which time is spent is that of tonsillectomy and
adenoidectomy, and this is eminently proper because, regard-
less of contrary opinion, most of the tonsillectomies in this
country are being done by nonspecialists. The general prac-
titioner interested in diseases of the ear, nose and throat can
gain much by a careful reading of the text.

Headache and Head Pains: A Ready Reference Manual for Physicians.
By Walton Forest Button, M.D., Birector, Medical Research Laboratories,
Aroarllin, Texas. Cloth. Price, $1.50. Pp. 301, with 6 illustrations.
Philadelphia : F, A. Davis Company, 1939.

Headache is a symptom which may occur with almost any
disease affecting the human body. To attempt to give a dif-
ferential diagnosis of headache with treatment would involve
a complete knowledge of all phases of medicine. One volume,
as one can readily see, would be quite inadequate. The intro-
duction deals with the neurophysiology, etiology, analysts of
causal factors and discussion, including history and method,
for relief of pain. This part in itself, although superficial, is
fairly well written. Opium is mentioned as the most impor-
tant analgesic, a statement with which the reviewer would not
agree. The rest of the book deals with diseases causing head-
ache and their treatment. This is arranged alphabetically
instead of in order of their importance. Such a common con-
dition as sinus disease is given two pages and so is the rare
condition actinomycosis. Brain tumor is said to be a common
disease, which is an erroneous statement; opium derivatives
are prescribed, which are actually contraindicated in most

craniocerebral diseases and injuries. Functional disturbances
are erroneously handled only with drugs. Although the book
has a few good prescriptions, the reviewer can see no value
for even the layman and certainly not for the practitioner or
specialist.

*

Index-Catalogue of the Library of the Surgeon General's Office, United
States Army (Army Medical Library). Authors and Subjects. Fourth
Scries. Yol. IV : Daae-Dztonara. [Including} Specimen Pages from a
Bio-Bibllograpliy of XVI. Century Medical Authors [and a] First Addi-
tion to the Reference List of Congresses. Cloth. Price. $2. Pp. 750.
Washington, D. C. : Supt. of Doc., Government Printing Office, 1939.

The fourth volume of the fourth series of the Index Cata-
logue of the Surgeon-General’s Office covers the letter D.
The Surgeon-General’s Library now contains approximately
409,223 volumes, 377 pamphlets and almost 200,000 theses.
About 18,000 new items are added to the library each year.
Recently the subscriptions of the library have been extended
by some 200 new medical journals, of which approximately
SO per cent are South American and IS per cent from soviet
Russia. This work has long been known as a competent index
to the material that it covers. In the current issue the head-
ings dementia, dentistry, digestive tract, disability and drugs
as well as dermatitis, diabetes, diarrhea and diet indicate the
importance of the letter D in any medical classification.

Pratsi y material! pershogo Kharkivskogo Derzhavnogo Medichnogo
Institutu. Vldpovldaluiy redakior: A Gasparyan. Vlpusk X: Organo-
gumoralna regulyatstya i aktlvnt metodi Ukuvannya. Chastina 1 :
Giperatsldni gastriti. [Works and Materials of First State Medical Insti-
tute of Kharkov. Volume X: Organohumoral Regulation and Active
Methods of Treatment. Part 1 : Hyperacid Gastritis.] Cloth. Price,
5 krb. Pp. I2S, with Illustrations. Kiev: Derzhavne medtehne vldav-
nitstvo, I93S.

This small volume of papers from the department of internal
medicine headed by Prof. A. P. Korkhov of Kiev deals with
acid gastritis. Korkhov develops the thesis that a number of
diseases of the liver, stomach, duodenum and biliary tracts
have for their basis a shift to acidosis in the blood and tissues.
He therefore advocates in the treatment of acid gastritis and
gastric ulceration, besides the rest and the diet, alkalization of
the organism by administration of sodium bicarbonate and
magnesium carbonate in the proportion of 4 ; 1 based on con-
sideration of the determined physicochemical indexes of the
urine, the blood and the gastric juice. The text is in Ukrainian,
with a summary in Russian and in French.

A Survey of Child Psychiatry Contributed by Contemporary British
Authorities. Edited on behalf of the Child Guidance Council by R. C«.
Gordon, M.D., D.Sc., F.R.C.P., Medical Director Child Guidance Council.
Cloth. Price, $3.50. Pp. 278. New York & London: Oxford University
Press, 1939.

Here a number of prominent British writers discuss child
psychiatry under the special headings of physical illness, mental
illness, sociologic aspects and special syndromes. The latter
concern chiefly enuresis, stammering, sleep disorders, tics and
sexual difficulties. A book of this type indicates how far we
have advanced in our study of the child since the leaders of
medical and social science began to give these problems special
attention. It is interesting to know that the Commonwealth
Fund of America aided in setting up a demonstration clinic
in London and was really responsible for introducing the whole
field of child guidance into Great Britain. The competent
articles here presented are an indication of the great advance-
ment that has been made.

Evaluation of the industrial Hygiene Problems of Illinois. Prepared
by Division of Industrial Hygiene. State of Illinois, Department of Public
Health, A. C. Baxter. M.D., Director. Paper. Pp. 23S. Chicago Illi-
nois, 1939.

A series of industrial hygiene surveys have been conducted
by divisions of industrial hygiene in state health departments
operating under plans and instructions originally devised by
the United States Public Health Service. As a result the
publications of the individual bureaus of industrial hygiene
take on aspects of uniformity which, in the event of subsequent
compilations on a countrywide basis, will provide data of
inestimable value. Even if such were not the case, a review
of the industrial hygiene problem in Illinois because of the
variety of its manufacturing processes takes on aspects of

1908

Jour, A, M. a
N ov. 18 , 1535

BUREAU OF LEGAL MEDICINE AND LEGISLATION

importance which transcend mere local interest. In this instance
the great number of tables which list the major exposures of
all the principal occupations occurring in the state and the
percentage of workers exposed to specified materials in those
occupations make it in many respects the most useful of the
state reports yet published. The compilers of this i , eport con-
sider it merely a statistical presentation. It is likely that a
future publication will present an industrial hygiene program
for the state based on this preliminary fact finding investigation.

The International Medical Annual: A Year Book of Treatment and
Practitioner's Index. Edited by H. Letlieby Tidy, M.A., M.D., F.R.C.P.,
and A. Rendle Short, M.D., B.S., B.Sc. Fifty-Seventh Year, 1939. Cloth.
Price, $0. Pp. 602, with 196 illustrations. Baltimore: William Wood
& Company, 1939.

This volume is now in its fifty-seventh year. A considerable
number of British physicians cooperate in producing the book,
which resembles the American Year Book series except for
the fact that here everything is in one volume. There is an
extensive index and the book is beautifully illustrated. Each
of the articles concerned is supplemented with a suitable bibli-
ography. Practically all the articles concern papers published
during 1937 and 1938.

Gastrointestinal Dysfunction. By Barton Arthur Rhinehart, A.B., M.D.,
Associate Professor of Roentgenology, University of Arkansas School of
Medicine, Little Rock. Cloth. Price, $G. pp. 311, with 48 plates. Little
Rock, Arkansas: Central Printing Company, 1939.

This is a comprehensive title, but the student or physician
who hopes to discover in this volume a comprehensive treatise
dealing in detail with the many and varied types of functional
disorders of the digestive tract will meet with disappointment.
It is not a textbook. The author states on the flyleaf : “This
book is dedicated to the proposition that nutritional deficiencies
cause the majority of the gastrointestinal disorders of civili-
zation” and he attempts to promulgate this highly debatable
theory by assembling a great and extremely heterogeneous mass
of material quoted from the writings of clinicians, investi-
gators in the field of metabolism and others. The author is
himself a roentgenologist. It is unfortunate that the equip-
ment he was able to bring to his task did not include a
requisite fundamental knowledge of disorders of the gastro-
intestinal tract.

Richtlinien praktischer Orthopadie. Yon Dr. Albert Lorenz. Taper.
Price, 15 marks. Pp. 464, with 123 Illustrations. Vienna : Franz
Deuticke, 1939.

The author, who apologizes for the similarity of his name
to that of the father of German orthopedics, Adolf Lorenz,
proposes his book for the use of specialists. He attempts to
present only material which he considers of proved value ;
etiology and unusual symptomatology are handled more briefly
than therapy and surgery; scientific experiments are given
secondary consideration to practical experience and the gen-
eral trend is conservative. The subject matter covers the
complete category of practical orthopedic problems and their
treatment. The fracture problem is confined to a discussion
of fractures of the neck of the femur. This volume serves as
a good compilation of current ideas in orthopedics. The author
quotes freely from the American literature throughout the
book, a large portion of which was written in New York.
Although the material presents little originality, the discus-
sions are adequate.

Arthritis in Women: A Clinical Survey with Notes and Statistics from
Representatives ot Committees on Rheumatism in Various Countries, and
a Statement on the "Campaign Against Rheumatism, Retrospect and
Outlook” (1935). Also a Suggestion for Setting up Rest Houses for
Rheumatoid Arthritis. By B. Fortescue Fox. M.D., F.R.C.P., F.B.Met.
Soc President of the International League against Rheumatism.
Founded on a Lecture Delivered at the Institute of Hygiene, London.
April. 1936. Paper, Trice, 2s. Gd. Pp. 35. London: II. K. Lewis &
Co.. Ltd.. 193C.

The clinical course of arthritis in women is described. The
material presented is accurate and wei! developed, but one
would expect a great deal more from the title of the pamphlet.
The pathology of arthritis is barely mentioned. The ideas
of rest homes and spa treatments are not new but deserve
emphasis at this time.

Trudy Stalmgradskogo Gosudarstvennogo Meditsinskogo Instltuta. Ton 1
Pod redaktsiey A. I. Bernshteyna, S. X. Kasatkina 1 A. Ya. l'jula
[Works of Stalingrad Medical Institute. Volume I.J Clolh. ]>n
with illustrations. Stalingrad : Obiastnoe knigolzdatelstvo, 3939 .

The volume consists of a monograph on the development of
sesamoid bones in man and a medley of unrelated subject-.
It presents little of interest to physicians and does not leal
itself to review.

The Story of a Baby. By Marie Hall Ets. Cloth. Trice, ?2.50. I'p.
63, with illustrations by the author. New York : Viking Press, 1931,

At the Century of Progress Exposition in Chicago in 1931
and 1934 one of the items of greatest interest was the exhibit
of human embryos. In this beautiful book the author has
redrawn the embryo and supplies a text printed in large type.
She describes succinctly and beautifully the development of
the baby. Many a parent will find a book of this type exceed-
ingly useful in telling the story of childbirth to children oi
various ages.

English-German and German-English Medical Dictionary. Pari I:
English-German. Englisch-Deutsches medizinisches Worterbuch. By Adal-
bert Springer. Fiftli edition. Cloth. Price, 6 marks. Pp. 201. Vlenm:
Franz Deuticke, 1939.

This little medical dictionary is useful as far as it goes but
omits a considerable number of words which might frequently
need to be consulted, such as calibration, arrhythmia, fibrosis,
ambulatory and sedation. The book is indicative of the rela-
tive ineffectiveness of any kind of dictionary which is not truly
inclusive.

The Genuine Works of Hippocrates. Translated from the Greek Jr
Francis Adams, LL.D. With an Introduction by Emerson Crosby KyU,
M.D. Cloth. Price, $3. Pp. 384. Baltimore : Williams & Wilkins too-
pany, 1939.

This translation of Hippocrates has been reprinted mam,
many times, and there continues to be a demand for it. Jbc
present edition is put out in good paper, with a suitable burn-
ing, and has an index.

Bureau of Legal Medicine
and Legislation

MEDICOLEGAL ABSTRACTS

Silicosis: Death of Employee Attributed to Failure
of Employer to Provide Safe Place of Work. The p
tiff sued the defendant corporation to recover *»"j 5 es
the death of her husband. She alleged that he die
silicosis, contracted as a result of the failure of the e c ^
to provide him with a reasonably safe place in which 1 ° '
The trial court gave judgment for the plaintiff and the
dant appealed to the Supreme Court of Pennsylvania. JS

The plaintiff’s husband was employed from BJ-M to .

an operator of a segment grinder, used for polishing
or pottery products manufactured by the defendant. at .

her 1935 he was admitted to a state sanatorium for < ’ ^

ment of tuberculosis and remained there until he di«. .
1936. The plaintiff contended that the defendant «'< ^

vide the grinder with an adequate hood and a su o
such as a suction fan and pipe, for carrying a " a} . . f rc;
Sbe charged that excessive quantities of dust conta » ^
;i!ica were released into the atmosphere about the
hat as a result of inhaling this silica-laden air °' c ‘ j ,‘^,2
>f years her husband contracted silicosis, which b •
he' tuberculous condition causing his death. I _ IC ^jr

vas negligent, she further contended because it failca ' ‘ f i!/
he employee with a dust mask of the charade - , ,

vorn by operators of such grinding machines. •’ v ;,«.

he plaintiff, the dust hazard arose because the dc ji/.;

3 ted the provisions of a Pennsylvania act pas> •
equiring that “The owner or person in charge 0 a .
ishment where machinery is used shall provide - - -

ins of sufficient power, or other sufficient device.- - ■ ■
he purpose of carrying off poisonous fumes an F

Volume 313
Number 21

BUREAU OF LEGAL MEDICINE AND LEGISLATION

1909

dust from emery-wheels, grind-stones and other machinery
creating dust.” The plaintiff’s evidence went to show that,
although an exhaust fan was installed at the machine which
her husband operated, it was not of sufficient power to carry
off the dust produced; that the mechanism of the fan was not
kept in working condition, and that the defendant failed to
warn the employee of the dangers to which he was subjected
in breathing the dust.

The defendant denied that the plaintiff’s husband died of
silicosis, claiming that the cause of his death was pulmonary
tuberculosis contracted from causes having no relation to the
conditions of his employment. It claimed that there was not
a sufficient amount of free silica in the atmosphere about the
grinder to cause silicosis. It further contended that it com-
plied with the provisions of the Act of 1905 by attaching to
the machine a dust-removal appliance of the best type available
and in general use throughout the industry, that it provided
the employee with a mask for his use but that he neglected
to use it and, finally, that the employee was guilty of con-
tributory negligence.

The disease to which the plaintiff attributed her husband’s
death, said the Supreme Court, was occupational and therefore
was not compensable at the time under the workmen’s com-
pensation act of Pennsylvania. The real question before
the court, therefore, was whether the defendant furnished the
deceased a reasonably safe place to work as measured by the
requirements of the Act of 1905. The provisions of that act
are mandatory, the court pointed out, and proof that the
employer has failed to comply with the duties imposed thereby
and that an employee, without negligence on his part, has
been injured as a result of such failure constitutes negligence,
rendering the employer liable for the harm so caused. While
the plaintiff admitted that there was a cover over the wheel
and that a suction fan was installed by the defendant, it was
denied that they were sufficient to eliminate the accumulation
of dust in the atmosphere. It was not disputed by the defen-
dant that the fan and cover were inadequate to carry away
the dust about the grinding machine. The defendant urged,
however, that it was not an insurer of the employee working
at a dangerous piece of machinery and that it performed its
full duty under the statute when the preventive devices which
it adopted were of the kind generally approved and in use in
like plants throughout the country. But, said the court, merely
because the particular device employed was similar to that
“generally approved and customarily used” in the industry of
itself would not exonerate the defendant of the charge of
negligence. While the custom or practice prevailing in a
particular business in the use of methods, machinery and
appliances is a most important factor in determining the ques-
tion of negligence, ultimately it is for the jury to ascertain
whether under all the circumstances the defendant was neg-
ligent. And certainly ordinary usage in disregard of a statu-
tory duty cannot relieve the defendant of liability for a failure
to respond to the legislative mandate. Whether or not the
defendant in the present case was negligent presented a ques-
tion for the jury to decide, and its finding for the plaintiff,
the court said, compels the conclusion that the device used by
the defendant was insufficient. An ineffective and feeble device
is no more a fulfilment of the legislative demand than no device
at all. The shadow of compliance will not be accepted for the
substance of the statutory requirement.

There was some conflict in the evidence as to whether the
death of the employee was caused by silicosis or by pulmonary
tuberculosis. He inhaled a vast quantity of the dust particles
in consequence of his constant exposure to them. The testi-
mony was at variance on the question whether the atmosphere
contained free silica in sufficient quantities to cause silicosis.
The plaintiff produced evidence to the effect that silicosis could
result from the constant inhalation of dust particles contain-
ing even a minute quantity of free silica. Experts testified
that an autopsy disclosed the presence of “gritty” substance,
scar tissue and “nodules” in the decedent’s lungs, indicating
that he suffered from silicosis. Other “nodules” were found
pointing to a tuberculous as well as a combined tuberculous
and silicotic condition. In the light of such testimony, the
court said, it cannot be said that the jury’s determination of
this question is not supported by the record.

Ordinarily available in master-servant cases, the defense of
assumption of risk is not permissible where the employee is
injured through the failure of the employer to comply with
a legislative requirement such as contained in the Act of
Pennsylvania of 1905. Although the employee in the present
case may have been aware of the presence of the dust in the
factory, it is, the court said, extremely doubtful that he was
conscious of the real risk involved, the danger of the contrac-
tion of silicosis. Such a degree of scientific knowledge is not
to be attributed to an ordinary factory employee. The defen-
dant contended that the employee was negligent in failing to
use the dust mask with which he was provided. The plain-
tiff’s witnesses testified, however, that no workable masks were
supplied, since those furnished were unfit for use. Here again
the question of contributory negligence was one for the jury
to decide, and the Supreme Court could find no reason to
disturb the finding of the jury with respect to this matter.

After a thorough review of the record, the Supreme Court
of Pennsylvania affirmed the judgment of the trial court for
the plaintiff . — Price v. Nciv Castle Refractories Co. (Pa.), 3
A. (2d) 41S.

Optometry: Cooperative Arrangement Between Opti-
cal Company and Physicians as Practice of Optometry.
— In this suit, the State of Iowa on relation of the Commis-
sioner of Health sought to enjoin the defendants from prac-
ticing optometry without a license. The trial court issued the
injunction and the defendants appealed to the Supreme Court
of Iowa.

The state undertook to sustain the injunction on the ground
that the arrangement entered into between the defendants and
the physicians constituted an employment agreement and that
the employment of one legally authorized to practice optometry
in the state of Iowa by an unlicensed person or corporation
is prohibited by statute. The business of the defendants con-
sisted of selling eyeglasses or spectacles by filling prescriptions
prescribed by authorized persons and selling optical merchan-
dise. They were opticians. Their practice was to rent an
office consisting of one or more rooms adjacent to the rooms
in which they carried on their business and to arrange with
a licensed physician to occupy such rooms and practice optom-
etry. The defendants paid the rent, light, heat and telephone
bills and furnished all the equipment used by the physician
in examining and testing eyes. The examination fees charged
by the physician, which ranged from $1 to §2, belonged to
him. None of the earnings of the physician belonged to or
was paid to the defendants. The defendants, however, guar-
anteed the physician that his earnings would be §40 a week.
If the earnings were under that sum they would pay him the
difference. While there was some testimony to the effect that
the physician was not obligated to send patients to whom pre-
scriptions had been given to the defendants, the court was
convinced that the real arrangement • was that the defendants
would send all persons who came to their establishment with-
out a prescription, and who desired glasses, to the physician
and that the physician was to direct his patient to the defen-
dants for the purpose of having his prescription filled.

In the opinion of the court, the state failed to establish its
contention that the relationship of employer and employee
existed between the defendants and the physicians. No witness
testified that the defendants under the arrangement had the
right to control or influence a physician in making the exami-
nation, and the test of the employer-employee relation, the
court continued, is the right of the employer to exercise con-
trol of the details and method of performing the work. After
reviewing the facts in this case, the court was convinced that
the defendants did not have that right under the arrangement
it bad with physicians. The physicians, all of whom had prac-
ticed prior to the arrangement, were not performing the busi-
ness of the defendants but were carrying on their own business
of optometry' under a reciprocal arrangement with the defen-
dants for the mutual financial benefit of both parties. When
a patient came to consult one of these physicians there was
the personal relationship of patient and physician between
them. The physicians, in making the refraction, represented
the patient and not the defendants. The record showed that
the business of the defendants was materially increased by the

1910

SOCIETY PROCEEDINGS

Joua. A. M. A.
Nov. 18, 1939

arrangement. The court was satisfied after a careful reading
of the record that the defendants did not coerce or influence
the physicians relative to prescriptions. The profession of the
physicians and the business of the defendants were separate
and each operated independently of the other.

The defendants urged that the employment of one legally
authorized to practice optometry in Iowa is not forbidden by
statute, and even if the arrangement did constitute an employ-
ment contract it did not constitute the practice of optometry
by the defendants in violation of the laws of the state. With
this contention, however, the Supreme Court disagreed and in
doing so reaffirmed the interpretation placed on Iowa laws
and the principles announced in two previous cases, State v.
Kindy Optical Company, 216 Iowa 1157, 248 N. W. 332, and
State v. Bailey Dental Company, 211 Iowa 781, 234 N W
260.

The decree of the trial court enjoining the defendants from
practicing optometry was therefore reversed and the case
remanded. — State cx rcl. Bierring, Commissioner of Public
Health, v. Rithoh ct al. (Iozva), 283 N. IV. 268.

Workmen’s Compensation Acts: Compensability of
Hernia. — The employee filed a claim for compensation under
the workmen’s compensation act of South Carolina, alleging
that he had suffered a compensable hernia during the course of
his employment with the defendant company. The industrial
commission disallowed the claim, which action was affirmed by
the common pleas circuit court of Spartanburg County. The
employee then appealed to the Supreme Court of South Carolina.

The workmen’s compensation act of South Carolina provides
that in all claims for hernia alleged to have resulted from
accidental injury sustained in the course of employment it must
be definitely proved that there was an injury resulting in hernia;
that the hernia appeared suddenly; that the hernia or rupture
immediately followed the accident; that it did not exist prior
to the accident for which compensation is claimed, and that it
was accompanied by pain. The employee had been in the employ
of the defendant company as a dispenser in one of its dye
rooms continuously from February 1937 until July 14, 1937, the
date he claimed to have suffered his injury. The employee’s
duties included bringing drums of hydrosol, weighing between
500 and 600 pounds, from a storeroom upstairs, inserting a
spigot in the head of the drum and placing the drum on a low
wooden rack. On the date of the accident, the employee, assisted
by a fellow employee, was engaged in lifting a full drum of
hydrosol on to the wooden rack when the spigot in the head
of the drum became entangled with the framework of the rack
and the drum slipped, jerking the employee and throwing a
heavy strain on him for two or three minutes. With the assis-
tance of a third employee, the drum was finally, after about
ten minutes, placed in position. The employee continued work-
ing at lighter tasks for the remainder of that day. He stated
that he was not conscious of any pain during the struggle with
the metal drum, but after the lifting was over he said he "felt
a tired and let down sensation.” The next morning, July 15,
when he got out of bed, he experienced a sharp pain, which
continued that day and the following day, both of which days,
however, he continued to work at light tasks. On July 17 he
consulted a physician who diagnosed his trouble as inguinal
hernia. On the succeeding morning he consulted the company
physician, who made the same diagnosis and instructed him to
quit work, which he did. The employee testified that he had
no hernia or evidence of hernia previous to this accidental injury.

The employee had been operated on in the hernial region at
the age of 7 years for an undescended testicle and was dis-
charged as cured. The surgeon who performed this operation
testified that there was no indication of hernia at that time.
The company physician testified that the incision in the abdomi-
nal wall for the operation in question was at approximately the
same place as for a hernia and that he found a scar in that
region on the employee. He said with reference to that opera-
tion that it might or might not have caused a weakness of the
tissues in that area and that a conclusion on that point could
not he definitelv stated. He testified, too, that the employee's
hernia might have existed for several years but that there was

no way to determine from an examination when it had its
inception or when the rupture occurred.

The industrial commission found that the hernia was con-
genital in origin and that it was caused by a preexisting weak-
ness of the tissue. The Supreme Court, however, could find
no evidence in the record to warrant that finding or a finding
that the employee suffered from a hernia at any time prior to
the accident. The commission found, too, that .the employee
felt no pain at the time of the accident, and the court thought
that there was ample testimony in the record to support this
finding. The employee repeatedly disclaimed that he felt pain
at the time of the accident. He argued, however, that the
language of the compensation act “that it was accompanied by
pain,” did not mean that pain must be coincident with the acci-
dental injury, but that the appearance of the hernia must be
accompanied by pain. As the court construed the act, however,
the injury and the pain must be referable to a definite time,
place and circumstance, and the pain must accompany the
accidental injury. The court did not feel warranted in ascrib-
ing to the words “tired” and “exhausted” the common sense of
the word “pain.” Nontechnical definitions of “pain,” said the
court, while varying in form of expression, all connote some
degree of present distress or suffering, contradistinguished from
normal fatigue.

The court further thought that the words “suddenly ’ and
“immediately” as used in the act in relation to hernia were
elastic terms, admitting of much variety of definition. The court
did not think that these words should be construed as the equiva-
lent of the word instantaneous. Like other similar absolute
expressions, they were used in the act with less strictness than
the literal meaning requires. To give them their literal signifi-
cation in all cases, regardless of the attendant situations an
circumstances, would, the court said, often defeat meritorious
claims on purely technical grounds. . ,

Because, however, the employee felt no pain at the time o
the accidental injury, the Supreme Court affirmed the ju g
ment of the lower court disallowing the employee s claim or
compensation. — Rudd v. Fairforest Finishing Co. (S. L.J,

S. E. 727.

Medical Services: Liability of County for Emergency
Medical Services Rendered Indigents — A physician, sau
the Supreme Court of Nebraska, not employed by a coun y
may' not recover from the county for services rendered to a
poor person in an emergency when a county physician ias
been duly appointed to care' for the poor, the latter
being able, willing and ready to serve but not consulted,
ignorance of the attending physician of the fact that the cow
had regularly employed a county physician, and thus P™' 1 .|
for the exclusive medical treatment of the poor, wi a '
him nothing. — Miller v. Banner County (Ncl).), 283
206.

Society Proceedings

COMING MEETINGS

American Association for tile Study of Neoplastic Diseases, Balb^o
Dec. 28-30. Dr. Eugene R. Whitmore, 2139 Wyoming Arcnue l
Washington. D. C., Secretary. , , Paul M.

American Society of Anesthetists, Los Angeles, Dec. 14. Dr.

Wood, 745 Fifth Ave., New Vork, Secretary. p r .

American Society of Tropical Medicine, Memphis, Tenn., Nov. zi-- •

E. Harold Hinman, Wilson Dam, Ala., Secretary. _ 0 , .ferial

eastern Section, American Laryngological, Rhinological and B 1 j K .,

Society,- Pittsburgh, .Tan. a. Dr. John R. Simpson, Medical l
Pittsburgh, Chairman. , , . „ n „ n .i 5 . Dr.

Radiological Society of North America. Atlanta, Ga„ R";. J c ccre t.w y.

Donald S. Childs, 607 Medical Arts Bldg., Syracuse, N. ^
society for the Study of Asthma and Allied Conditions, F I P
Dec. 9. Dr. W. C. Spain, 116 East 53d St., New lark, b'm ^

Society of American Bacteriologists New. Haven, Conn.. V ■ - t Madison ,
I. £. Baldwin, Agricultural Hall, Lmversity of Wisconsin.

Wis., Secretary. ... ,,., 4 . Mr. C. P-

and Otologic*^
“5“b-,ow. Doctors

Bldg., Columbia, S. C., Chairman. u r . & A^CT 5

iouthern Surgical Association, Augusta, Ga.. Dec. a /

Ochsner, 1430 Tulane Ave., New Orleans, Secretary. ^ A1Ltrt 11.
Vestem Surgical Association, Los Angeles. Dec. 15 16.

Montgomery, 122 South Michigan Blvd., Chicago. Secret J-

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1912

CURRENT MEDICAL LITERATURE

JOL'R. A. JI. .1
Kov, IS, ]S”,

American Journal of Medical Jurisprudence, Boston

2: 301-336 (Aug.-Sept.) 1939

Barbiturate Poisoning: Review. M. Pijoan, Boston.— p. 301.
Preparation by Attorneys for Medicolegal Trials. J. R. Garner, Atlanta,
Ga.— p. 313.

Problem of Interference with Radio Communication by Electromedical
Apparatus. F. H. Krusen, Rochester, Minn. — p. 315.

Legal Aspects of Radiodontics. A. P. S. Sweet, Rochester N. Y.

p. 323. 7

Medical Jurisprudence: The Medical Witness. A. M. Sho waiter,
Christiansburg, Va. — p. 326.

Medicolegal Problems. A. W. Stearns, Boston. — p. 331.

American J. Obstetrics and Gynecology, St. Louis

38: 371-556 (Sept.) 1939. Partial Index
Studies on Concentrations of Estrogenic and Gonadotropic Hormones in
Serum of Pregnant Women. A. E. Rakoff, Philadelphia.— p. 371.
Growth of Fetus and Infant as Related to Mineral Intake During Preg-
nancy. W. W. Swanson and Vivian lob, Chicago. — p. 382.
Evaluation of Human Vaginal Smear in Relationship to Histology of
Vaginal Mucosa. S. H. Geist and U. J. Salmon, New York. — p. 392.
Changes in Uterine and Placental Circulations During Different Stages
of Pregnancy. P. J. Kearns, Montreal.— p. 400.

‘Complications Associated with Excessive Development of Human Fetus.

A. K. Koff and Edith L. Potter, Chicago. — p. 412.

Factor of Anesthesia in Pathogenesis of Asphyxia Neonatorum. M.

Rosenfekl and F. F. Snyder, Baltimore. — p. 424,

Certain Laboratory Findings and Interpretations in Eclampsia. L. C.
Chesley, Jersey City, N. J. — p. 430.

♦Bacillus Welchii Infections in Pregnancy: Review of Literature and
Report of Seventeen Cases. P. B. Russell Jr. and M. J. Roach,
Memphis, Tenn. — p. 437.

Prevention of Tuberculosis Begins Before Birth: Tuberculin Testing
During Pregnancy as Fertile Field for Case Finding and Prevention.
C. L. Ianne and J. C. Muir, San Jose, Calif.— p. 44S.

Treatment of Menopause with Estradiol Dipropionate. E. M. Dorr and
R. R. Greene, Chicago. — p. 458.

Surgical Treatment of Bilateral Polycystic Ovaries— Amenorrhea and
Sterility. I. F. Stein and M. R. Cohen, Chicago. — -p. 465.

Vitamin A Deficiencies in Pregnancy: Case Reports on Two Unusually
Severe Examples. W. A. Ricketts, Dayton, Ohio. — p. 484.

Changes of Urinary Tract Associated with Prolapse of Uterus. A. J.

Wallingford, Albany, N. Y. — p. 489.

Study of Cause of Hydramnios. J. R. Goodall, G. Morgan and R. H.
Power, Montreal. — p. 494.

Concentration of Serum Sulfate During Pregnancy and Preeclamptic
Toxemia. A. B. Hunt and E. G. Wakefield, Rochester, Mum. — -
p. 498.

Hidradenoma of Vulva. D. Rothman and S. H. Gray, St. Louis. —
p. 509.

Carcinoma of Cervix in a Girl of 19 Years. II. Charache, Brooklyn.
— p. 518.

Simple Technic for Craniotomy on High Aftercoming Head. G. W.
Gustafson, Indianapolis. — p. 522.

Dietary Requirements in Pregnancy. W. J. Dicckmann and W. W.
Swanson, Chicago. — p. 523.

Estrogenic and Gonadotropic Hormones in Pregnant
Women.— Rakoff studied a simplified improved technic for the
titration of estrogenic and gonadotropic hormones in the serum
of pregnant women, which proved to be useful in following the
concentrations of these hormones in normal gestation and in a
number of the complications of pregnancy, especially the tox-
emias and abortion. The method requires from 20 to 50 cc.
of blood. Estrogenic hormone was assayed by a modification
of the Fluhmami technic. Gonadotropic hormone was titrated
by a modification of the Aschheim-Zondek test. Whole serums
were used as the test solutions and mice as the test animals.

It was observed that the estrogen and gonadotropic hormone
values on unextracted serums are much higher than those
obtained on extracted specimens. Serum titrations repeated at
frequent intervals gave much more consistent results than those
obtained from urinary assays. A total of 162 serum titrations
were conducted on forty normal pregnant women in various
periods of gestation, and graphs were prepared showing the
normal range and average values from the fourth week of
gestation to term. Serum titrations conducted on a group of
-twenty-two patients with toxemias of late pregnancy usually
showed abnormally high gonadotropic hormone and low estrogen
values. The severity of the toxemia did not appear to be
directly related to the degree of abnormality in gonadotropic
hormone and estrogen values, except that those patients with
marked edema showed unusually high gonadotropic hormone
readings in the serum. Improvement in the clinical condition
was generally associated with a return of the estrogen and
gonadotropic hormone values to the normal range. Studies on
three patients in whom titrations were available before the onset
of toxemia showed in two instances high gonadotropic hormone
values preceding the onset of toxemia by several weeks. These
were later followed by low estrogen values. There was gener-

ally a reciprocal relationship between the rise and fall of eslrv
gen and gonadotropic hormone. Three patients with nephrite
toxemia showed high gonadotropic hormone and usually Ion
estrogen values during the period of clinical toxemia, How
ever, one patient with a glomerulonephritis, who had a history
of nephritic toxemia and eclampsia in the previous pregnancy
showed normal values for estrogen and gonadotropic hormones,
except during two periods associated with signs and symptoms
of toxemia. When intra-uterine fetal death was suspected,
repeated examinations of the serum for gonadotropic hormone
furnished a better means of determining the fate of the f '
than did tiie Friedman test. With the author’s technic v
the gonadotropic hormone content of the serum fell to 50 mi
units per hundred cubic centimeters or less the Friedman
usually became negative. One patient with pernicious nai
and vomiting had a low gonadotropic hormone content of
serum, while the serum estrogen was normal.

Complications from Excessive Development of Fe 1
— Koff and Potter say that, provided the pelvis is not contrac
it is rare for infants weighing less than 4,500 Gm. to give
to dystocia due to size. It has been found, however, I
delivery of an infant weighing more than 4,500 Gm. is !
quently attended with serious difficulties. Investigating the ii
deuce of the birth of excessively developed fetuses, the auth
found that among 20,219 births at the Chicago Lying-in H
pital 195, or 0.94 per cent, of the infants weighed more ll
4,500 Gm. Since the size of the fetus is largely dependent
the length of gestation, the authors investigated the duration
pregnancy (calculated from the first day of the last menstr
period) in the cases on which this study is based. The aver!
length of gestation of the women with excessively deyclo;
fetuses was 288 days. This figure when compared with I
figures for normal pregnancy demonstrates the direct relate
ship between prolongation of pregnancy and excessive devek
ment of the fetus. However, size of the parents, multipart
advancing age, or diabetes in the mother may be contributi
factors in producing excessive fetal development. Labor preset
a greater hazard for both mother and offspring when ovf
development of the fetus has occurred. The necessity f
operative intervention is increased and the incidence of tox cm
of postpartum hemorrhage, of maternal morbidity and of fet
mortality is -definitely higher than when the fetus is sina £
Accurate estimation of fetal size prior to delivery with cons
quent modification of the technic employed will decrease mate
nal complications and fetal mortality.

Bacillus Welchii Infections in Pregnancy. — Russell a "

Roach report their experiences in seventeen cases

of Bacilli

welchii infections occurring in their clinic. They differen a
the following types: (1) local gas gangrene, (2) . e JuP">’ se ™
the uterine wall and (3) gas sepsis. They subdivide the •
type into (a) general sepsis and (fc) metastatic gas
After discussing these various types they give their at
to the differential diagnosis, pointing out that the P
examination does not give much information in Bacil us v ^
infections because the predominating symptom is tended -
the lower part of the abdomen, uterus, liver, kidneys an -
and all these may be tender in a simple case of abortion.^^
heart cycle and pulse rate are again of no value. ? rl , y
is not found in the mild cases, but it is found in cases in
there is a general sepsis with or without emphyse ^

physometra. Cyanosis is one of the common symptoms ^

accompany Bacillus welchii infection but it is irnpor ^
differentiate between that resulting from sulfamiami e

or that which is seen in the later stages of eclampsia. „

lore severe cases v-
infection. The oo

is another symptom which occurs in the more severe case

not in those which are classified as local
of the patient suffering from a Bacillus welchii '. n ‘ cc ,j..
much different from that associated with, typhoid. c ;j; c <
also is similar; however, the patient suffering. from jj...

welchii infection has not the facies of anxiety o ( ,.,

patient with typhoid. The temperature is usually lower ^
former disease than in the latter, and the patient.
a Bacillus welchii infection has a cold and clammy s n p3 lkrk
distinction to the hot and moist skin of the tjpi f[r;:
Incontinence of urine and feces is a rather commo } j 5 , ;
in severe infections of Bacillus welchii. The exa b

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1914

CURRENT MEDICAL LITERATURE

Joub. A. 31. A.
Xov. 18, 1939

his fingers or in any way he could without comment on or
correction of his manners. The tray was taken away when
he had definitely stopped eating, which was usually after from
twenty to twenty-five minutes. The foods offered were weighed
before and after the infant’s selection. There were no failures
of infants to manage their own diets ; all had hearty appetites ;
all throve. Constipation was unknown among them and laxa-
tives were never used or needed. Except in the presence of
parenteral infection, there was no vomiting or diarrhea. Colds
were usually of the mild three day type without complications
of any kind. There were a few cases of tonsillitis but no
serious illness among the children in the six years. The only
epidemic disease to visit the nursery was acute glandular fever
of Pfeiffer, with which all the children in the nursery came
down like ninepins on the same day. During this epidemic
t raj’s were served as usual. This led to the observation that,
just as loss of appetite often precedes by twenty-four to forty-
eight hours every other discoverable sign and symptom of acute
infection, so return of appetite precedes by twelve to twenty-
four hours all other signs of convalescence, occurring when
fever is still high and enabling the observer to predict its fall
correctly. This eating of a hearty meal when fever is still
high is often not in evidence when children are put on restricted
diets during such illnesses. The correctness of the observation
has been confirmed in the Children’s Memorial Hospital, where
a modification of the self-selective method of feeding prevails.
During convalescence unusually large amounts of raw beef,
carrots and beets were eaten. The demand for increased
amounts of raw beef and carrots can be easily accounted for
but for the beets; it may be possible that they furnish an
antianemic substance (iron?). Beets were eaten by all in much
larger quantities in the first six months or year after weaning
than ever again save after colds and acute glandular fever.
Whether appetite was or was not a competent guide to an
adequate diet was checked by diets with nutritional laws and
standards and it was found that the infants either approxi-
mated or exceeded the average daily calory requirement.
There was a moderate preponderance of the potentially alkaline
in every six months period in fourteen infants. The other
one was observed for only six months. The food list was
confined to natural, unprocessed and unpurified foods, without
made dishes of any sort, and it reproduced to a large extent
the conditions under which primitive peoples in many parts of
the world have been shown to have had scientifically sound
diets and excellent nutrition. By providing conditions under
which appetite could function freely and beneficently the
experiment resolved the modern conflict between appetite and
nutritional requirements. It eliminated anorexia and the eating
problems that are the plague of feeding by the dosage method.

Delaware State Medical Journal, Wilmington

11 : 191-210 (Sept.) 1939

Modern Trends in Psychiatric Therapy. K. E. Appel and J. A.
Flaherty, Philadelphia. — p. 191.

Psychoneuroses in Relation to General Medicine. A. Gordon, Phila-
delphia. — p. 197.

Florida Medical Association Journal, Jacksonville

36: 109-160 (Sept.) 1939

Some Observations on Treatment of Pellagra. J. F. Wilson, Jackson-
ville. — p. 123.

Thyroid and Adrenal Glands as Factors in Control of Fever: Heat
Regulation and Climate. N. L, Spengler, Tampa, p. 1-6.

Myocardial Infarction; Electrocardiographic Changes and Necropsy
Findings. J. W. Annis, Lakeland. — p. 131. ^

Surgical Conditions Caused by Intestinal Parasites. T. H. Bates, Lake

Abdominal Foreign Body: Case Report. J. K. McShane, Miami.

Erythematous Lupus in Negro Youths: Case Report. J. L. Kirby-Smith,
Jacksonville. — p. 141.

Georgia Medical Association Journal, Atlanta

2S: 347-390 (Sept.) 1939

Some Phases of Medical Economics. H. H. Shoulders. Nashville, Tenn.

The Social and Economic Value of Health. R. F. Maddox, Atlanta.

Advances' in Recognition and Treatment of Nutritional Disturbances.
V. P. Sydenstricker. Augusta.— p. 359.

Effect of Nervous Influences on Digestion. E. F. \\ ahl, Tcomasviile.

Prf4ic 5 ncam. Progress. S. C. Rutland, LaGrnn-e.— p. 367.

Journal of Bacteriology, Baltimore

38: 249-354 (Sept.) 1939

Studies on Life and Death of Bacteria; I. Senescent Phase in Apr;
Cultures and Probable Mechanisms Involved. E. A. Steinhaus ard
J. M. Birkeland, Columbus, Ohio. — p. 249.

^Cultural Study of Filamentous Bacteria Obtained from Human Mouth.
B. G. Bibby and G. P. Berry, Rochester, N. Y. — p. 263.

Optimal Temperature for Differentiation of Escherichia Coli from Oth:r
Coliform Bacteria. A. A. Hajna and C. A. Perry, Baltimore.—
p. 275.

Some Growth Factors for Hemolytic Streptococci. D. W. Woolley and
B. L. Hutchings, Madison, Wis. — p. 285.

Growth Factors for Bacteria: VIII. Pantothenic and Nicotinic Acids
as Essential Growth Factors for Lactic and Propionic Acid Badcrit
E. E. Snell, F. M. Strong and W. H. Peterson, Madison, Wk—
p. 293.

Influence of Nicotinic Acid on Glucose Fermentation by Members of
Colon-Typhoid Group of Bacteria. I. J. KHgler and N. Grosowitz,
Jerusalem, Palestine. — p. . 309.

Collodion Sac for Use in Animal Experimentation. A. H. Harris,
Albany, N. Y. — p. 321.

Studies on Mode of Action of Sulfanilamide in Vitro. Julia T. Weld
and Lucy C. Mitchell, New York. — p. 335.

Bacteria Obtained from Mouth. — By the use of anaerobic
methods and of a wide variety of culture mediums, Bibby and
Berry isolated from the mouth many strains of filamentous
bacteria. On the basis of the morphology and the characteris-
tics of growth of the eighty-three strains which were success-
fully carried in subculture, a tentative working division into
seven groups is proposed. Six of these have distinct charac-
teristics. Only two, however, can be identified with organism:
which have been isolated by previous investigators, although
organisms showing some resemblance to a third group hare
been described. Four of the groups of filaments have the
characteristics of the genus Leptotrichia, one of the genus
Fusiformis and one of both genera. Of all the groups, only
one embraced strains all of which were alike in biologic prop-
erties. For these organisms the authors suggest the name
Leptotrichia buccalis because they represent the most common y
isolated of the culturable oral filaments.

Journal of Immunology, Baltimore

37: 179-304 (Sept.) 1939. Partial Index
"Agglutinative Reaction in Relation to Pertussis and to. DolL>?k
Vaccination Against Pertussis, with Description of Aew
J. J. Miller Jr. and Rosalie J. Silverberg, San Franc.sco.-p. w-
New Schick Toxin. E. M. Taylor and P. J. Moloney, Toronto.-P--- -
Complement Fixation and Precipitative Tests in Poliomyelitis. I'
Harrison, Philadelphia.— p. 233. . Frotri-

Studies of Sparing Effect of Lymphocytic Choriomeningitis i o > o(fc
mental Poliomyelitis: I. Effect on Infcctivity of Monkey -
C. Dalldorf, Valhalla, N. V. — p. 245. ewific M

Group Specific Differentiation of Organs of Man: DP e P „
Factors and N Factors in Organs. P. N. Kosyakov and u.
Tribulev, Moscow, Soviet Union. — p. 283. factors of

Effect of Temperature and Drying on M i Factors and i N g ov j !t

Human Blood. P. N. Kosjakov and G. P. Tr.bnlev, Moscon,
Union.- — p. 297. .

Agglutinative Reaction and Pertussis.— Miller an 1
verberg describe a new technic of tube agg f or

Haemophilus pertussis. Mechanical rocking ot , , u .. ntv .f 0 ur
two hours at room temperature is sufficient. A srna ||

hour growth of Haemophilus pertussis is used. iron

amount of serum required (0.1 cc.) may be collecte - ]() l

tube by ear or toe puncture. The serums from
children with negative histories for pertussis produce
tination, but in children less than 5 years of age “than
tinative titers in the positive serums were no ^

1:20. The serums from 161 of 164 children wb ,
injected with phase I Haemophilus pertussis vacctn P
agglutination. The titers of the positive serums w . ny
eral high, usually 1 : 160 or higher. Second and oe® up
third specimens of serum were obtained at two j 3

to thirty-eight months after vaccination and these 0 f

tendency to maintain their titer. The serums from t
seventeen children with pertussis produced age'ut'nation fncd
time during the disease. The titer of agglutination at ^
was extremely variable and seldom more than 1 ‘ d r ’ ccen tly
serums from thirty-six of sixty-seven children uho rctcjtin; r
recovered from pertussis produced agglutination. U ^
after intervals of several months d _ ative though

were observed. Many serums had become nc*a five

yccasional serums produced agglutination up to
months after the onset of the disease.

Volume 113
Number 21

CURRENT MEDICAL LITERATURE

1915

Medical Annals of District of Columbia, Washington

S: 255-284 (Sept.) 1939

-Phenolphlhalein Eruptions: Report of Three Cases. I. L. Sandler,
Washington. — p. 255.

General Considerations and Differential Diagnosis of Jaundice Depicted
by Cryptograms. \V. M. Yater, Washington. — p. 258.

Surgical Considerations of Jaundice. A, Horwitz, Washington. — p. 261.
Phjsioiogy of Digestion. E. C. Albritton, Washington.— p. 265.
Comparison of Roentgen and Gastroscopic Findings in Diseases of
Stomach. J. F. EHvard, Washington. — p. 269.

Phenolphthalein Eruptions. — Sandier discusses phenol-
phthalein eruptions and reports three such cases, one of which
leads him to believe that phenolphthalein is present in the skin
in the early stage of the eruption. The author finds no refer-
ence to a similar observation in the literature. It has been
stated that except for the ingestion test no other forms of
testing have been evolved which are of value in the diagnosis
or prognosis of existing hypersensitiveness to the drug. The
author shows that the oral administration of a small dose
(0.006S Gm.) of the suspected drug is the best method of
determining the causative agent. In his cases, in about one
hour after its administration, edema of the lips with deep seated
vesicles occurred and the hue in the fixed phenolphthalein
lesions was greatly accentuated.

Michigan State Medical Society Journal, Lansing

38: 837-924 (Oct.) 1939

What Price Depression? R, Sleyster, Wauwatosa, Wis. — p. 853.

Ideals. H. A. Luce, Detroit. — p. 859.

Poliomyelitis. H. B. Rothbart, Detroit. — p. 861.

Survey of Syphilis in Oakland County for 1938. The Committee on
Syphilis of the Oakland County Medical Society. — p. 867.

Our Changing Medical Service. A. H. Miller, Gladstone. — p. 869.

Carbon Monoxide Poisoning. W. D. McNally, Chicago. — p. 871.

Massive Gangrene of Colon Secondary to Acute Appendicitis. V. W.
Jensen, Shelby, — p, S 77.

Two “Liver Deaths” Following Ovariotomy. H. W. Hewitt, Detroit.—
p. 879.

Blood Groups and Their Medicolegal Applications. A. W. Frisch,
Detroit. — p. 881.

Luminal and Postoperative Temperature. B. F. Gariepy, Royal Oak. —
p. S87.

Report of an Isolated Case of Paratyphoid B. F. L. Graubner, Marshall.

— p. 888.

Role of Allergy in Some Dermatoses of Questionable Etiology. H. L.
Keim, Detroit. — p. 888.

Fundamentals of Treatment in Gynecology. H. M. Kirschbaum, Detroit.
— p. 891.

New England Journal of Medicine, Boston

281 : 403-444 (Sept. 14) 1939

Prothrombin and Vitamin K Therapy. J. D. Stewart and G. Margaret
Rourke, Boston. — p. 403.

*Use of Cobra Venom in Relief of Intractable Pain. R. N. Rutherford,
Brookline, Mass. — p. 408.

Practical Psychotherapy with Adolescents: Brief Survey of the Field
for the General Practitioner. D. J. Sullivan and N. B. Flanagan,
Boston. — p. 414.

Bcnno Reinhardt, 1S19-I852: Biographic Study and Contribution to Early
History of Virchows Archiv. G. J. Newerla, Albany, N. Y. — p. 419.
Report on Medical Progress; Physical Therapy. F. P. Lowry, Newton,
Mass. — p. 424.

Cobra Venom for- Intractable Pain. — Rutherford used
cobra venom for the relief of intractable pain in seventeen cases,
generally because of terminal cancer. It is important that the
drug be given intramuscularly, for if it is given subcutaneously
it will cause local redness and tenderness for several days.'
At the beginning of the series, treatment was started with
an injection of 0,5 cc. (V/i mouse units), followed by daily
injections of 1 cc. (5 mouse units). Later the author endeav-
ored to adjust the initial dose to the requirements of the
patient, beginning in some cases with 2 or o cc. (10 or 15
mouse units) and continuing the dosage at that level for from
four to six days or until complete relief was obtained, and
then considerably lowering the dose to a maintenance level.
Eight of the seventeen patients (46 per cent) considered them-
selves completely relieved. Four of the group (24 per cent)
estimated their relief at from 75 to 95 per cent. Three (IS
per cent) estimated their relief at from 50 to 75 per cent. In
only two did the amount of relief fall below 50 per cent. In
other words, nearly 50 per cent of the patients were completely
relieved of pain and in SS per cent the relief was 50 per cent
or more. If there is a response it usually begins on the third
or fourth day of injection, despite the amount used, and is
complete by the sixth or seventh day. The benefits are not

likely to increase after that time, but the relief of pain is
likely to continue at that level, even though the amount of
cobra venom is reduced to a maintenance level, determined by
the patient. The majority of patients were able to maintain
their relief on one ampule every other day or one a day,
although several required two or three a day. There were
no side reactions and there was no evidence that increasing
amounts of the drug were necessary. The drug seemed to act
on pain no matter what its etiology. When relief from pain
is obtained the mental outlook and general health of the
patients are benefited by release from the sharp drag of con-
stant pain. Some patients are able to return to their work
and to become wage earners again. In those who are only
partially helped, the drug makes an excellent basal analgesic
which can be augmented by analgesics that are not habit form-
ing. This avoids the danger of morphine addiction and increas-
ing opiate tolerance. For those patients who are not helped,
intrathecal alcohol injection or chordotomy should be consid-
ered. Since cobra venom can be self administered, it makes
an ideal outpatient treatment or treatment which can easily be
followed by the general practitioner in the nonhospitalized case.
There is no evidence of danger of addiction, increasing tolerance
or toxicity of the drug.

New Jersey Medical Society Journal, Trenton

36: 525-563 (Sept.) 1939

Value of Roentgen Therapy in Acute Subacromial Bursitis. \V. G.

Herrman, Asbury Park. — p. 529.

The Eye in Diabetes. S. Schulsingcr, Newark. — p. 533.

Histology of Radiation Effects in Inflammatory Conditions. R. Pome*
ranz, Newark. — p. 536.

Cystocele. J. W. Davies, New York. — p. 538.

Chronic Paranasal Sinusitis, a Medical Problem. G. H. Lathrope,
Newark. — p. 542.

The Medical Approach to Gallbladder Problem. S. B. Kaplan, Newark.
— p. 550.

New Orleans Medical and Surgical Journal

02: 171-234 (Oct.) 1939

Extra-Uterine Pregnancy. C. P. Gray and C. P. Gray Jr., Monroe,
La. — p. 171.

Management of Urinary Infections in Pregnancy. U. S. Hargrove,
Baton Rouge, La. — p. 176.

The Twisted Nose. \V. R. Metz, New Orleans. — p. 180.

Treatment of Empyema. R. M. Penick Jr., New Orleans, — p. 185.
Some Problems in Surgical Treatment of Thyroid Disease. J. E. Heard,
Shreveport, La. — p. 190.

Cataract. G. M. Hnik, New Orleans. — p. 195.

Mode of Action of X-Rays in Otitis Media. L. L. Titche, Monroe, La.
— p. 203.

Acute Spinal Epidural Abscess: Report of Four Cases. J. O. Weil*
bacchcr Jr., New Orleans.— -p. 208.

Oklahoma State Medical Assn. Journal, McAlester

32: 317-358 (Sept.) 1939

Experiences with- Internal Fixation in Fractures of Hip. C. R. Rountree,
Oklahoma City.— p. 317.

Removal of Nonmagnetic Foreign Bodies from Vitreous; Report of
Case. J. J. Caviness, Oklahoma City.-— p. 326.

Practical Management in Peripheral Vascular Disease. B. E. Mutvey,
Oklahoma City. — p. 330.

Interstitial Radium Treatment of Cancer of Lower Lip. L. K. Chont,
Oklahoma City. — p. 334.

*Usc of Autohemotherapy Reinforced with Artificial Fever in Treatment
of Rheumatic Disease. \V. K. Ishmael, Oklahoma City. — p, 337.

Autohemotherapy and Hyperpyrexia for Rheumatic
Disease. — As an increase in the body temperature is a natural
defense mechanism, it occurred to Ishmael that the artificial
fever may reinforce the reaction of the injected blood (auto-
hemotherapy). Based on this idea he applied these measures
to 168 rheumatic patients. From 10 to 20 cc. of blood was
withdrawn and immediately reinjected into the muscles oi the
hip. This is done before clotting takes place and nothing need
be added to the blood. The artificial fever is instituted imme-
diately following the autotransfusion and a temperature of
101.5 F. for one hour, the inductotberm being used for adults
and intravenous typhoid vaccine for children. With inducto-
thermy, approximately one hour was required to reach 101.5 F. ;
this temperature was maintained for one hour and about two
hours was necessary for the temperature to return to normal.
Patients were allowed to eat a norma! meal before the fever
was started and occasionally from 10 to 25 grains (0.65 to
1.6 Gm.)^ of sodium chloride was supplied along with ample
fluids. Xo untoward reactions have been experienced and

1916

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Volume 113
Number 21

CURRENT MEDICAL LITERATURE

1917

the apophysial joints, with which they have many connections.
They are directly applied on the vertebral column behind the
aorta and the vena cava. In a woman, the lymphatic vessels
of the uterus and the vagina follow approximately the same
path and also lie near the intervertebral joints. Conversely,
the lymphatic vessels of the fallopian tubes and of the ovaries
are much more laterally situated in the pelvis, and when they
ceme up into the abdomen they lie on the ventral aspect of
the large blood vessels — the aorta and vena cava. Since the
draining of the uterus and vagina is far easier than that of
the ovaries and tubes, the infrequent occurrence of ankylosing
spondylarthritis among women can be understood. This theory,
the author believes, explains the slow progress of the disease,
first to the sacro-iliac joints and later ascending along the
different segments of the spine. The sacro-iliac joints were
roentgenographically involved in more than 98 per cent of
the 1S3 cases. From the x-ray examination of twelve cases
observed in the early stages of the disease, evidence is given
that sacro-iliac joints are involved previously to any changes
of the spine. The reverse has ‘not been observed.

Rocky Mountain Medical Journal, Denver

SO: 6*5-743 (Oct.) 1939

Is the Child Ready for School? E. Jackson, Denver. — p. 703.

Causes of Dizziness. K. G. Cooper, Denver. — p. 703.

Transurethral Prostatic Resection. H. Buchtel, Denver. — p. 708.

Essential Hypertension: General Consideration and Surgical Treatment
by Resection of Splanchnic Nerves and Celiac and First and Second
Lumbar Ganglions and Intervening Trunks. \V. R. Lipscomb, Denver.
— p. 715.

Southwestern Medicine, El Paso, Texas

23:281-318 (Sept.) 1 939

Malignancies of Female Genital Tract. J. \V. Cathcart, El Paso, Texas.

— p. 281.

Medical Control of Silicosis. F. T. Hogeland, Cananea, Sonora, Mexico.
— p. 284.

Proctology for the General Practitioner. W. H. Daniel, Los Angeles,
—p. 287.

Diabetes MeUitus: Analysis of Cases Treated with Protamine Zinc
Insulin. L. B. Smith, Phoenix, Ariz. — p, 289.

Angina Pectoris and Its Masquerades. G. Werley, El Paso, Texas. —
P. 294.

Case Specific Bacterial Vaccines. O. H. Brown, Phoenix, Ariz. — p. 297 .
Gastroscopy as Diagnostic Procedure, N. Giere, El Paso, Texas. — p. 299.

Tennessee State Medical Assn. Journal, Nashville

33: 303-338 (Sept.) 1939

Acute Abdominal Emergencies: Report of Some Interesting Cases.

J. B. Haskins, Chattanooga. — p. 303.

A Doctor Looks at Socialized Medicine and Raises the Question: Shall
the First Aim of Medical Service Be Quality or Quantity? E. L.
Shore, Atlantic City, N. J. — p. 314.

Leukemia. R. H. Monger, Knoxville.— p. 319.

Texas State Journal of Medicine, Fort Worth

35: 325-384 (Sept.) 1939
Rabies. G. K. Wasscll. Dallas, — p. 330.

Varying Virulence of Hemolytic Streptococci: Determination of Serum
Sulfanilamide. T. \V. Folbre, San Antonio. — p. 336,

* Atypical Pneumonia with Leukopenia. J. R. Maxfield Jr., San Francisco.
-~p. 340.

Use of Sulfapyridine in Pneumonias of Early Life. H. L. Moore,
Dallas. — p. 346.

Rocky Mountain Spotted Fever: Report of Case. W. S. McDaniel,
Houston. — p. 34S.

•Tularemia: Report of Case Treated with Sulfanilamide and Antiserum.
G. L. Powers and Evelyn Gass Powers, Amarillo. — p. 350.

Drugs in Treatment of Congenital Syphilis. J. E. Ashby and H. Moore,
Dallas. — p. 353.

Evaluation of Endocrine Therapy in Menstrual Disorders. H. R. Robin-
son, Galveston. — p. 357.

Review of 2,422 Cases of Contraception. J. Z. Gaston, Houston. — p, 365.
Maternal and Child Health Demonstration Program in Health Education.
J. M. Coleman, Austin. — p. 368.

Recurrent Familial Headaches (Migraine). V. R. Hurst, Longview. —
jn 372.

Atypical Pneumonia with Leukopenia.— Maxfield states
that recently sixtv-three cases of an atypical pneumonia with
leukopenia have been seen in Baylor Hospital, Dallas, Texas.
These pneumonias seem to be a clinical entity. There was
usually a prodromal stage of from five to ten days. The dis-
ease started with dryness of the throat and some soreness.
The symptoms of a mild upper respiratory infection, general
malaise and mild to severe headaches were observed. The
patient became progressively worse. A rapid change with
unset oi fever and usually a chilly sensation then occurred.

Pain and fulness in the chest often occurred at this time.
The patient’s face showed anxiety and there was an elevation
of temperature (from 102 to 104 F.) and an increase in the
pulse and respiratory rate. There was usually a productive
cough frequently accompanied by hemoptysis, which was fol-
lowed in a few days by a coarse, dry, nonproductive cough
which persisted even after the temperature returned to normal.
This occurred between the fifth and the tenth day after admis-
sion. Although a diligent effort has been made, the causative
organism has not been determined. A virus is strongly sus-
pected. Repeated examinations of the sputum revealed acid
fast organisms in only one instance and this patient had a
previous history of tuberculosis. Repeated throat cultures and
smears showed only normal organisms of the mouth and throat,
with a gram-negative short chain nonhemolytic streptococcus
in a few cases. In a few instances pneumococci were found.
When these pneumococci were typed, no capsular swelling was
observed with types I through XXXII of the Neufeld pneu-
mococcus typing serum. The blood picture was that of a
mild leukopenia, varying' from 4,000 to 12,000 leukocytes per
cubic centimeter of blood, with 82 per cent of the cases giv-
ing a leukocyte count of less than 8,000. The mononuclear
leukocytes were 8 per cent or above in 38 per cent of the
cases. The neutrophils varied from 40 to SO per cent, the
average being 61 per cent. A communicable factor was present,
since the disease developed following contact with patients in
eight nurses, four interns and three of the attending staff of
Baylor Hospital. Two of the patients had a relapse, one four
weeks and one three months after discharge from the hospital.
The x-ray appearance of the lesions was usually infiltrative in
character. They had feathery, indefinite edges with moderate
homogeneous density toward their inner portions. The size of '
the lesions varied from those that were barely demonstrable
in the roentgenograms to an almost complete involvement of
both lung fields. Those cases with involvement of more than
one lobe showed no increase of symptoms. There was a wide
variation in the location and appearance of the lesions. Therapy
was of a symptomatic and expectant nature. However, tinc-
ture of benzoin inhalations, steam inhalations, sulfanilamide,
blood transfusions, nonspecific protein therapy and opiates for
pain and persistent cough and the like were used. There were
no mortalities. The duration of symptoms did not seem to be
either shortened or lengthened by the type of treatment used.
The author feels’ that the prognosis is good in all cases so
long as the leukopenia exists and repeated bacteriologic studies
fail to reveal typable pneumococci, tubercle bacilli, virulent
streptococci or viruses of influenza, psittacosis or others. In
the differential diagnosis typhoid, undulant .fever, psittacosis,
tuberculous pneumonia, influenza, influenzal pneumonia, tular-
emia and coccidioidal granuloma should be considered.

Tularemia.— In reporting their case of tularemia, G. L. and
Evelyn Powers wish to call attention to the fact that the disease
occurs in all parts of the United States. They believe that
theirs is the first case in which treatment with sulfanilamide
and antiserum was successful.

Wisconsin Medical Journal, Madison

3S: 709-840 (Sept.) 1939

Gastrointestinal Distui bailees Among: Infants and Children. R. L J.
Kennedy, Rochester, Minn- — p. 727,

•Angina Pectoris and Tobacco Smoking: Presentation of Three Cases
with Electrocardiographic Records. B. J. Birfc and H. H. Huber.
Milwaukee. — p. 733.

Perforating Hemorrhagic (Chocolate) Cysts of Ovary. C. B. Hatlebertr
Chippewa Falls. — p. 736.

Results o( Routine Examinations of Candidates for Teachers’ Certifi-
cates at the University of Wisconsin, 1937-1938. L. R. Cole, Madison
and P. II. Schmiedicke, Marinette. — p. 740.

Significance of Hematuria. H. L. Kretschmer, Chicago.— p. 742.

Angina Pectoris and Tobacco Smoking.— Three patients
exhibiting the syndrome of angina pectoris caused bv smoking
were seen by Birk and Huber. They obtained electrocardio-
grams when the patients sought relief from their symptoms and
again when the underlying offending factor (smoking) was
removed, after which the electrocardiograms were normal and,
the patients felt well. The changes noted in the electrocardio-
grams were definite. One of the patients with angina pectoris
caused by tobacco smoking was a woman.

1918

CURRENT MEDICAL LITERATURE

Jour. A. Jf. A
KOV. tt, I«;S

FOREIGN

An asterisk (*) before a title indicates that the article is abstracted
below. Single case reports and trials of new drugs arc usually omitted.

British Journal of Children’s Diseases, London

36:171-250 (July-Sept.) 1939

Diphtheritic Infection of Umbilicus. A. R. Thompson.— p. 171.
Congenital Abnormalities of Gallbladder and Extrahepatic Ducts: Review
of 245 Reported Cases with Reports of Thirty-One Unpublished Cases.
E. Stolkind. — p. 1S2.

British Medical Journal, London

2: 631-670 (Sept. 23) 1939

Significance of Auditory and Visual Hallucinations. P. K, McCowan.— -
p. 631.

Neurologic Aspect of Visual and Auditory Hallucinations. M. Critchley.

, — p. 634.

♦Puerperal Sepsis and Hemolytic Streptococci. Amy M. Fleming.— p. 639.
Ophthalmic Services to Civil Population in National Emergency. A.
Sorsby. — p. 641.

♦Sulfanilamide in Treatment of Scarlet Fever. E. C. Benn. — p. 644.

Puerperal Sepsis and Hemolytic Streptococci Since

evidence is accumulating that the upper part of the respiratory
tract of the patient herself or her contacts is the most probable
source of puerperal infection with hemolytic streptococci Flem-
ing, with a view of preventing the transfer of these organisms
to the genital tract of pregnant women immediately before,
during and after childbirth, determined the incidence of group A
hemolytic streptococci in 120 women medical students before
they began their work in the maternity wards of the obstetric
and gynecologic unit of the Royal Free Hospital. In each case
the throat swab was taken about three weeks before the student
was due for her two and a half months of resident training in
the hospital. If a growth of streptococci was found, McLeod's
test was carried out to see if it showed soluble hemolysin, and,
if it did, the Lancefield group to which the hemolytic strepto-
cocci belonged was ascertained by the precipitin reaction. A
growth of hemolytic streptococci was obtained in 22.S per cent
of the cases. In only five of the 120 students examined— that
is, in 4.2 per cent — did the hemolytic streptococcus belong to
the Lancefield group A. The series, spread over two years,
gave no evidence of any seasonal variation in the frequency of
the carrier rate of all hemolytic streptococci or of Lancefield
group A. There was no evidence of any relation between the
incidence of hemolytic streptococci in the throat belonging to
group A and the presence of tonsillar tissue. Complete tonsil-
lectomy had been performed in about 50 per cent of the students.
Hemolytic streptococci were absent in as large a proportion of
students with tonsils or remnants of tonsils as of those in whom
complete tonsillectomy had been performed. Each student with
hemolytic streptococci was given leave of absence, and moderate
exercise in the open air, painting or gargling of the throat or
the administration of sulfanilamide compounds was recommended.
Whenever it ceased to be possible to grow group A strepto-
cocci from their throat swabs the students were considered fit
to begin their residence. The time required for treatment varied,
but the persistence of the positive throat swab was noticeable in
those students whose nasopharynxes were in an unsatisfactory
condition. From an inquiry into the medical work previous to
obstetrics there seems ground for the suggestion that the cur-
riculum of medical students should be so arranged that work-
in the children's wards should not immediately precede or be
contemporary with work in obstetrics unless special steps are
taken to control the carrier rate in the children’s wards. Those
in contact with respiratory ailments should exercise particular
care, with the knowledge that their own susceptibility to act
as carriers of group A hemolytic streptococci may be _ an
important factor in the transmission of the infecting organism
of puerperal fever. Only on four occasions during these two
years, when throat swabs were examined because puerperal
pvrexia had developed in a patient, were hemolytic streptococci
found in the patient’s throat. The same strain of hemolytic
streptococci was isolated from the cervix of one of the patients
and also from the throats of a student and a nurse in contact.
In only one of the other cases was a student found to be a
carrier] It appears that routine examination of throat swabs of
the medical and nursing staffs is indicated.

Sulfanilamide for Scarlet Fever. — Since January 1937
Bonn treated 256 patients with scarlet fever with sulfanilamide
(Bayer), and 261 control patients were simultaneously treated

without the drug. Antiscarlatinal serum was given to tlr-e
patients in both groups who were thought to require it irre-
spective of the sulfanilamide. It was realized that sulfanilamide
has little or no effect? in the acute febrile stage of scarlet teu-r,
except perhaps in patients with a frankly septic tvpe of the
disease ; therefore it was thought that the incidence of com-
plications (which occur more often in children less than 10 years
of age) would probably give the best indication of the vale:
of the. drug. The general treatment of the patients did not
differ in the two groups. The amount (divided into three equal
doses in twenty-four hours) of sulfanilamide, after a previous
trial period, was fixed at 0.75 Gm. for children less than 2 years
of age, 1.5 Gm. for children from 3 to 7 and 3 Gm. for those
from 8 to 10. Administration of the drug was continued until
the temperature had been normal for a week in uncomplicated
cases. If complications developed, administration was pro-
longed for as long as was indicated. Signs of sulfanilamide
toxemia were seen infrequently and in no case gave rise to
anxiety. All patients suffered from simple scarlet fever, and
no death occurred in either series. The early acute stage of
scarlet fever seemed to be uninfluenced by sulfanilamide except
in cases in which some septic element was apparent: The
subseptic patients appeared to benefit from the drug. There
were a total of forty-eight complications in the test group as
compared to eighty-one in the control group. Individual com-
plications, with two exceptions, showed a greater frequency in
the control group than in the test group, and certain complica-
tions, including rheumatism, endocarditis and myocarditis, were
absent from the test series but present in the control cases.
The incidence of suppurative otitis media was greater in the
control series than in the test series, 10.3 and 6.3 per cent,
respectively. It appears that an important action of sulfanil-
amide in the mild type of scarlet fever is prophylactic in that
it lowers the incidence of complications. For this reason seventy-
nine patients have been given 1 Gm. of sulfanilamide daily, in
four equal doses, from admission until the fourteenth day and
again from the twenty-first to the twenty-eighth day. The
results in these seventy-nine are sufficiently good (there were
only four cases of suppurative otitis media, two of ademtn.
two of paronychia and one of albuminuria) to encourage further
prophylactic trial. The most striking effect is the comparative
absence of the many minor septic sequels. Cyanosis was wt
encountered in this group, but a maculopapular erythema rt
morbilliform type, which first appeared on the extremities, the"
on the face and finally on the body-, occurred in two cases. 1"
one patient this was accompanied by pyrexia, which sub.nuc
within forty-eight hours after the drug was withdrawn. - 0
other toxic effects were encountered.

Lancet, London

2: 675-722 (Sept. 23) 1939

Inoperable Carcinoma of Rectum. D. C. L. Fifewilfiams. P- ! J, \' p
"Treatment of Epilepsy with Sodium Diphenyl Hydantoma

Williams. — p. 678. _ itckilpr!.

Chemotherapy of Experimental Anthrax Infection. J- C. Cru

— p. 681 . _ , tit: \l-v art

Action of Sulfonamides in Experimental Anthrax, li. J - - -
S. C. Buck.— p. 685. ... - e ir. j.

Complete Heart Block in Voung People: Report of Two u-

Bower. — p. 686. . , tirar.f

"Stilhestrol and Anhydro-Oxvprogestcrone: _ Their Effects on -t
and Lactation. R. Wenner and K. Joel. — p. 6S8.

Sodium Diphenyl Hydantoinate in Epilepsy.-—
lecided to try treatment with sodium diphenyl hydantouw t ^
linety-one patients with chronic epilepsy who had ccas £
-espond to other anticonvulsants. The patients all live I* .
tnd had been under regular observation and treatment \u
Irugs for an average of 6.4 years. The longest c0 " jfn
icriod of treatment with sodium diphenyl hydantoma ic ■ , fl
nonths and the shortest six weeks, the average
lighty-three cases being 4.1 months. Sodium dtphen) . ,

nate was given in capsules of 0.1 Gm. An initial <• - v , ;
,f 0.2 or 0.3 Gm. was slowly increased, and 0.6 Gm. u. i
liven in some cases. Phenobarbita! and bromides vice ^
inued in decreasing doses during the period ot su 1
t was sometimes necessary to reduce the ore ...j.;,
liphenvl hydantoinate and to supplement it with oi
onvulsants. After trial of the drug alone the foUouing r.
ions were found to give an optimum therapeutic eiuv-- _
fphenyl hydantoinate alone in fifty-two cases, com?

Volume 313
Number 21

CURRENT MEDICAL LITERATURE

1919

phenobarbital in nine cases, with bromides in sixteen cases and
with phenobarbital and bromides in six cases. As a result of
this treatment the fits were reduced in frequency in 79 per cent
of the subjects with grand mal and in 63 per cent of those
with petit mal. In 19 per cent the improvement was dramatic
and has been maintained for over five months. Toxic symptoms
arose in 36 per cent, and two patients died in status epilepticus
while receiving the drug. The drug seems to be of value in
the treatment of epilepsy in some cases when other forms of
treatment have failed, but there are no indications that it should
supersede the less toxic anticonvulsants in the initial stages of
treatment. Its administration requires careful observation of
the patient.

Stilbestrol and Anhydro-Oxyprogesterone in Menstrua-
tion and Lactation. — Wenner and Joel say that although all
investigators agree about the similarity of the properties of
stilbestrol to those of the estrogenic hormone, emphasis is
constantly laid on the yet unresolved question of dosage. They
sought to ascertain (1) the minimal dose necessary to produce
proliferation in a resting or atrophic endometrium, (2) the dose
necessary to induce a hyperproliferation (in the sense of glandu-
lar cystic hyperplasia), and (3) the doses necessary to prevent
and to inhibit lactation in the puerperium. At the same time
they tried to ascertain the oral dose of corpus luteum hormone
(anhydro-oxyprogesterone) necessary to produce the stage of
transformation of the endometrium with subsequent menstrua-
tion. The authors studied the effect of stilbestrol and of
anhydro-oxyprogesterone on the endometrium of one woman
who had attained the climacteric thirteen years earlier and on
eight women who had been castrated by means of roentgen
treatments two or three years previously, when they were over
45 years of age. Each woman was subjected to three curet-
tages : one before treatment was begun, the second after the
administration of stilbestrol and the third after treatment with
anhydro-oxyprogesterone. They found that in order to obtain
proliferation of a resting or atrophic endometrium, it is neces-
sary to give 25 mg. of stilbestrol by mouth or 15 mg. by intra-
muscular injection. If from 50 to 60 mg. of stilbestrol is given
by mouth, a glandular cystic hyperplasia can be produced. The
stage of transformation and the menstruation following pro-
liferation can be produced by the oral administration of from
220 to 300 mg. of anhydro-oxyprogesterone. In only two cases
did the administration of stilbestrol cause slight secondary
symptoms, and even these disappeared rapidly. In the second
part of this report the authors describe their studies on the
effects of stilbestrol on lactation. Since several investigators
had succeeded in either preventing the influx of milk or inhibit-
ing lactation by the administration of estrogenic hormone, the
authors decided to use stilbestrol for the same purpose. In
six cases (four stillbirths, one case of tuberculosis and one of
depressed nipples) they administered stilbestrol on the first day
after confinement to prevent the secretion of milk. In three of
these cases one tablet (5 mg.) was given and in the other three,
two tablets (10 mg.). The treatment was successful in all of
these cases; no milk was secreted, and the breasts remained
flaccid. In fourteen cases stilbestrol was given to inhibit estab-
lished lactation, the indications being hypogalactia, bleeding
fissures, mastitis, eczema of the breasts and tuberculosis. It was
found that to arrest lactation, from 5 to 10 mg. of stilbestrol
is usually effective, but in some cases larger doses are necessary
(not more than 20 mg.). All women took stilbestrol without
difficulty, and no secondary symptoms were observed.

Medical Journal of Australia, Sydney

3: 345*382 (Sept. 2) 1939

Emotional Factors in General Medicine. Anita M. Muhl. — p. 345.

Review of 120 Cases of Bronchiectasis in Children in New South Wales.
C. Selby. — p. 352.

General Paralysis of Insane in Victoria, F, G. Prendergast.— p. 361.

South African Medical Journal, Cape Town

13: 587-632 (Aug. 26) 1939

^*As Others See Us: Doctors and Patients.** E. G. D. Drury. — n. 5S9.

The Hospital Dietitian. G. SI. Sedgwick.— p. S9S.

Alcohol Injection of the Gasserian Ganglion. A, J. de Villiers. — p. 59S.

Incidence of Appendicitis in the Bantu: Some Observations on Its
I atnology as Seen in Series of Cases. J. F. P. Erasmus. — p. 601.

Congenital Defect of Sternum. C. J. H. Brink.— p. 606.

Current Views on Gallbladder Disease. J. S. Alexander. — p. 608.

Luxation of Innominate Bone: Case. S. V. Humphries. — p. 61 1.

Strasbourg Medical

99 : 291-302 (Aug. 5) 1939

•New Conceptions on Essential Epilepsy, Its Pathogenesis, Familial
Existence and Prophylactic Measures. J. Wertheimer. — p. 291.
Tumor of Left Frontal Lobe: Case, Helene Weiss. — p. 297.

New Conceptions on Essential Epilepsy. — According to
Wertheimer, the term essential or idiopathic epilepsy does not
designate a nosologic entity but is generally applied to all cases
of epilepsy in which neither the clinical examination nor the
history reveals exogenic factors as cause of the attacks. He
concludes that essential epilepsy is a sequel of obstetric intra-
cranial lesions, especially of intracranial hemorrhages, which
may have escaped observation because their symptoms were
slight. Intracranial hemorrhages are often caused by the use
of forceps, that is, in extremely retarded deliveries, but they
occur also as sequels of extremely rapid deliveries. Studies on
the course of labor in epileptic women revealed a high incidence
of the precipitate type of deliveries. Thus the infants from epileptic
mothers are especially predisposed to intracranial hemorrhages
and their consequences. The author shows that this circum-
stance may give rise to the familial and apparently “hereditary”
appearance of epilepsy. However, he maintains that a hereditary
epilepsy in the biologic meaning of the term “hereditary” does
not exist, the apparent heredity being a result of a vicious circle.
After giving the clinical histories of five children he stresses
that, as a result of the dorsal position of the nursling, the blood
discharged during the cranial hemorrhages settles in the occipital
region and remains there like a foreign body until it gradually
becomes organized, which may require several months. The
cicatrization resulting from this process may produce epileptic
attacks. The ventral position of the nursling, on the other hand,
facilitates cranial circulation, favors the resorption of the
sanguine effusion and thus avoids the cicatrization and the sub-
sequent epilepsy. Placing the nursling in the ventral position is
a prophylactic measure against the frequently disastrous sequels
of obstetric meningo-encephalic hemorrhages.

Helvetica Medica Acta, Basel

6 : 415-524 (Aug.) 1939

Spinal Funiculitis in Endemic Sprue. H. W. Hotz and F. Luthy. —
p. 415.

Perforation of Interventricular Septum by Infarct G. Bickel and
J.-J. Mozer. — p. 427.

Insuloma of Extremity of Pancreas: Case; Can Carcinoma be Caused
by Induction? H. Dubois-Ferriere. — p. 458.

•Quantity and Distribution of Hepatic Glycogen in the Newborn. J.
Fopp. — p. 466.

Demineralization of Bone Extremities After Trauma Incurred in
Accidents as Partial Symptoms of Dystonia and Dystrophy of
Extremities. U, Frutiger. — p. 480.

Hepatic Glycogen in the Newborn.— -Fopp studied the
glycogen content and distribution in late fetal and neonatal
livers in eighty cases: twenty-four fetuses with an intra-
uterine. existence from seven to nine months, the remainder
(fifty-six) consisting of infants either stillborn or dying within
the first twenty-four hours. The majority of the necropsies
were performed during the second or third day on bodies kept
in refrigeration. Portions of the liver 0.5 cm. in thickness
were steeped in a 95 per cent solution of alcohol, embedded
in celloidin and tinted according to the Bestsch method. In
addition, control analyses were made on fifteen infants who
had died within the first month. The results obtained showed
glycogen content in the combined late fetal and neonatal livers
(eighty) in the following proportions : no glycogen 26 per cent
(twenty-one), little glycogen 24 per cent (nineteen), interme-
diate group 25 per cent (twenty), much glycogen 25 per cent
(twenty). The glycogen content for the fetal group taken by
itself (twenty-four) indicated about the same percental propor-
tion as for the combined group : no glycogen 21 per cent (five),
little glycogen 29 per cent (seven), intermediate group 25 per
cent (six), much glycogen 25 per cent (six). These results
warrant the inference, confirmatory of the studies made by
others, that the glycogen content is often high in fetal livers
but give . no support to the assumption that high glycogen
presence is the “norm.” In comparison with the data obtained
for the livers of unselected healthy adults accidentally killed
the gl) cogcn content was more frequent and pronounced. On
the other hand, tests on the fifteen controls clearly indicated

1920

Jour. A. if. A.
Nov. 18, 1919

CURRENT MEDICAL LITERATURE

loss of glycogen, only five attaining to intermediate and high
rating.. These indications, according to the author, point to
a special stability of glycogen retention in neonatal livers and
were confirmed by consecutive testings especially made on the
liver of another newborn infant at intervals between one and
one-half and forty-eight hours. Morphologically, the author
finds a close analogy between the glycogen in fetal and neo-
natal livers and that of adults, with the exception of a com-
plete absence of nuclear glycogen, which he accounts for by
the absence of acidosis. Observations made on the hepatic
cells of adults could be verified in the livers of the newborn.
Evidence for glycogen distribution in the lobule was too con-
flicting to admit of generalized inferences. Differences between
neonatal and adult livers may he due to pathologic processes
in adult livers. The author does not seek to explain the great
loss in the glycogen content of neonatal livers on a uniform
basis. Factors such as prolonged labor, intra-uterine ante-
partum death, premature detachment of the placenta, febrile
infection, marked fatty degeneration and blood congestion in
the liver, causing enlargement of the central veins and capil-
laries, may all cause glycogen impairment while congenital
goiter, thymus hyperplasia, sex and the number and size of
hemopoietic hepatic centers, except in fetal myeloblastosis,
seem not to affect the glycogen content. The evidence for
the effect of the size of the liver on glycogen is too meager
to justify conclusions.

Schweizerische medizinische Woclienschrift, Basel

69.-80S.824 (Sept. 9) 1939. Partial Index

Marble Bone Disease. A. Willi. — p. 80S.

"Effects of Ketogenic Diet. M. Julesz and E. Winkler.— p. 807.

Diazotization Speed of Blood Serum. A. Gigon and M. Noverraz. —

p. 811.

Ketogenic Diet in Asthma. — Julesz and Winkler studied
the effects of a ketogenic diet on fourteen patients (twelve
asthmatic) with four healthy persons as controls. Concluding
from earlier experiences of their own and others that neither
acidification nor dehydration was the key to the problem, the
authors turned from iiivestigating the bicarbonate content of the
blood to the analysis of ammonia secretion, with the purpose of
obtaining a better insight into the metabolic disturbances caused
by asthma and into the processes whereby effects are secured
through a ketogenic diet. The conditioning of the controls
included a standard diet, administration of phosphoric acid, a
ketogenic diet for from one to two weeks and repeated tests
for ammonia and alkali reserve. In their preliminary assays
the authors discovered, on the average, no quantitative difference
in ammonia secretion between the controls (650 mg.) and the
asthmatic patients who had been put on a standard diet for
three days (630 mg.); according to the literature ammonia
elimination varies between 400 and 600 mg. Neither did phos-
phoric acid have any appreciable effect on the daily quota of
ammonia excretion. In their study of the effect of a ketogenic
diet on ammonia excretion the authors found that in the non-
asthmatic controls ammonia elimination during the ketogenic
diet was increased by 45 and 50 per cent as compared with the
standard diet, continued for from one to two weeks with ace-
tonuria and then decreased, at which time not even increased
ketosis could enhance ammonia excretion. The authors differen-
tiate four kinds of ketogenic diet effect on ammonia secretion
of asthmatic patients: 1. In patients with normal ammonia
secretion under conditions of normal diet, the ketogenic diet
increases ammonia secretion considerably. 2. In patients in
whom absotute ammonia elimination is normal, the ketogenic
diet does not increase it. 3. In patients whose ammonia elimina-
tion on a standard diet is subnormal, the ketogenic diet con-
siderably increases it. 4. In patients whose ammonia elimination
is subnormal, the ketogenic diet does not affect it. A ketogenic
diet was found effective only in patients belonging to groups 1
and 3. Those in groups 2 and 4 were patients affected with
serious forms of asthma and were not benefited by the ketogenic
diet. In their investigations of the ketogenic diet on the alkali
reserve the latter being defined as the sodium bicarbonate con-

tent in the plasma expressed in cubic centimeters of carbon
dioxide obtained from 100 cc. of plasma— the authors ascertained
that the ketogenic diet diminished the alkali reserve both of

asthmatic and of nonasthmatic persons by from 1 to 20 per cent.
The exceptional detection of an increased alkali reserve after
from one to two weeks of the ketogenic diet, amounting in one
case to 24 per cent, is explained by the authors on the assump-
tion that the organism, under the influence of the ketogenic
diet, adjusts itself so much to neutralizing acidity by means of
ammonia that after a time it impairs its power to neutralize
with bicarbonate. They appeal for confirmation of their assump-
tion to the results obtained from the phosphoric acid administra-
tion during the conditioning period and to the abnormal reaction
of some of the asthmatic subjects.

Archivio Italiano di Chirurgia, Bologna

56 : 237-338 (May) 1939. Partial Index
Regional Enteritis. E. Ragnotti. — p, 237.

Importance of Circulation on Formation of Bone Callus: Experiments.
M. M. Reggiani. — p. 272.

"Abdominal Syndromes from Adenopathies of Mesentery. A. Pariol
— p. 314.

Abdominal Syndromes from Mesenteric Adenopathies.
— According to Parini there are certain acute forms of ade-
nopathies of the mesentery with symptoms simulating those of
acute appendicitis and also forms with abscess formation and
possible rupture of the abscess and consequent peritonitis. The
condition is generally found in children and adolescents,
although it may be seen in adults. The enlarged mesenteric
lymph nodes can be felt by palpation only in rare cases. The
differential diagnosis of mesenteric adenopathies with acute
appendicitis is made from the type of pain, which is of an
intermittent character and located in the ileocecal or perium-
bilical region rather than in the appendicular region. The
presence of leukocytosis with lymphocytosis is of diagnostic
value. Mesenteric adenopathies may be secondary to tubercu-
losis, chronic inflammation of certain abdominal organs, or else
chronic infection of the throat, teeth, respiratory tract or
intestine. The treatment is etiologic, namely chemotherapy,
especially sulfanilamide, in infection and medical, physical and
other treatments in tuberculous adenopathies. In the latter the
treatments indicated are administration of iodide, exposure ot
the patient to sun irradiations, administration of roentgen
irradiations, sojourn of the patient in the proper climate and
proper diet and general hygiene. Surgical intervention is W 1 '
cated only in acute forms in the presence of (1) intestinal
obstruction or stricture from compression of the enlarged Jy mp“
nodes or from adhesions, (2) acute suppuration, especially «
there is a menace of rupture of a lymphatic abscess, or (3)
peritonitis from rupture of an abscess. It is advisable “
establish ample drainage after the operation. It is also advis-
able to resort to surgical intervention only in the specific
conditions mentioned, since removal of enlarged lymph nodes
may be followed by production of hemorrhages or developmen
of necrosis, suppuration or formation of adhesions. Five casc>
of either the tuberculous or the infectious etiology are repor
by the author.

Giornale Medico dell’ Alto Adige, Bolzano

11:241-308 (May) 1939. Partial Index (

Roentgen Examination in Study of Intestinal Occlusion from z so
iasis. A. Barbieri. — p. 241. , . , r . Tor-tu-

Variations of Glycemia in Relation to Peristalsis and wsme
A. Bauce.— p. 260. .

•Treatment of Open Fractures. A. Chinienwo.-p-

Treatment of Open Fractures.— Chiatellino has treaty
more than fifty cases of open fractures in the course
last four years. The group included open fractures
large bones (with exposure of the articular ^

cases) and open and comminuted, cranial fractures. ,,

some diabetic and old persons in the group. .,.; on 0 f

a modification of Bohler’s, consists of surgical dismtec^

the soft parts of the wound and of the bone tissues
by complete suture of the wound. The operation P ■

in the following manner : General care is given .
to prevent development of traumatic shock. J He
of the skin is sterilized with iodine (without any preo.
gaiion on the wound and nearby- tissues). •'

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1922

CURRENT MEDICAL LITERATURE

Jo ue. A. Jr. A.
Jfov. rs, im

hormones ceases, which would seem to indicate that the processes
in the female genitalia are influenced not only by the estrogenic
and the corpus luteum hormones but at times also by the hor-
mone of lactation. On the basis of their observations the authors
suggest that lactation hormone of the anterior lobe of the
hypophysis acts not only on the mammary gland but at times
also on the ovary and the uterine mucosa in that it is involved
in the rupture of the follicle and in the menstrual decomposition
of the uterine mucosa.

Folia Haematologica, Leipzig

G2 : 337-480 (No. 4) 1939

•Myelogenic Osteopathy: Clinical and Experimental Stud}'. N. Markoff.
— p. 337.

Cholesterol Content of Erythrocytes in Human Subjects. G. C. Brun.— -
p. 36/.

Complex of Symptoms of Panmyelophthisis During Childhood. T. Illing.
— p. 369.

Experimental Changes in Opsonic Index. V. Papilian and I. G. Russu.
— p. 39 2.

•Blood Picture During Alarm Reaction. A. J. Dalton and H. Selvc.— •
p. 397.

Problem of Megaloblasts. H. E. Bock and B. Malamos.— p. 408.

Experiences with Coagulation According to Weltraann at Medical Clinic
of University of Zurich. T. Keller. — p. 430.

Myelogenic Osteopathy. — Markoff directs attention to
recent advances in the knowledge on the relationship between
osteal and medullary structure and functions, pointing out that
the intravital examination of the bone marrow according to
Arinkin’s method permits an evaluation of the morphology and
function of the medullary tissue. A comparison of the osteal
structure and of the morphology and function of the medullary
tissue shows a coupling between medullary and osteal changes
under physiologic and under pathologic conditions. This con-
nection is designated by the author as the medullary-osseous
relation. Functional activity and morphologic aspects run parallel
under physiologic conditions, though a study of the various
forms of osteopathy reveals a diverging development between
osteal and medullary changes. The author gives his attention
to the medullary-osteal relationship in various forms of oste-
opathy. He demonstrates that in osteoporotic processes the
marrow is not atrophic and hypo-active but rather hyperplastic
and hyperactive. In studies on different forms of osteopathy,
lie shows that the myelogenic factor is of decisive influence in
the pathogenesis of these forms of osteopathy. If the functional
relationship between the medullary and osteal tissues is impaired,
there develops a syndrome which can be designated as myelo-
genic osteopathy. The author thinks that the syndrome of
myelogenic osteopathy represents a proof of Naegeli’s hypothesis
of the medullary origin of osteomalacia. He further shows that
the idea of hematic dysplasia, which Giinsslen formulated for
the age of growth, applies in a slightly different form also to
adults, except that here there is not a single functional direction
from bone marrow to bone but relations between cellular marrow
and osteoporosis and between fibrous marrow and osteosclerosis.

Blood Picture During Alarm Reaction. — Dalton and
Selye say that it has been shown that acute damaging stimuli
(such as exposure to cold, muscular exercise, toxic doses of
drugs, hemorrhage and surgical intervention) elicit a group of
typical symptoms. The most characteristic among these are
enlargement of the adrenal cortex with a decrease in its lipid
content, loss of chromafHnity of the adrenal medulla, acute
involution of the thj’mus, the lymph nodes and the spleen, for-
mation of ulcers in the gastrointestinal tract, hemoconcentration,
and characteristic changes in the chemical composition of the
blood. The fact that, irrespective of the type of damaging agent,
the resulting symptoms are always approximately the same,
led to the conclusion that they are merely the somatic expression
o£ the response of the organism ; that is, a hitherto unrecognized
generalized reaction of the body. These considerations, and the
fact that the reaction can be elicited only by the first exposure
and disappears in subsequent exposures, suggested the name
“alarm reaction.” Since previous investigations had shown that
one of the best indexes of an alarm reaction is the blood count,
the authors decided to investigate the hematologic changes of
the alarm reaction in experiments on animals. They found that
following exposure to an agent such as formaldehyde, which
elicits a typical alarm reaction, there is an initial decrease in
t|, c total white cell count followed by an increase which is

mainly due to neutrophil leukocytosis. At the same time the
red cell count rises because of the accompanying hemoconccn-
tration. This rise may be preceded or interrupted by a tran-
sitory decrease during the first hour of the experiment. In the
case of an alarm reaction produced by muscular exercise, the
changes in the white ceil count are similar to those elicited by
formaldehyde but the red ceil count shows a progressive and
prolonged decrease, which has not as yet returned to norma!
even seventy-two hours after the one hour period of exercise.
During the neutrophil leukocytosis, eosinophilopenia develops in
most cases, the eosinophils reaching their lowest level (they
almost disappear from the blood) before the neutrophils reach
their peak. After this, eosinophilia ensues at a time when the
neutrophils are returning to normal. Reticulocytes increase in
number during the alarm reaction, this increase being much
more obvious after exercise than after treatment with formalde-
hyde. It appears that the so-called nonspecific leukocytosis,
preceded by a decrease and followed by an increase in eosinophils,
is a constant feature of the alarm reaction.

Klinische Wochenschrift, Berlin

18: 1077-1108 (Aug. 12) 1939. Partial Index

Structural Analysis of Coagulation of Blood. C. AVolners and H. Rush,
p. 1077.

^Behavior of Gastrointestinal Tract in Lead Poisoning: Intestinal Bis*
turbances. H. Otto and F. Kuhlmann.— p. 3081.

Electrolytic Equilibrium of Serum in So-Called Serum Inflammation.
E. Poli. — p. 1084.

Alimentary Fluctuations in Leukocytes and Acidity Conditions of
Stomacli. B. G. Hager.— -p. 3087.

Investigations on Albucid (Sulfanilamide Derivative) Contents of Blood
and Urine After Administration of Albucid in Gonorrhea and Th«f
Significance for Therapeutic Result. W. Gertler. — p. 1089.

Extraction of Protein Substances from Diphtheria Bacilli. K. Soehring.
— p. 3093.

Disturbances of Mitosis in Tissue Cultures Produced by Carcinogenic
Hydrocarbons and by Sex Hormones. W. von Moellendorff. — p. 1053.

Gastrointestinal Tract in Lead Poisoning.— Otto and
Kuhlmann first discuss the different ways by which lead can
enter the human organism, mentioning absorption by the lung,
the mouth and the skin. Whether the severity of the gastro-
intestinal disturbances depends on the mode of intake of the
lead has not been determined as yet. The oral changes, although
of diagnostic significance, do not greatly trouble the patient,
whereas the esophageal symptoms have been known to do tins.
Lead esophagitis, for instance, causes retrosternal pressure,
pyrosis and, in rare cases, regurgitation. Spasmodic contrac
tions and even paralysis of the esophagus have been observe^
as the result of lead poisoning. Inflammatory changes of the
internal wall of the stomach are a frequent symptom of ea
intoxication. Moreover, gastritis and ulcers have been knw
to develop in lead poisoning. Reviewing the intestinal dis ur
bances resulting from lead poisoning, the authors give 1 '
attention especially to the localization of the lead colics. 1 .
reject the generally accepted opinion that the lead cows nr
localized exclusively in the colon and show that the sma in
tine is involved. They point out that the patients often loo
the spasmodic pains in the region of the umbilicus and 0
hypogastrium and that the intestinal pains fail to subside,
complete evacuation of the colon. The roentgenologic o > c
tions demonstrate even more clearly that the small Giles m ’
involved. For instance, in patients with lead poisoning
were troubled with continuous and severe colics roenlgcnos >
failed to reveal colonic spasms but disclosed segmenta
strictions and spasms of the small intestine. Cases of c ' •

established ileus of the small intestine are further proot ■
significance of lesions of the small intestine in lead mtoxirai .
The authors further discuss the different modes of devep
of the disturbances in the small intestine. They consi
the direct irritation of the mucosa and of the museum - .

(2) the irritation of Meissner’s and Auerbachs plexus, t .
impairment of the vagus and sympathies, (*») rca c cd

brain and spinal cord, (S) vascular crises and J jj.. :
hepatic elimination of porphyrin into the small mtes
differential diagnosis of lead colic must consider sue "
as biliary and renal calculi, perityphlitis, pancrca >
embolism of the mesenteric vessels, gastric crises . (
porphyria. In the treatment of colic of the small int . '

necessary to differentiate between the acute and cii

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'■e<l h

1924

CURRENT MEDICAL LITERATURE

Joint. A. JI. A.
Nov. 18, 1939

Basophil Stippling of Erythrocytes in Sulfanilamide
Anemia. — -According to Myhre it is a well known fact that
anemia may occur in connection with sulfanilamide treatment.
Having observed basophil stippling of the erythrocytes in study-
ing the blood of a woman who developed granulocytopenia after
taking 19 Gm. of sulfanilamide, the author decided to examine
the blood of patients with slowly developing sulfanilamide anemia
for basophil stippling. In the first patient the highest count of
stippled cells was 3,200 per million erythrocytes. In the second
patient, a girl aged 17, who was given large doses of sulfanil-
amide in the course of meningitis, after having previously
received it in an attack of tonsillitis, the stippled cell count
reached the maximum of 6,500 per million erythrocytes. Two
other patients who had received sulfanilamide for pyelitis showed
a moderate increase in stippled cells (1,000 and 700 per million
erythrocytes, respectively). In two other patients, in whom the
total dose of sulfanilamide was unknown, the treatment having
begun previous to hospitalization, the stippled cells reached a
total of 3,000 per million erythrocytes. The author counted the
stippled cells by means of Schmidt’s method. He says that the
phenomenon of stippling is an acknowledged sign of blood
regeneration but that he has never seen it in connection with
anemias secondary to infections but only in toxic anemias. Lead
poisoning, the most common cause of stippling, could be excluded
in the reported cases. In these patients, who had received sulf-
anilamide, the stippling was unusually fine. The stippled cells
are not identical with reticulocytes but may appear simultane-
ously. The author suggests that the rapid increase in stippled
cells (6, 500) and reticulocytes observed in one of the patients
may have been the result of the treatment with liver extract.
He never observed stippling after the customary doses of sulf-
anilamide. Nevertheless, the reported cases show that sulf-
anilamide may have a profound influence on the hemopoietic
system, even if no alarming anemia occurs.

nerve. Exophthalmos was present in all but one case. One
case, with bilateral aneurysm, is believed to be the fifth of its
kind to be reported. The symptomatology is marked by two
phases, (1) the acute episode due to rupture of the aneurysm
and (2) . symptoms due to pressure of the aneurysm on the
neighboring structures. The history is often characteristic of
a vascular disorder and suggests the diagnosis. Verification of
the diagnosis depends on arteriographic, operative or postmortem
establishment of the aneurysm. Treatment consists of ligation
of the artery central to the aneurysm, the primary aim being
to prevent future ruptures. This possibility is always at hand
and the prognosis as far as life is concerned is doubtful.

3:2375-2460 (Aug. 5) 1939. Partial Index
Hospitalstidende

Bacteriologically Controlled Experiments to Change Abnormal Intestinal
Flora . by Administration of Bacillus Acidophilus (Thermobacterium
Intestinale, Orla-Jensen) in Therapeutic Doses. E. Mejlbo and F.
Nygart. — p. 2383.

“Studies on Certain Pneumococcic Antibodies (Agglutinin and Cap-
sular Swelling Antibodies). Emilie Faber. — p. 2391.

Symptoms and Treatment of Roentgen Climacteric. Jobanne Christ-
iansen. — p. 2295.

Autochthonous Sinus Thrombosis as Postoperative Complication. K.
E. Petersen. — p. 239S.

Pneumococcic Antibodies. — In her investigations on the
pneumococcus agglutinins and capsular swelling antibodies of
types I to XXXII in serums from 100 healthy persons, Faber
found antibodies against one or more types, with titers of from
2 to 16, in 18 per cent. The presence of antibodies of a certain
type in the postcritical serum of a pneumonia patient, she says,
does not establish this pneumococcus type as the etiologic factor
in the pneumonia unless antibodies of this type were demon-
strated in the blood before the crisis.

3: 2461-2516 (Aug. 12) 1939. Partial Index

Nordisk Medicin, Helsingfors

3: 2305-2374 (July 29) 1939. Partial Index

Hospitalstidende

"Treatment of Pneumonia in Adults and Children with Acetyl Sulf-
apyridine. A. Eldahl. — p. 2309.

Investigations on Active Spectral Range in Phytogenic Photoderma-
tosis Due to Pastinaca Sativa (Oppenheim’s Dermatitis Striata
Bullosa Pratensis). T. Jensen and K. G. Hansen. — p. 2314.
Eleven Cases of Incomplete Menstruation. Karen Rdjel, nee For-
mann. — p. 2319.

Treatment of Pneumonia with Acetyl Sulfapyridine. —
Eldahl says that of the fifty-five patients treated with acetyl
sulfapyridine thirty-four were adults and twenty-one were chil-
dren. Pneumococcus types I, III, VI, VII and XIX were
found respectively in ten, five, eight, seven and five cases (21,
10.4, 16.4, 14.6 and 10.4 per cent). The average amount given
adults was 40 Gm. and children 25 Gm. In twelve patients
(22 per cent) the temperature dropped to 38 C. (100.4 F.) dur-
ing the first twenty-four hours of treatment, in twenty-five
(45 per cent) in the course of the second day. Two patients
with pneumococcus types III and XVIII respectively died in the
acute stage, with a resulting mortality rate of 3.6 per cent.
The toxic symptoms were vomiting in thirteen cases, hematuria
in one; whether the jaundice which occurred in one instance was
due to the drug or to an acute infectious hepatitis could not
be determined.

Norsk Magasin for Lasgevidenskapen

“Infraclinoidal Aneurysm of Internal Carotid-Ophthalmoplegic Mi-
graine. B. Nyquist, S. B. Ref sum and A. Torkildsem— p. 2325.
Treatment of Pellagra with Nicotinic Acid: Clinical Review with
Report of Case. A. H. Brinchmann.— p. 2335. .

Several Kinds of Block, Interference and Paroxysmal Tachycardia m
Same Person. J. H. Vogt.— p. 2337. _

Significance of Material for Degree of Sensitivity of Sumle Pirquet
Reaction with 1 Mg. Tuberculin. G. Hertzberg.— p. 2340.

Infraclinoidal Aneurysm of Internal Carotid — Ophthal-
moplegic Migraine. — Nyquist and his associates say that the
accepted conception of the syndrome of ophthalmoplegic migraine
as due to infraclinoidal aneurysm was expressed by ^ the Nor-
wegian Eduard Bull in 1S77. Six cases of infraclinoidal aneu-
rvsm associated with typical symptoms are reported. In five
the symptoms began with pain corresponding to the first branch
of the trigeminal nerve, followed by palsy of the oculomotor

Hospitalstidende

“Hematuria in Treatment with Sulfapyridine. N. I. Nissen and C.
R. Roesgaard. — p. 2461.

Inhibiting Action of Liquid Petrolatum in Utilization of Substances
with Active Vitamin A. T. K. With. — p. 2468.

Hematuria from Sulfapyridine. — Nissen and Roesgaard
state that on examination of the daily urine of forty-one patients,
mostly with various types of pneumonia, all treated with
sulfapyridine, hematuria was demonstrated in fifteen: macro-
scopically in five and microscopically in ten. In two cases
the hematuria was accompanied by subjective symptoms o
kidney disease (renal colic and anuria respectively). As a rule
the hematuria lasted only a day or at the most a few da>s,
there was no lasting symptom of any kidney lesion in the sur-
viving patients. As the urine after a few days intensive treat-
ment with sulfapyridine often changes from a dark brown to a
reddish brown, a slight hematuria may easily escape obserU
tion unless daily tests of the urine are made. If the indication
for continuation of the treatment is not vital, discontinuanc-
of the drug is advised on the slightest sign of hematuria.

3 : 2517-2592 (Aug. 19) 1939. Partial Index

Hospitalstidende ^

Diagnosis of Gastritis: Comparative Investigation of Gastroscopy 3
Other Diagnostic Aids. K. Lundbsek. — p. 2517.

"Studies on Type III Pneumococcus Pneumonia. G. Allstcd. P-

Type III Pneumococcus Pneumonia. — Alsted reports
thirty cases of type III pneumonia (sixteen of the mar •
fourteen of bronchopneumonia) treated in Bispebjerg M P
in the same period with twenty-four cases of type I P nc f
(all lobar) and nineteen of type VII pneumonia (cig 1 ^

lobar form, one of bronchopneumonia). He says that >P
apparently predominates in women and in older P :
although the mortality rate is highest among the m T nts
In type I and type VII pneumonia two thirds of t D ^ .
were under 40. Type III is regarded as a special elm >
pathologic entity, differing distinctly from types 1 J™ ^
which generally have a less dangerous course a ‘ ( (rcat .

easily influenced by specific treatment. The mo t .
ment at present for type III pneumonia 1 ^ course

getic chemotherapy, instituted as early as P 0ss ' blc ' n . v ..; t hout
of the disease; specific therapy, however, seems to
notable effect in bronchopneumonia.

The Journal of the
American Medical Association

Published Under the Auspices of the Board of Trustees

/or,. 213, No. 22

Copyright, 1939, by American Medical Association

Chicago, Illinois -

November 25, 1939

VASOMOTOR .CHANGES IN THE CORO-
NARY ARTERIES AND THEIR
POSSIBLE SIGNIFICANCE

chairman's address
N. C. GILBERT, M.D.

CHICAGO

Just what might he “the nature and the cause” of
angina pectoris has been a subject of interest and of
varied opinion from the time of Heberden. Huchard,
in the last quarter of the last century, listed some sixty-
three various theories as to the cause. This list covered
the possibilities so thoroughly that the only addition
since that time has been that ascribing the source of
pain to the esophagus and stomach — and not to the
heart at all. Each theory has won adherents in its
time, only to lose them again and then to rewin them
in later decades. Each theory has had as its exponents
some of the most distinguished physicians of the period.
It may be said of angina pectoris in general what
W. Townsend Porter said of the experimental work
on the coronaries: “Seldom have the results of physio-
logical studies been more at variance. The attentive
reader will find no statement that is not denied, no fact
not in dispute.”

Today little essential difference of opinion remains.
Clinicians and physiologists alike agree with Huchard’s
dictum: “There are-not several anginas of the breast;
there is only one — coronary angina.” He was consider-
ing as instances of angina, however, only those cases
in which definite anatomic changes in the coronary
arteries could be assumed from the history and from
physical examination or demonstrated at autopsy. Other
cases, even though symptomatically identical, were
classed as nervous, toxic or reflex. There still exists,
to some extent, this same reluctance to consider as
angina pectoris conditions which are apparently free
from demonstrah’ ■ ■ *’ 1 ‘ ’ iges in the heart or

its vessels. In other than angina,

attention has also been fixed on the effects of decrease
in flow consequent on structural changes, and little
attention has been paid to the possible effects of tran-
sient decrease in flow consequent on vasomotor changes.

The symptoms of angina pectoris result when the
blood supply to the heart muscle is inadequate for its
needs at that moment. In most cases this is due in
whole or in part to anatomic changes in the vessels
which render them unable to meet the increased
demands which accompany increased work of the heart.

Rend before the Section on Practice of Medicine at the Ninetieth
Annual Session of the American Medical Association, St, Louis, May 18,

However, a similar disproportion between supply and
demand would result if the vessels failed to increase
in caliber in response to the increased needs, even
though they might be adequate anatomically to furnish
a sufficient blood supply. This same disproportion
would result also in cases in which the needs of the
muscle remained constant, increased or even decreased,
but in which the blood flow was diminished in conse-
quence of a vasoconstrictor action.

From clinical observation there is reason to assume
that in some cases angina may be due to vasomotor fac-
tors which are responsible for the lack of equilibrium
between supply and demand. One would have to con-
sider a failure of the vasodilator mechanism to respond
to increased needs, a failure of relaxation of the vagus
tone which Rein 1 has shown to be present or, in some
cases, an actual vasoconstriction. Theoretically, one
or the other mechanism might be the determining factor
in different cases.

Such clinical concepts find some confirmation in
experimental work on animals. Porter 2 and Maass 3
demonstrated a vasomotor control of the' coronary flow.
This work has been confirmed and extended by Anrep, ■*
Greene, 5 Rein 1 and others. Reflex changes in coronary
flow have been demonstrated by these same authors.
That such changes in coronary flow may result clinically
from factors occurring in daily life is evidenced by
the coronary vasoconstriction which Anrep, 4 Greene 0
and others have shown to result from an increase of
cephalic blood pressure past a certain point. In the
cases reported by Lewis 7 in which anginal attacks
occurred after a rise in pressure past a certain point,
it seems probable that some such mechanism was pres-
ent. The effect of gaseous distention or hiatus hernia
in provoking attacks has long been a common observa-
tion. Von Bergmann s lias shown that the inflation of
a balloon in the stomach of the dog produced a coronary
vasoconstriction abolished by atropine or vagus section.
Fenn, LeRoy and I have confirmed this work in the
last few months and will report on it later.

1. Rein, Hermann: Die Physiologie der Herz-Kranz-Gefassc, Ztscbr.
f. Biol. 92:100-114 (Nov. 30) 1931.

2. Porter. W. T. : The Vasomotor Nerves of the Heart, Boston M.
and S. J. 104 : 39-40, 1896.

3. Maass, Paul: Experimentelle Untersuchungen fiber die Innerva-
tion der Kranzgelasse des Saugethierherzens, Arch. f. d. res. physiol
(Pfluger’s) 74 : 281-306, JS99.

4. Anrep, G. V.: Lane .Medical Lectures: Studies in Cardiovascular
Regulation, Stanford University, Calif., Stanford University Press, 1936,

5. Greene, Charles W.: The Nervous Control of the Coronary Circu-
lation and Its Clinical Significance, South. M. J, 20:478-483 (May)

6. Greene, Charles W.t An Analysis of the Relations of the Coronary
Constrictor and Dilator Serves in the Cervical Vagosympathetic of the
Dog, Am. Heart J. 11: 592 (May) 1936.

Tho S as L -T/T 3 ' K'tating to Coarctation of the Aorta of
the Adult Type, Heart 10 : 205-261 (June 14) 1933.

8. von Bergmann, G.: Das "epiphrenale Syndrom,” seine Beziehun"
58 : 603-609 (ApriM?) 19?Z Deutsche mcd. Wchnschr.

CHANGES IN CORONARY ARTERIES — GILBERT

Jout. A. M. A.
Kov. 25, 1939

Hall 0 and de Takats and Fenn 10 have recently
reported on reflex vasomotor changes in the coronary
arteries following coronary occlusion and following pul-
monary emboli.

It seems probable also that there is such a thing as
toxic vasoconstriction, as Huchard predicated, resulting
either from a direct effect on the vasomotor mechanism
or reflexly from other visceral effects of the agent.
That some drugs have a vasoconstrictor effect is known,
and considerable evidence is- accumulating against
tobacco.

The assumption of vasomotor changes in the caliber
of the coronary arteries is not new, dating well back
into the last century. Such reflex vasomotor response
or lack of response is not a normal physiologic process
and is not to the advantage of the organism. In that
respect it is not unique, sharing a place with esophageal
or gastric neuromuscular disturbances, spastic colon,
bronchial asthma and allied symptomatic disorders. It
is necessary to predicate some alteration in the normal
physiologic background which renders nerves and
tissues more amenable to subversive propaganda.
Deviations from the physiologic normal involving
hyperactivity or hypoactivity of the autonomic nerv-
ous system are matters of daily observation in clinical
practice. They are the basis of many of the disorders
on which the physician is called to give advice.

If one assumes that the lack of equilibrium between
the needs of the heart muscle and the blood supply can
result from vasomotor changes or from lack of such
changes, as well as from anatomic changes, one will
explain a great many of the observations regarding not
only angina pectoris but degenerative changes in the
heart muscle which it is difficult to explain on a purely
structural basis.

It is recognized, for example, that angina pectoris
frequently occurs in patients of whom there is no clin-
ical reason to suspect pathologic changes in the. heart
or its vessels and in whom there is no clinical or
laboratory evidence of such changes. At autopsy such
persons frequent!]' show onl]' such alterations as would
be expected at the age at which they die. It must
always be borne in mind that most persons will have
very definite coronary changes by the age of 45, as
shown by Brooks. 31 Also, as Allbutt puts it, “few
elderly persons die without as much coronary disease
as would content a coronarian disputant,” and yet only
a portion will have had angina.

The assumption of a vasomotor factor would also
explain why angina seems to be more frequent in a
group of persons who appear to be more highly organ-
ized or less stable nervously or who have what Hous-
ton 1 - referred to as the “spasmogenic aptitude.” In
such a group, autonomic imbalance is frequently
expressed in many ways.

In this connection the observations of Gregg 13 are
of interest. In a study of a psychotic group as com-
pared with the normal population, he found coronary
disease one-fourteenth as frequent and ulcer of the
stomach one-third as frequent in the psychotic group.
He stated the belief that this is because in the normal

9. Hall, G. E.: Arch. Int. Med., to be published. _ .. .

10 tic TftVats, Geza, and Fcnn> G. K. t The Mechanism of Death in
Pulmonary Embolism. Arch. Int. Med., to be published.

H. Brooks, Harlow: A Preliminary Study of the \ isceral Arterio-
Am. I. M. Sc. 131: 778*786, 1906.

v 1 ? Houston/ William K-: The Art of Treatment, New York, Mac-
, 10 . 16 . . „ . . _

'he Relative Immunity of Psychotic Cases to
and Other Diseases, Tr. Am. Neurol. A., 29JS,

person there is a more prolonged physiologic response
to autonomic stimuli, while in the more primitive pat-
tern of the psychotic person such reactions are brief
and the organism is relatively immune to the results
of emotional stress and fatigue. It is possible also that
emotional phenomena express themselves in behavior-
istic activity rather than in a physiologic equivalent.

The assumption of such vasomotor phenomena would
also explain the frequent occurrence of angina pectoris
in patients working tensely, under conditions of stress
and strain, with inadequate rest and relaxation. There
is reason to think that fatigue and emotional stress also
tend to produce an autonomic imbalance, just as during
the World War the aviators showed evidence of an
overlabile autonomic system as the result of staleness.
This condition would be relieved by a period in the
rest camp.

It would also explain why the patient who suffers
daily attacks of angina of effort under the strain of
his daily work is able to undergo much more physical
effort without attacks while he is away on vacation.
On his return to what Dr. Bucknill, in his reply to
Thomas Arnold, referred to as the “anxiety and eager
competition” of his business life, he experiences the
return of the attacks. Certainly the anatomic condition
of the coronary arteries does not change back and forth
between city and country.

It would explain also the occurrence of anginal pain
in the so-called effort syndrome, or neurocirculatory
asthenia. Whatever the group with this condition may
or may not be, it is a group of younger persons char-
acterized by an overlabile autonomic system, responding
to smaller stimuli than normal and over-responding to
such stimuli. This condition frequently follows as the
result of fatigue or of physical or psychic trauma. It
may follow such trauma in normal persons, if the trauma
is severe enough or exerted over a long enough period-
It will result more readily in the group which Camp-
bell 14 classified as “constitutionally inferior.”

It is my own impression also that such an assumption
of a vasomotor factor might explain in part the age
incidence of angina. Several years ago I attempted
show that the autonomic response as measured by digi a
pressure on the carotid sinus increased with age "P
to the middle or late fifties and then showed a decrease,
with a curve approximating the morbidity cane
angina pectoris. 15 _ . . j.

Quite apart from angina pectoris, however, I t '
that one should bear in mind the possible resit s
such frequently repeated vasomotor changes _ on
structure of the cardiac muscle and their part in 1Ci

allure. ,

Hall, Ettinger, Banting and Manning 10 have s i ^
he anatomic changes produced in the heart muse
he dog by a prolonged or repeated vagus stimu* '
Ilumgart and his co-workers IT have shown lhat
i 0 rary arrest of the blood flow in a sing e coronal

rtery leads to anoxemic electrocardiographic c ■

14. Campbell, C. Macfie: The Hole of InstincJ. Emol.^o
maKty in Disorders of the Heart, }. A. M. A. -

*15! Gilbert, X. C.: The Increase of Certain
tcrcascd Age. Arch. Int. Mel. SI: 425-452 (Mafc » An

1C. Hall. G. E. ; Ettincer, E. IE. ant BantmK. 1 1. “y rdijl
ental Production of Coronary TbrotAojH and M> ■ „ slli t.
. * a y »> « . o.i s ilrrn 1 10 . 16 . .Manning. o- * , _ r

• Vastus Nerve in the Dos;. Aid. ~rf} </ “{"Jonnc, Miltt»v—
17. Bhirogart, Herrman L.; Hoff. *. Effect of

Mesintrcr. Monroe J.-. Experimental bodies physician* -*-•

rary Occlusion of Coronary Arlene*. Tr. A. Am.

|»J». J Jl’UU,

1927

Volume h3 POLYPS OF COLON AND RECTUM— SWINTON AND WARREN

Number 22

in one minute. Arrest of flow for from twenty-five to
forty-five minutes resulted in areas of necrosis.

As I have said previously, the assumption of such
vasomotor influences on the coronary flow is by no
means new and is a clinical concept accepted in whole
or in part by a large number of clinicians today. In
attempting to emphasize its importance, I do not wish
to appear to minimize at all the importance of anatomic
changes. The physiologic factors are frequently super-
imposed on such anatomic changes. Nor do I wish
to minimize the importance of the many other factors
of which the volume of coronary flow is the resultant.
Among these are included the observations of Dr. Kerr, 18
confirmed as they are by his therapeutic results, and
the work of Kountz 10 and others.

Such vasomotor phenomena constitute only one fac-
tor in many. The primary importance of such physio-
logic factors lies in the place which they hold in therapy
and in future lines of investigation. Dr. J. B. Murphy
used to say: “Listen to the patient’s story. He is
telling you the diagnosis.” And, one might also add,
the patient is giving you hints as to treatment. The
necessity of avoiding any stimuli which might tend to
produce any vasomotor changes in the coronary blood
supply is obvious. There is also the possibility of
avoiding or minimizing such stimuli by therapy directed
toward that end. Because of the nervous background
in so many cases, what Kipling once referred to as “the
therapeutic value of words” is often quite as important
as any one form of therapy.

Because a patient has typical anginal pain does not
always mean that conditions are present in the heart
which absolutely preclude any possibility of an adequate
coronary flow. Changes in the coronary arteries are
undoubtedly present in the usual case of angina pectoris,
just as such changes are present also in any normal
person of a similar age. In many cases the anatomic
changes in the coronary arteries are the largest single
factor, or even the one single factor, responsible for
the symptoms. In a great many others, such arterial
changes are only one of many anatomic and physiologic
factors. Just what these other factors are must be
sought for in the patient’s history and in the- physical
and laboratory examinations.

Treatment must depend on an evaluation of just what
conditions are valent in producing a disproportion
between cardiac needs and cardiac blood supply. In
spite of all that has been said and written, a great deal
still remains to be learned with regard to the physiologic
background of anginal pain and with regard to thera-
peutic means to offset or combat whatever conditions
may be responsible for angina pectoris.

104 South Michigan Avenue.

18. Kerr, W. J. : Tr. A. Am. Physicians, to be published.

19. Kountz, W. B,: The Coronary Flow in Dilated Human Hearts,
Proc. Am. Soc. Clin. Investigation 15 : 453, 1936.

Ideal Weight. — The amount o! fat which an individual
should normally carry can only be stated vaguely. The ideal
quantity is undoubtedly that which allows the maximum of
physical enjoyment and mental happiness. Every one should be
acquainted with the weight which is best for himself, remember-
ing the figure in stones and pounds just as readily as he remem-
bers his size in hats, gloves, shoes and stockings. For most
people the best weight is that which they held in the twenties,
but as age advances many leave it gradually behind ; most people
look back to those years as the fittest of their existence. —
Christie, 'W. F. : Ideal Weight : A Practical Handbook for
Patients, London, William Hcinemann, 193S.

POLYPS OF THE COLON AND RECTUM
AND THEIR RELATION TO
MALIGNANCY

NEIL W. SWINTON, M.D.

AND

SHIELDS WARREN, M.D.

BOSTON

During the past ten years the treatment of carcinoma
of the colon and rectum has been vastly improved. At
this clinic the resectability of lesions of this type has
risen from 50 per cent in 1928 to 89.9 per cent for
the year 1938. In the same period the operative mor-
tality has also been greatly reduced. A mortality of
36 per cent in 1928 has been lowered to 10 per cent
in 1938. These figures are but an index of what has
occurred generally when there has been an especial
interest in this subject. The improvements have been
due largely to the better preparation of these patients
for operation, improved anesthesia, increased experience
in the actual removal of these lesions and better post-
operative care. The end results following the removal
of malignant lesions of the colon and rectum are among
the most satisfactory of any group of patients with
malignant disease. In this clinic at the present time
42 per cent of the patients who have undergone radical
resection for carcinoma of the colon and 47 per cent
of those who have undergone radical operation for
carcinoma of the rectum are alive and well, without
evidence of recurrence, five years after operation.
However, last year, in reviewing a series of 300 patients
with carcinoma of the colon and rectum, we were a
little discouraged to find that the average duration of
symptoms at the time of resection was nine months.
This was the same duration that was revealed by a
similar study five years previously. We believe that
the early diagnosis of malignant disease in the large
bowel has not been sufficiently emphasized and that
there is a need for further study and discussion of the
development and early stages of carcinoma of the colon
and rectum.

It is our purpose in this paper to review a series of
156 patients with benign and malignant polyps of the
colon and rectum who have been operated on at this
clinic during the past eight years. By this study we
hope to bring about a more widespread understanding
of the development of malignant disease in this region
and emphasize factors that will bring these patients to
operation earlier than in the past.

In this analysis of polypoid disease of the large bowel
the premalignant nature of polyps of the colon and
rectum will become evident. The etiology of this dis-
ease will be briefly discussed. The transition of benign
polyps into carcinoma will be reviewed from a clinical
and histologic standpoint. Criteria will he discussed for
the diagnosis of malignancy in polypoid disease of the
large bowel. The plan of management in both the study
and the treatment of these patients as employed in this
clinic will be presented.

The term polyp has been defined as a tumor arising
from mucous membrane and attached to that mucous
membrane by a pedicle. In this study the term polyp
will include not only those pedunculated tumors arising

J- rum me uepannient
England Deaconess Hospital.

he J°F , th c e S . ecti ™ ™ Castro-Emerology and Proctology at the
May'rf 1 Sesslon of t)lc American Medical Association, St. Louis,

umic, ana the New

1928

POLYPS OF COLON AND RECTUM— SW INTON, AND WARREN M-*.a.su

Nov. 25, |}i|

from the wall of the large bowel but also those sessile
tumors arising from mucous membrane which have no
demonstrable pedicle. We refer to these polyps as
mucosal polyps ; the majority are true adenomatous
polyps, although in a few fibromatous and papillomatous
characteristics may predominate. Thrombosed inter-
nal hemorrhoids, hypertrophied anal papillae and other

Fig. 1. — Benign mucosal polyps of the rectum seen through the sigmoido-
scope.

fibrous tumors arising distal to the true rectal mucosal
segment har e been erroneously referred to as rectal
polyps'. We have never seen malignant disease develop
in tumors of this type, and such polyps are not included
in this study.

Polyps of the colon and rectum may be single or
multiple and may he found in any portion of the large
bowel. They may involve the entire colon and rectum.
Clinically, we classify mucosal polyps as benign or
malignant, single or multiple, and refer to cases of
multiple polyps as multiple polyposis. Buie 1 has
pointed out that this use of the term multiple polyposis
is fundamentally incorrect; nevertheless it has been

iv. • "A . . v • • j -

& ;■ ~ V-* V i; ;.' \

"c 4:' v.

m-w.

. ‘ *•> .

Fig. 2 - — Benign polyp in sigmoid demonstrated by contrast a»r enema
technic.

generally accepted. The cases of polypoid disease ot
the entire colon and rectum, demonstrated by McKen-
nev 2 to be congenital in character, we refer to as con-
genital multiple polyposis of the colon and rectum.

j Jiule, L. a.: Practical Proctology, Philadelphia, W. B. Saunders

^TltcKmueV. D. C.t Multiple Polypes of Colon: Filial Factor
and Malignant Tendency, J. A. M. A. 10, : IS, 1-18,6 (Uec. aj lvsu.

Histologically, the structure of polyps varies mark-
edly. A fairly typical polyp may be described as at
epithelium covered stalk of connective tissue, moderately
vascularized and usually provided with a muscularis
mucosae continuous with that of the intestinal wall,
and it may contain scattered smooth muscle fibers in
its deeper substance. This stalk may be single and
fairly straight or it may be frondlike. Multiple closely
adjacent stalks may make up a single sessile polyp.
The covering epithelium ranges from the normal mucosa
of the large intestine to irregular glands, variable in
size and shape and lined with tall columnar epithelium
with large, vesicular nuclei and prominent nucleoli fre-
quently containing mitotic figures. Many times the
normal mucosa is absent or is present only along the
base of the stalk. The amount of mucous secretion
varies greatly ; goblet cells may be numerous. Masses
of mucus may occur on the surface of the polyp and
may penetrate into its stroma. Occasionally no mucous
secretion is apparent.

Fig. 3. — Malignant adenoma of transverse colon.

In the sessile type of polyp with broad base ^
nay be multiple small prolongations of the su
of the intestine with any of the aforementionc
of mucosa covering them. In these the stran s ^
rective tissue are never so long as in the more ..
:ype and the amount of muscularis mucosa
greatly, sometimes being entirely absent, m < > .

;he mucosa is of fairly even thickness and usua )

■veil defined boundaries from the stroma. f

In either type of polyp there is usually no e\
jf inflammatory reaction other than a M'g 1 > '- on
:ytic infiltration at the base. Rarely f° ca
m necrosis may be present, usually at t re >P- ^

:o the marked vascularity, small hemorrhages > ^ ,j ; e
md hemosiderin-laden macrophages apP« ' f ;

stroma as evidence of past trauma. L re ^ t !;c
:he polyp always merges smoothly vviHi i j ^

rdjacent normal intestinal wall and fl 3 )nri

je noted the normal mucosa continues "

:he stalk.

1929

Volume 113 POLYPS OF COLON AND RECTUM— SWINTON AND WARREN

Number 22

It is possible in our series to demonstrate histologic-
ally all stages in the sequence of change from normal
colonic mucosa to actual adenocarcinoma.

The etiology of polyps of the colon and rectum has
not been accurately established. McKenney has made
a careful study of a group of patients with polyps, one
of whom was an infant aged 2 years. He obtained con-
vincing evidence of the congenital nature of the cases
of multiple polyposis of the entire colon. Erdmann and
Morris 3 classified all cases as either congenital or
acquired. The reported frequent observation of the
development of multiple polypoid-like structures in cases
of ulcerative colitis suggests the “acquired” nature of
some of these tumors. From a microscopic study of a
large series of intestines from patients with chronic
ulcerative colitis, both specimens removed surgically at
varying lengths of time after onset of the disease 'and
specimens obtained at autopsy, we believe that chronic
ulcerative colitis is not a factor predisposing to the
development of polyps. While the very extensive ulcer-
ations may at times fuse and leave elevated strips of
mucosa, or may actually undermine strips of mucosa
communicating with one another so that bridges or free
tags of mucosa may be left, examination of these
bridges or tags which may simulate polyps shows a
definitely different type of structure. The mucosa is

Fig. 4. — Large benign mucosal polyps successfully removed from sigmoid
by colotomy.

never normal, nor is there the usual hyperplastic change
seen in polyps. Instead, there are atrophy of the mucosa
and varying amounts of chronic inflammatory reaction,
often with fibrosis — a marked contradistinction to the
! neoplastic type of polyp.

In our patients with ulcerative colitis we have
observed another interesting fact. Following healing
of the acute ulcerative process, we have known these
pseudopolvpoid tumors to regress and disappear. After
ileostomy and total colectomy in multiple stages in
patients with severe ulcerative colitis in which tumors
of this type have developed, examination of the removed
sections of colon and rectum has frequently revealed the
‘ complete disappearance of these mucosal irregularities.

- We have never observed the regression or disappearance

’ of true polyps of the large bowel except in rare

instances in which the polyp has broken away from
? ks pedicle. This, of course, also definitely suggests

' that the pseudopolypoid tumors resulting from known

.• irritation and infection have different fundamental

growth characteristics than the discrete and multiple
polyps which are not the result of known infectious
processes. It must be recognized that, in cases of exten-
, sive polypoid disease of the large bowel, bleeding and
discharges will frequently be observed. The marked

0 3* Erdmann, J. F., and Morris, J. H. : PoJvposis of the Colon, Surg.*
y Gyncc. & Obst. 40: 460-468 (April) 1925.

increase in epithelial surface and the increased activity
of the mucosa of the polyp account for the increased
mucus in the stool. The numerous thin-walled vessels
in the stalk are easily traumatized and are the source
of frequent small hemorrhages. The differentiation
between ulcerative colitis in which polypoid changes

‘j : ■ “““"V “ i . " V

Fig. 5. — Malignant adenoma originating from mucosal polyp removed by
modified Mikulicz resection.

have taken place in the mucous membrane and multiple
polyposis associated with blood and increased amounts
of mucus in the stool must be recognized. We have
never observed the polypoid changes seen in ulcerative
colitis progress to a malignant stage.

Because of these facts and because of the well dem-
onstrated congenital nature of the cases of multiple
polyposis of the entire large bowel, we believe that
the majority of polyps of the large bowel are true
tumors and are the result of some inherent defect in
cellular growth.

Fig. 6. -—Adenocarcinoma of the colon arising in benign mucosal polyps
removed by modified Mikulicz resection.

There is no way in our series of cases of polypoid
disease to determine the true incidence of colonic and
rectal polyps. Buie has reported that about one in
thirty-five patients on whom proctoscopy was performed
for colonic and rectal disord ers had polyps. Lawrence, 4

505^March? C 1936.‘ C " Gast! ' o!n * esliM ' Polyps, Am. J. Surg. 31:499-

1930

POLYPS OF COLON AND RECTUM— SW INTON AND

-- 1 AtrNuJj-, , v.-.. <x'f

M

'-v* it * flS*. ,% ***v. » **- * ' ■ ** * ‘ >Si - — ^

A*

SMi^' ....

Fig. 7. — Section of beingn mucosa] polyp of pedunculated type. Note
normal mucosa on one side of stalk and abnormal mucosa on other;
reduced from a photomicrograph with a magnification of S diameters.

of 1,100 autopsies. This low incidence of polypoid
disease in the rectum as compared with that in the
colon does not agree with our experience, as our figures

j--.

Fig. S. — Mucosal polyp of sessile type,
the submucosa of tbe intestine.

Note multiple prolongations of

will demonstrate. As our interest in polypoid disease
of the colon and rectum has increased and our indica-
tions for proctoscopic and roentgenographic examina-
tions have widened, we have found more and more
polyps in this region, and we believe that the incidence
of polyps of the rectum and colon is much greater than
has been recognized.

WARREN Jo?*-a.m..i

Nov. 25, 19J?

reporting a series of 7,000 autopsies from the Cook
County Hospital, found an incidence of polyps in the
colon of 2.37 per cent and in the rectum of only 0.42
per cent. Lawrence quotes Susman as finding an inci-
dence of polyps in the colon of 6 per cent in a series

The location of the polyps found in this series o!
patients is identical with the generally recognized dis-
tribution of carcinoma in the colon and rectum. Seventy
per cent of the polyps in this series were visualized
through the 10 inch sigmoidoscope. In this study we
have included only those cases in which histologic sec-
tions were made of the removed polyps. There have
been an additional number of instances of polyps that
were small and were destroyed by figuration in which
no sections were taken for microscopic examination.
Actually the incidence of polypoid disease in our series
that could be demonstrated on sigmoidoscopic examina-
tion was above 70 per cent.

In thirty-five cases in this series the polyps were
benign. Single polyps were found in thirty-one and
multiple polyps in four. Malignant polyps were encoun-
tered in 121 cases. A malignant adenoma alone was
found in seventy-two cases and multiple malignant ade-
nomas were noted in four other cases. The malignant
adenomas were associated with either single or multiple
benign polyps in forty-two additional cases. Three
cases presented the congenital type of multiple polypo-
sis, in two of which malignancy was present at the time
of resection.

Fig. 9, — Adenocarcinoma arising in the tip of a benign ntcccvi r
Insert shows cross section of the entire polyp with its base ana a i
intestinal mucosa.

This high incidence of multiple polypoid lcsions^bodi

benign and malignant, must be recognized and cm
sized. In this series of 156 patients the polypoid Ies 10i
were multiple in 35 per cent. ,n, c

Polypoid disease may be found at_ any age-.

patients with benign polyps in our series varied in
from 7 to SO years. The average age^was -«•

The

the malignant group the average was 57.7 years. jj
youngest patient with a malignant adenoma was^
years of age and the oldest was a man of/o. > j

not see a large number of children in this clirn^ 1

we do not believe that we have a representative ^
group to determine accurately the age inciden
polypoid disease in younger persons. j.|, c r

The proportion of males and females wit
benign or malignant polyps was equal. _

Unfortunately, polyps do not give rise to sympKfj

early in their development. Bleeding was
with one half of the benign polypsjnjnir sen ^ {fl

in the majority of these cases it wc
determine whether the bleeding canw A , a! in

or from associated anal disease. Brust “ stated — — -

Frclum act LJi

5 Brust J. C. M-: Solitary Adenomas of (l> *

Portion of the Sigmoid. Tree. Staff Meet.. Mayo Clin. 0.6->

17) 1934.

1932 POLYPS OF COLON AND RECTUM— SWINTON AND WARREN

recognized by the anaplastic character of the cells, the
irregularity of the glandular structure and the invasion
of not only the immediate stroma but also the adjacent
intestinal wall, there are many early or transitional
forms that are difficult to classify. If one accepts three
important criteria of malignancy — anaplasia, irregularity
of architecture, and invasion — it is necessary to have
at least two of these three factors present before making
a diagnosis of malignant growth. It is possible for any
one of these three criteria to be present without an actual
malignant condition, with one exception: Definite
lymphatic or intravascular invasion nearly always means
a clinical malignant condition.

It is important, in attempting a histologic diagnosis,
to recognize that different portions of the polyp may
present entirely different histologic pictures. There-
fore we feel that it is important to make a sufficient
number of representative sections and to' include an
adequate representation of the base. It is particularly
important to determine whether or not the base is

• **£V r "TV- -

•• -• U -/

• t «*-v ? / { &.* v *h -7

/«• ■. ‘t/jy /

. w *$#*■-

W21 L*

Fig. 12 . — Method of fulguration of broad, sessile polyp and removal of pedunculated polyps with
high frequency electric snare. The Buie type sigmoidoscope with built in suction is very useful
for this work.

involved, as this determines the extension of the lesion
into the intestinal wall. One of the most satisfactory
means of sectioning is to have the plane of the section
parallel to the long axis of the polyp and at right angles
to the intestinal wall.

We believe that malignant change may begin any-
where in a polyp. Saint 6 has pointed out that the
youngest glands will always be found near the periphery
of a polvp and that early malignant change in a polyp
will be found near its tip. This cannot be depended
on in determining malignancy in polypoid disease. In
a patient recently examined, we removed fourteen sec-
tions of tissue from a large polyp before finding a
region of malignant growth in the polyp near its base.
The entire polyp together with its base must be exam-
ined microscopically for an accurate diagnosis of malig-
nancy. However, in a few of the broad based polyps
complete removal may not be feasible. In tumors of
this type biopsy specimens should be taken from the
firmest areas near the base of the polyp.

The visualization and palpation of polypoid structures
are of the utmost importance in establishing their benign

c T H • Polvni of the Intestine with Special Reference to the
Adenomata*' Brie j. SuZ 15:99-119 (July) 1927.

Jouit, A. St. .(
Nor. 25, !?;•

or malignant nature. Ulceration, nodular irregularities
and a broad pedicle and base suggest malignant change,
rirmness, induration and fixation to palpation arc 1
pathognomonic of malignant disease. Although it is
probably true that a malignant condition is rare in
polyps less 'than 1 cm. in diameter, during the past
two years we have encountered malignant change four
times in polyps smaller than a walnut. The size of a
polyp is not an accurate index of its benign or malig-
nant character.

In the last eight years we have operated on 82?
patients with malignant tumors of the colon and rec-
tum. In 32 per cent of this series the lesions were
in the colon, and in 68 per cent the malignant condition
was found in the rectum and rectosigmoid region of the
colon. . In 120 cases, or 14 per cent of this entire series,
the lesions were true malignant adenomas. We believe
that we can say from our study of this series of cases
that 14 per cent of the malignant tumors of the colon
and rectum can histologically be demonstrated to have
arisen in benign mucosal polyps. Jr
the remaining cases of carcinoma ot
the colon and rectum the invading
tumor was so extensive that the
original architecture of the tumor
could not be identified, but we
believe that a much larger per-
centage of carcinoma of the colon
and rectum arises from preexisting
benign mucosal polyps. Fitzgibb®
and Rankin/ following the classifi-
cation of Schmieden and YVesthii®.
believe that certain polyps ne_' cr
undergo malignant degeneration.
Although polyps that are entire*)
covered with norma! mucous mf™'
brane may not become malignant,
clinically' we believe that this J* 3
dangerous doctrine to follow. ie
facts that in 14 per cent of all 011
cases of carcinoma of the colon ®
rectum the malignant condition 03
be demonstrated to have arisen «
mucosal polyps, that in our sen ’
it has been possible histologic*,
stages in the sequence of c!®Vj
from normal mucosa to nrlonnrarcinoma an

to demonstrate all

adenocarcinoma

the distribution of polypoid disease in the

colon and
iwtln

rectum parallels the distribution of malignant
in this region are sufficient evidence to justify '
eration of all polyps of the colon and rectum a.

malignant lesions. inwvetf

If we are to detect early malignant change ana P
the subsequent dev'elopment of carcinoma m tins » ,
all polypoid structures in the colon and t cc Z x n! 'c
be removed or destroyed. It is our policy at 1 ^

to fulgurate those polyps which are believer .
benign and which may be visualized throng !
nroidoscope. With the high frequency e ec r ."jjj;.

*hiy

polyps with a pedicle may be removed W1 . u „ n J
cultv. The small sessile polyps may be A sn :
destroyed with the fulgurating unit, tj s U,...,
to destroy thoroughly the base of the po DP ; y, t ; : -
ing fulguration, to observe that area fr — —

. - . — i ■* . . . * * ■ * * . * * *' 1 " 1 ^ *

7 Fitzgilibon, Grattan, and Itankin. F. W. : j/Aj , ,

Intestine, Snrg.. 0>ner. * Ota. 53 W

8 . Schmieden, V., and W«Au». H- Z» r
Dickdarmpolypen und deren khmsche un ' P A f Ch*r.
hungen zum Dickdarntkarzinom, Deutsche Ztschr,

1927.

VotUME 113
Number 22

PERINEAL COLOSTOMY— BABCOCK

1933

polyp has been removed at frequent intervals for a
period of months to be certain that the tumor does not
recur. In polyps above the reflection of the peritoneum
and in the rectosigmoid region of the colon, consider-
able care must be exercised to avoid perforation of
the bowel. Troublesome hemorrhage may at times be
encountered. We have never had to proceed with resec-
tion to control hemorrhage following figuration, but
particularly in polyps that lie at a high level this pos-
sibility must be borne in mind. The removal of large
polyps and all polyps that arise above the peritoneal
reflection should be carried out in a hospital where all
facilities are available.

CONCLUSIONS

From this review of 1S6 patients with polypoid dis-
ease of the colon and rectum the following conclusions
may be drawn :

1. Polyps in this region are not the result of diffuse
inflammatory processes but are true tumors.

2. The incidence of polypoid disease in the colon and
rectum is not known, but we believe that it is much
more common than has been recognized.

3. Seventy per cent of the polyps in our series could
be visualized through the 10 inch sigmoidoscope, but
they may be found anywhere in the colon or rectum.
This distribution is the same as that of malignant
growths found in this region.

4. Thirty-five per cent of the patients in this series
had multiple polyps.

5. Polyps may occur at any age and have an even
distribution in the sexes.

6. Symptoms due to early benign polyps are rare.
Symptoms due to malignant polyps are primarily an
alteration in the stool, the presence of blood or mucus,
an alteration in bowel function and abdominal pain.

7. The detection of polyps of the colon and rec-
tum depends on sigmoidoscopic and roentgenographic
studies. The importance of the preparation of patients
for these examinations and the use of the contrast air
enema must be appreciated.

8. Histologically, in this series all stages in the
sequence of change from normal mucosa to adenocar-
cinoma can be demonstrated.

9. In the determination of malignancy in polypoid
disease the importance of the inspection and palpation
of these tumors is emphasized. Histologically, the diag-
nosis of malignant change depends on the study of the
entire polyp together with its base.

10. In our series of 827 patients with carcinoma of
the colon and rectum, 14 per cent can histologically be
demonstrated to have arisen in benign mucosal polyps.
We believe that a high percentage of malignant change
in the colon and rectum arises in previously benign
polypoid tumors.

11. From the data presented in this analysis we
believe that polyps of the colon and rectum are true
tumors which are premalignant lesions; that polyps in
this area are much more common than lias been appre-
ciated and that if all physicians called on to treat dis-
orders of any type of the colon or rectum will submit
these patients to sigmoidoscopic and roentgenographic
studies an increasing number of polyps will be found,
the incidence of carcinoma of the colon and rectum will
be reduced and patients with malignant lesions will be
submitted to operation earlier than has been the case
in the past.

THE ADVANTAGE OF PERINEAL OVER
ABDOMINAL COLOSTOMY

WITH TECHNIC FOR TRANSFERRING THE ABDOMI-
NAL OPENING TO THE PERINEUM

W. WAYNE BABCOCK, M.D.

PHILADELPHIA

In 1930, having observed marked advantages of a
perineal colostomy in resections of the pelvic colon, I
eliminated a permanent abdominal opening in any case
in which the lesion was considered surgically removable.
Since this change in technic 220 patients with cancer
of the large intestine have been treated by operation.
In twenty-six instances the disease was so advanced
that only an exploration or colostomy was done. In
103 the rectosigmoid was resected with the formation
of a perineal anus but without sphincter control.
After the first three or four months of adjustment
these patients have been very appreciative of the
perineal .opening, quite different from the attitude of
many who have been left with an abdominal colostomy.
An abdominal colostomy necessitates a pad or other
protection. With an adequate perineal opening, although
without sphincter control, 5 per cent of my patients
require no local protection, special diet or other mea-
sure to prevent soiling ; 50 per cent by regulated
emptying of the colon and some restriction in diet
are enabled to dispense with a pad much or all of the
time; 30 per cent find the constant wearing of a pad
desirable although it is infrequently soiled, while 15 per
cent, chiefly those careless as to diet and personal
hygiene and those with local recurrence, report fre-
quent soiling.

But the person best able to evaluate the perineal as
contrasted with the abdominal colostomy is the man
who has had both. Such evidence is presented by four
patients for whom I have moved an abdominal colos-
tomy to the perineum. The abdominal colostomy had
been present for from seven months to eleven years and
in three instances it was well formed and uncomplicated.

Case 1. — Dr. H. S., aged 47, in September 1936 had a
one stage abdominoperineal proctosigmoidectomy for carcinoma.
A well formed median abdominal colostomy resulted; evacua-
tions were controlled by colonic irrigations every eight hours.

Nov. 27, 1937, transplantation was made of the colostomy
with an attached ring of abdominal skin to a sphincterless
perineum. The patient was ambulant and discharged from
the hospital ten days later.

March 1939 he reported a gain of more than IS pounds
(6.S Kg.), no incontinence, escape of gas only once or twice
daily, and ability to use a more varied diet than with the
abdominal colostomy. The colon is emptied every other morn-
ing by a plain or salt water enema, between which times he
is free from soiling.

Case 2. — Miss M. H., aged 58, had been treated for mucous
colitis with diarrhea for eighteen months when vaginal bleeding
from invasion of a rectal carcinoma developed.

April 21, 193S, a one stage abdominoperineal proctosigmoid-
ectomy, panhvsterectomy, vaginal resection and left inguinal
colostomy were done. Small cancerous nodules were palpated
in the liver.

By October 27 she had lost her cachectic appearance and
had gained P/z pounds (3.S Kg.) but had had to give up her
work in a bank because of offensive gaseous discharges from
the colostomy.

Read before the Section on Gastro-Enterologv and ProctoloKy at the
May'js' 1 is"? Scssl0n of d>r American Medical Association, St. Louis,

1934

PERINEAL COLOSTOMY— BABCOCK

November 3 the colostomy was moved to the sphincterless
perineum. The nodules in the liver had enlarged.

November 13 she was out of bed; the colostomy was nearly
healed.

December 1 she reported that each enema is followed by
freedom from movement for three days. There is much less
discharge of gas, better control and warning and less care and
more comfort than with the abdominal colostomy.

In April 1939 there was increasing weakness with enlarging
liver.

Case 3. — Mrs. F. H., aged 32, weighing 90 pounds (40.8 Kg.),
had had increasing diarrhea for two years with occasional blood
spotting, recurrent abdominal cramps for six months and recta!
distress for four weeks. The diagnosis was cancer of the
proctosigmoid, infiltrating the uterus, upper part of the vagina
and the region of the right ureter.

March 31, 1938, a one stage abdominoperineal proctosigmoid-
ectomy, panhysterectomy, partial colpectomy, resection and
anastomosis of the right ureter, incision of the bladder and
left inguinal colostomy were done. Postoperative herniation
of the ileum into an open drainage tube and secondary ileal,
ureteral and vesical fistulas occurred.

I 7 6v*.\AVt*e s -to

vvoV. suVureA Vo wound
VsvxV: VacA a\_ Voip oZ

m

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r i

vwvxtfr V\*No c.

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oy'c-'v crvA

i

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cpcw,

3

‘sump" drain

Fig. 1. — (a) The sump drain is valuable in the prevention of spreading peritonitis by keeping
the peritoneal cavity free from blood, serum and contaminating fluids during and after the operation.
Aspiration, most conveniently produced by a miniature electric pump and collection bottle, should be
continuous for the two or three days after operation, that the general peritoneal cavity may be
drained by glass. These tubes, of any desired diameter, length or curve, may be made by any glass
blower, (b) Glass lamp chimney drain, to be anchored by four alloy steel wire sutures over intestinal
suture lines or septic or necrotic areas. These glass tubes, from 2 to 6 cm. in diameter, enable the
daily inspection of questionable healing processes within the body and provide a large vent for fecal
and other drainage. Differing from gauze and rubber drains, the glass is not walled off by adhesions
for several days. These drains should not be used unless they are so anchored that viscera will
not enter and herniate.

In July 1938 abdominal closure of ileoperineal fistula was
done.

Jan. 27, 1939, transplantation of the' abdominal colostomy to
the perineum was done, with closure of the vesical fistula
and a secondary temporary ileostomy.

April 2 a right nephrectomy was done for the uteropermea!

fistula.

April 13 she weighed 105 pounds (47.6 Kg.). She was in
excellent condition. Evacuations were produced only by enema
every third day. There was no evidence of recurrence. There
was a marked "improvement over the abdominal colostomy.

Case 4— S. B., a man aged 60, had a two stage proctosig-
moidectomv for carcinoma with a left inguinal double barreled
colostomv in 1927, followed by an incisional hernia and massive
eventration of the proximal and distal loops through the colos-
tomy opening. The colostomy required hours of attention daily.
There were recurrent draining sinuses in the perineal scar
for which six or more operations had been done. Pollakiuria
and nycturia were present for two years following irradiation.

Joust. A. M. A
Nov. 25, 195!

Dec. 5, 1938, the abdominal colostomy was transferred to
the sphincterless perineum with excision of redundant bowel
and distal loop. Repair of the incisural hernia was accomplished
with buried alloy steel wire sutures. The adherent bladder
in the perineal scar was entered and sutured.

April 1939 the condition is much improved. There are bane!
movements only with enemas, without interval soiling. Pol-
lakiuria is decreasing.

These four patients offer, impressive evidence of the
superiority of the perineal outlet.. It is less messy and
more convenient to care for. ' It requires little or no
local protection. Fecal . discharges are infrequent and
occur with better warning and the expulsive effort of
the abdominal muscles -is more- effective. Escaping
flatus is not as obvious and apparently is better con-
controlled, the pressure of the buttocks' being an added
restraining factor.

The perineal opening also enables the early detection
of a pelvic recurrence by palpation. Thus in six cases
a recurrent nodule was detected and excised at a rela-
tively early stage. Three of these
patients are now living without pal-
pable recurrence from two to more
than four years after the last opera-
tion. Without the diagnostic advan-
tage of the perineal opening, such
recurrences may reach an inoperable
stage before detection.

The site of the colostomy may
influence marriage, as in the case oi
the woman of 32 who insisted that
the abdominal opening be moved to
the perineum. A second patient
after an abdominoperineal procto-
sigmoidectomy with perineal open-
ing at 27 has married and u
considering pregnancy at the age
of 31.

As with an abdominal colostomy
the comfort of the patient with * 1C
perineal opening depends largely on
determining and utilizing st0 . r ’
age function of the colon, u 1C
patient regularly empties the coon
just before its capacity has
reached he will, as a rule, ha'
freedom from evacuation for ron
twenty-four to seventy-two hoim-
Most patients obtain the best rest) -
from a physiologic solution ot
dium chloride or tap water enei ■

3 5 aVVoy cV wire

SuVurci Vo sevous eo&t

“LAMP chimney’ DffAIN

ujuih uuuiiut, r e-

taken in the morning or evening every twenty
to seventy-two hours. For the seventy-two '
schedule a low residue diet the day' after the cn ‘
followed by' a full diet the day' preceding the en
often works well. About 20 per cent of the pa
however, prefer a small dose of a quickly a r
saline laxative, such as one or two teaspoon J ■’
sodium sulfate taken in a little cold w? ,er .
diately on arising. Soon after breakfast, which m
a cup of hot coffee, the colon empties, alter
constipation follows for the two or tin rec < .

Is found feasible to wait before repeating ] .

live. A few of the patients prefer the actu ? a
small amount of castor oil, which with them ‘j .^
more secure secondary constipation. Ui c - ’
petrolatum or laxatives of delayed or pro c, -£ :t .
should not be used. In any' case the pe , (r ; c turc!
should be of adequate size. A narrow or s

22

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1936

PERINEAL COLOSTOMY— BABCOCK

Joes. A. SI. A
Nov. 25, 15.;;

D. When the cancer is attached to the prostate or
posterior vaginal wall, an incision curving forward from
one tuber ischii to the other is used. The traction tape
has preferably been packed somewhat anterior to the
rectum. In women an elliptic excision of the posterior
vaginal wall is made. The attached vaginal wall or
resected portion of the prostate is delivered en masse
with the rectosigmoid. The rectum is divided by
cautery between clamps just above' the sphincters, the
anal ring being divided anteriorly to avoid constriction
and the sigmoid laid but not sutured in the anal groove.

ation js nearly finished. The tied-in rectal tube prevents
fecal soiling of the wound until after the drain has
been removed and primary adhesion obtained.

The operation may be so planned as to be very
radical. . From 25 to 65 cm. of intestine with attached
lymphatics and soft tissues are delivered through the
perineum and removed. In four cases an invaded uterus
with appendages and part of the vagina were removed
with the rectosigmoid. In others, portions of the
vagina, prostate, bladder or small intestine have been
resected. In two patients the ureter was divided or

Fig. 2. — Methods of forming a perineal sigmoidostomy: The rectosigmoid, liberated through an abdominal incision, is pulled indrawn V'-
neum with an attached tape. Method 1, for low lying carcinoma. The anorectosigmoid with lymphatics and pelvic floor has been '' j. t {,c
excised after the placement of dressings. Method 2, the rectosigmoid loop has been withdrawn through a postanal incision. After ” c .t, r0UR h a
openings will be made one by division of the two intermediate partitions. Method 3, the rectosigmoid has been delivered and r « m0V * ttac hcd to
anal incision and amputated and the sigmoid laid but not sutured in the split anus. Method 4, for growths of anterior rectal wai 3nu « t

prostate. The diseased tissues are delivered through an anterior curved incision and removed and the sigmoid end is brought throug
is split anteriorly.

A 2 cm. curved perforated glass tube drain is carried
through a stab wound at the right side of the coccyx
along the sacrum. The anterior perineal wound and
vagina are closed without tension, preferably with
buried layer sutures of alloy steel wires. After the
dressings are in place, the protruding sigmoid is cut
away and a soft rectal tube tied in. It will be observed
that the technic eliminates bacterial contamination from
crushing or suturing the bowel and that the diseased
segment need not be entered or excised until the oper-

resected. In both a ureteroperineal fistula forme
the point of anastomosis, for which a nephrectomy
later done with recovery. • r( j 2

As the divided sphincters are often reU . ^. a5
secondary plastic reconstruction of the ana r =. ..

tried in a few of the early cases. Most patien ^
ever, soon learn to regulate their evacuations - ,

that they consider such an additional operation j £f
sary. In some the motor innervation ot t " ufa |
has been damaged. In any case a tight o

Volume 113
Number 22

PERINEAL COLOSTOMY— BABCOCK

1937

anal opening gives much more trouble than a wide
open one that is properly cared for.

Stage operations to divide the operation into steps or
to enable what is at best an inadequate cleansing of the
cancerous segment of intestine have not been found of
advantage. To the dangers of the first stage there is
added a second stage made more difficult by post-
operative adhesions and complicated by the danger of
contamination of the wound from the openings of the

Table 1. — Operations for Cancer of the Intestine, 1930-1939

Arcs

. . 20-29 30-39

40-49

50-59

CO-69

70-74

75-79 Total

Number

..3 17

50

75

53

15

7 220

Per cent

.. 3 A 7.8

22.$

34

24.2

6.6

3.2

colon on the abdomen. I have found that the single
stage operation may be done with greater facility, in
shorter time and with no greater shock than the second
stage of the two stage operation. A preliminary
enterostomy or an appendicostomy (which may be
gradually dilated to admit a rectal tube) is, of course,
important if there is preoperative intestinal obstruction.

Perineal proctectomy or proctosigmoidectomy with a
perineal anus for cancers lying below the peritoneal
reflection is a safer operation (mortality in forty-one
cases, 4.5 per cent) than the abdominoperineal operation
but has important disadvantages. It does not enable an
abdominal exploration, radical removal of tributary
lymphatics or, in many cases, an adequate blood supply
to the retained bowel. If more than from 15 to
20 cm. of bowel is removed the end of the sigmoid
brought to the perineum usually sloughs, and a stric-
tured and cicatricial anal opening results. Neverthe-
less, on account of its greater safety I consider it the
operation to be selected for the lower lying rectal
cancers when, because of great obesity, senility or
grave organic disease, the mortality of an abdominal
operation would be high. An example is a man weigh-
ing 278 pounds (126 Kg.), who had an uncomplicated
recovery from the perineal operation. As with the
combined operation, a perineal glass drain is desirable.

After an abdominal colostomy a collateral circulation
to the terminal bowel develops and the retained portion
of sigmoid may elongate — conditions favorable to the
transfer of an abdominal colostomy to the perineum.
The opening is plugged with antiseptic gauze and
closed with sutures. The liberated end of the intestine

Table 2. — Radical Operations for Cancer of the Colon and
Rectum Since January 1930

• - - -

Deaths

13

Mortality

25 %

3

Resection and End to End or End to Side Anastomosis

Total cases, 34

5.8%

Early cases, IS

4

22 %

Recent cases, 16

Mikulicz Operation

1

C.2%

45 eases

9

20 %

is covered by a cap of gauze and rubber dam securely
tied on with a long tape. The sigmoid segment and,
if necessary, the descending colon are then sufficiently
mobilized from peritoneal and other attachments to
slide at least 12 cm. (5 inches) below the posterior
pelvic brim. The soft tissues in the midline close to the
sacrum are divided and then tunneled to the pelvic floor
until a channel is formed through which the sigmoid
may easily be drawn. The tape is packed in this
tunnel, the end of the sigmoid laid over the opening
and the abdominal wound closed. With care not to

injure the urethra or bladder, the perineal scar is
opened from below and .the tape and attached sigmoid
are pulled through. A glass tube drain is introduced
at the side of the coccyx or through the incision back
of the sigmoid. If a ring of abdominal skin has been
brought down with the bowel, it may be sutured to the
edges of the perineal wound; otherwise the sigmoid
protrudes through the perineal wound without suture.
It is desirable to fasten a rectal tube in the sigmoid
so as to prevent soiling during the first few days after
the operation. The glass drain is usually removed in
from twenty-four to forty-eight hours.

Palliative colostomy for advanced and ineradicable
carcinoma of the colon is to be deprecated. The post-
operative hospital mortality in my experience is 27 per
cent, and often it seems better to use simple decom-
pressive methods or let the patient die obstructed,
soothed by opiates and perhaps an intradural injection
of alcohol, than to render his last days a burden and
offense to himself and friends by a colostomy.

F*S'- 3 (case 4). — Colostomy with incisural hernia and prolapse of
proximal and distal segments, previous to resection and transfer to the
perineum.

I have seen no worth while benefit, and much
unnecessary suffering, from the use of x-rays or
radium in large dosage in the treatment of well advanced
carcinoma of the large intestine or as a prophylactic
postoperative treatment.

Ileus is a fairly frequent complication after resection
of the large intestine. When not due to diffuse puru-
lent peritonitis, the mortality under proper treatment
should be low, for recovery usually follows a simple
but early decompression of the distended bowel. Rectal
and duodenal tubes with aspiration are first used. If
no relief follows, the most distended intestinal coil is
carefully localized by physical signs and an overlying
3 to 6 cm. muscle splitting incision made. A small
portion of the distended coil is withdrawn, occluded with
a soft rubber covered clamp, and a fine silk purse string
suture introduced, with which a 14 F. soft rubber
catheter is tied in. The intestine is anchored to the
edge of the incision, and the small wound is closed
around the catheter. Gentle continued irrigations with
warm saline solution are continued until the intestine
is decompressed. After the decompression the obstruc-
tion usualh disappears in from twenty-four to seventy-

1938

PERINEAL COLOSTOMY— BABCOCK

Joui. A. 31. .1
Nov. 25, li:;

two hours, but the tube should be left in place a week
or more. Common mistakes. responsible for mortality
are delay, prolonged exhausting procedures, as in using
evacuants or the Miller-Abbott tube, large abdominal
incisions with eventration, introduction of the hand into
the abdomen, attempts to liberate adherent intestine,
and the use of large caliber rubber tubes for the colos-
tomy, which may cause perforation. If intestinal coils
continue to be distended, additional simple enterostomies
should be done. Thus in one case aij ileostomy,
cecostomv and finally a transversostomy was done
before relief was obtained. With diffuse purulent
peritonitis the mortality is, of course, much higher,
but a percentage of the patients can be saved by a
similar type of enterostomy or enterostomies and the
use of “sump” drains.

Metastasis to the liver was found in twenty-nine cases
at operation. In nine the invasion of the liver was
far advanced or the primary lesion inoperable. A
palliative colostomy was done in six and simple explo-
ration in three. In the remaining twenty cases the

postoperative distention or distress. Not infrequently
they were out of bed by the tenth or twelfth day and
were discharged from the hospital a few days later.
But 25 per cent of the patients died, usually from
peritonitis. In separating and delivering cancerous
colon, recognized or unrecognized breaks in the bowel
or in overlying contaminated tissues frequently occur.
The liberated bacteria multiply in residual blood and
wound secretion and diffuse in the serum of the
peritoneal cavity, causing a spreading peritonitis.
Therefore it was found desirable to keep the abdominal
cavity free from blood and fluid until isolating adhesions
had formed. Four years ago I introduced a method of
“internal exteriorization” by' anchoring glass tubes of
large caliber (lamp chimney drains) over septic intra-
peritoneal areas or lines of intestinal suture where
leakage was feared. Through these open tubes I have
observed day by day the very slight reaction of the
human peritoneum to glass or air. With glass drains
the general peritoneal cavity remains open, free from
adhesions and drainable for from forty-eight to seventy-

co\osYow\>f c\ooe^« .^recA.anA

Volume 113
Number 22

DISCUSSION ON NEOPLASMS OP LARGE INTESTINE

1939

with better drainage peritonitis is not the predominant
cause of death, the more recent mortality from procto-
sigmoidectomy has been due to thyroid crisis from
massive intrathoracic goiter (one case) and pyoderma
of the abdominal wall (one case) .

Operations on patients with perforated carcinoma of
the intestine with abscess, internal or external fistula
and necrotic soft tissues usually carry a high mortality.
This was an important factor in my mortality with the
Mikulicz- Paul stage resection (20 per cent). Recent
experience indicates that this figure also may be sharply
reduced by well placed tubular and aspirating glass
drains. In my general series the bladder was invaded
in five, the uterus or ovary in five, the ileum in three,
the pancreas and jejunum in one and the stomach and
jejunum in one, while the vagina or prostate was
invaded in several cases. As a rule, the invaded part
was resected or removed.

SUMMARY

Superiority of the perineal over the abdominal arti-
ficial anus is evidenced by 103 operations in which the
sigmoid was brought to the perineum and four opera-
tions in which an old abdominal colostomy was trans-
ferred to the perineum.

With a perineal colostomy most of the patients are
able to dispense with pads or other local protection.

There is slight peritoneal plastic adhesive reaction to
glass or alloy steel wire as contrasted with a marked
reaction to gauze, rubber, catgut, silk and other
substances.

Special glass drains are introduced which have
proved of value in preventing and treating peritonitis
following resection of the large intestine.

There is a simple and effective operation for post-
operative ileus.

Colostomy and heavy irradiation should not be
employed in the terminal stage of intestinal cancer.

Alloy steel wire is valuable in the abdominal and
perineal closure of clean and contaminated wounds
incident to the operations on the intestine.

1720 Spruce Street.

ABSTRACT OF DISCUSSION

ON PAPERS OF DRS. SWINTON AND WARREN
AND DR. BABCOCK

Dr. C. F. Dixon, Rochester, Minn.: The paper dealing with
colonic and intestinal polypi emphasizes what can be accom-
plished if several such lesions are diagnosed early. Robertson
is of the opinion that SO per cent of malignant lesions of the
colon and rectum arise from polypi. The classification the
authors have worked out seems sound. Polypi of the large
intestine may be broadly classified in two groups : Those which
stud the mucosa of the colon and rectum would comprise one
group. Sometimes one encounters several patients having this
condition among members of the same family; no doubt there
is a familial tendency toward the disease. Not infrequently the
predominant symptom of such patients is hemorrhage of a vary-
ing severity. Total colectomy is often indicated. Occasionally,
however, the surgeon is able to perform subtotal colectomy and
anastomose the ileum to the rectosigmoid and later fulgurate
through a proctoscope the polypi within the lower bowel. It
has been my experience that a malignant condition invariably
develops if these patients do not receive radical surgical treat-
ment. The second group is that in which one or more polypi
invade the rectum or colon. The condition is not diffuse poly-
posis, as is that of the first group. In the case of discrete
polyps of the pedieled type, the surgeon may make a trans-
colonic approach, remove the lesion along with its stalk and feel
sure that a sufficiently radical procedure has been carried out.
If the polyp is sessile, as a rule a segmental resection is in
order. Figuration of rectal polypi is often sufficient. However,
patients having such polypi should be examined at frequent

intervals. If recurrence is found, further treatment, . such as
figuration or resection, should be carried out. The improve-
ment in roentgenologic diagnosis has been a greater step for-
ward in the detection of polypoid lesions of the colon than many
realize. Formerly, even though the patient gave a history of
bleeding by rectum, roentgenologic observation after a barium
sulfate enema would not disclose the presence of a polypoid
lesion. Now, by means of the contrast method, expert roent-
genologists are able to determine the presence of a polyp which
may be no larger than a pea. Regarding the other paper,
perineal resection for carcinoma of the rectum and rectosigmoid,
without the establishment of an abdominal colonic stoma, will
of course not meet with the approval of every one. At present
I do not feel qualified to make a definite statement to the effect
that any one type of resection for cancer of the rectum or
rectosigmoid should be employed as a routine.

Dr. W, J. Martin Jr., Louisville, Ky. : A few years ago
it became apparent to me that a good many polyps were being
found in my routine examinations of private patients. On
collecting these cases it was rather astounding to find that sixty-
three polypoid lesions had been found in 1,500 routine sigmoido-
scopic examinations, giving an incidence of 4.2 per cent. This
is ascribed to three or four factors. One is absolute cleanliness
of the bowel. A great number of polypoid lesions are probably
missed because so many sigmoidoscopic examinations are done
on bowels which are not properly prepared. Another important
factor is the position of the patient when one is examining him.
The inverted position, with head down, which lowers the dia-
phragm and allows the lower bowel to be straightened and
smoothed out, brings out more clearly any eminence that might
be present. Another factor of great importance is proper light-
ing of the examining instrument. Reflected or proximal light-
ing is not thought to be as satisfactory as distal lighting. The
distal lighting gives a cross light which makes the smaller
masses stand out more clearly. Another factor of importance
is the preparation of these patients for the roentgenologic
examination. Absolute cleanliness is imperative because small
amounts of waste material in the bowel may be mistaken for
polypoid lesions or vice versa. In some cases of obscure pain
or tenesmus in the bowel, with proper roentgenologic examina-
tion pedunculated lesions were demonstrated, -which was thought
to account for the pain. It is believed that if those factors are
followed in routine sigmoidoscopic and roentgenologic examina-
tions more of these polypoid lesions will be found.

Dr. Louis J. Hirschman, Detroit: Too many of us have
been prone to fit the patient to the type of operation rather than
fit the operation to the Individual patient. The ideal way in
which to remove a carcinoma of the rectum and rectosigmoid
is the type of operation in which one makes an abdominal
incision and can see and feel not only the neoplasm but the
surrounding bowel as well and get a good idea of where there
are palpable metastases to the liver. When there are large
nodules in the liver it is unfair to subject the patient to a great
deal of surgery. In the past in some localities there have been
many colostomies improperly performed, which have thrown
colostomy into disrepute. When a patient is told “You have a
carcinoma which should be removed and you must have a
colostomy," he replies “I won’t have it. So-and-so in my neigh-
borhood has one and nobody will go near him.” It is neces-
sary to break down the prejudice of the individual to the
colostomy, and there are few patients who absolutely refuse.
What most of us consider the ideal is an abdominal colostomy.
I prefer a centrally located colostomy to one in the lower left
quadrant, for cosmetic reasons. The patient doesn't have a
telltale bulge through the clothing, particularly if the patient
happens to be a woman and happens to he thin. For this and
other reasons a centrally located colostomy is much more to be
desired. There are still a few patients who will not submit to
an abdominal colostomy, and for those one must have an opera-
tion like Dr. Babcock’s or the old James Tuttle operation to
fall back on. I have performed them, and, strange to say, those
patients seemed to get along pretty well. I don’t think the
incidence of recurrence was any worse and at least they were
happy in having the colostomy where they wanted to have it.
So far as I am concerned, if a patient wants to keep dean, he
had better have it where he can see it rather than some place
where he can’t see it.

1940

NEUROTROPIC VIRUSES— KING

Jovst. A. M. A.
S*v. 25, 1535

Dr. Frank H. Lahev, Boston : I am sure that you as
gastro-enterologists are interested in whether a colostomy in an
operation for cancer of the rectum is in front or in back, but I
am equally sure that that is not the problem I should discuss
with you. After all, that is a technical problem for surgeons
to have their individual opinions about. The most interesting
part of Drs. Swinton and Warren’s statistics has to do with
the fact that they have taken 100 cancers of the rectum, 100
cancers of the left colon and 100 cancers of the right colon,
all proved by removal at operation, and demonstrated that, in
terms of pain, altered bowel function or blood in the stools,
97.7 per cent of these cases give such evidence. In other words,
wlten but 2.3 per cent of 300 proved cases of cancer of the
colon and return fail to have in the history the evidences of an
alteration in bowel function, the diagnosis should be made earlier
than it is. Another thing that ought to interest gastro-enterolo-
gists is figures of nonrecurrence after radical removal in malig-
nant lesions iii these locations. Forty-seven per cent of our
patients with carcinoma of the rectum who have had the radical
operation are alive and well over five years without recur-
rence, and 42 per cent of those whose colons were affected.
Equally good figures have been reported by other surgeons who
are particularly interested in this subject. They do demonstrate,
however, that this is a particularly favorable lesion from the
point of view of five year nonrecurrence. I do not want to
discuss the technical side of surgery of cancer of the colon and
rectum but I do want to present some convictions to you as
gastro-enterologists which I think are important and which I
definitely think have to do with increasing the number of
patients who are cured or at least have long periods after opera-
tive procedures without recurrence of the lesion. At the Lahey
Clinic we are seeing patients in considerable numbers with car-

Except with patients with stricture or recurrence or those of
such social or mental status that they cannot or will not
attend to personal hygiene, there should be little involuntary
soiling with a perineal colostomy. However, usually it requires
about three months after the operation for a regulated adjust-
ment to be established. Finally, the expulsive action of the
abdominal muscles is more effective when the opening is on
the perineum than when it is above and then I think the
apposed buttocks offer some bar to escape of gas, which there-
fore is retained and in part absorbed.

SOME PROBLEMS IN THE PATHOL-
OGY OF NEtJROTROPIC VIRUSES

LESTER S. KING, M.D.

PRINCETON, N. J.

With regard to virus infections of the nervous sys-
tem, generalizations are of limited validity. In the
study of any single disease, plurality of strains of the
virus, relative susceptibilities of various experimental
animal species and differences between natural and
experimental hosts offer serious complications. And
different diseases seem to behave in quite different fash-
ion. Only isolated data are available, and inferences
can be suggested rather than proved.

With this word of caution, three arbitrarily selected
topics may be critically examined.

cinoma of the colon and rectum, who have had their abdomens
opened and have been closed as inoperable when we have proved
by reoperation that they were not inoperable. I speak particu-
larly of the matter of contact carcinomas.

Dr. Neil W. Swinton, Boston : I was interested to hear
Dr. Dixon’s remarks on the comparison of these polyps. I
think we are particularly indebted to Dr. Martin for his
emphasis on the necessity for careful preparation of these
patients for proctoscopy and sigmoidoscopy. Adequate prepa-
ration makes it possible to examine carefully all of the nutcosa
surface of the rectum and rectosigmoid so that no polyps will
be missed.

Dr. W. Wayne Babcock, Philadelphia: Abdominal dis-
comfort, usually not recognized as colic, which may follow
intake of food or other exciter of peristalsis, is the common
hut often ignored first symptom of intestinal carcinoma. It
may precede melena or obvious change in bowel habit by months
or even a year or more. In my experience nearly all patients
object to an abdominal colostomy, while those with a functional
perineal opening are grateful that it is not on the abdomen.
Those who have had the abdominal opening moved to the
perineum tell us that they are now more constipated, have
much less soiling or escape of offensive gas and better expul-
sive effort than before, and that the opening is much more
conveniently cared for. The gas from the abdominal colostomy
was so objectionable that the woman hank clerk mentioned
had lost her job, while the physician as well as a business
man who bad found it necessary with the colostomy to irri-
gate several times a day now can go without a pad by empty-
ing the colon by enema once every three or four days. With
a perineal opening one young woman has married, while a
second has had an abdominal colostomy transferred, apparently
in the belief that she could then marry. Possibly evacuations
and the discharge of gas are less frequent with the perineal
opening because the colon can then be more conveniently irri-
gated or completely emptied. Irrigation and thorough empty-
ing of the colon with the necessary use of large quantities of
water is a messy procedure with the abdominal opening, even
though the patient sits in a bath tub. The colon may be
compared to a storage tank that overflows when filled. Thus
soiling from a colostomy opening is a sort of "incontinence of
overflow,” which usually can be obviated by regulated empty-
ing of the large bowel: the patient must find out for himself
whether this should be every day or every three or four days.

THE SIGNIFICANCE OF THE NASAL PATHWAY
IN INFECTION

The possible importance of the nasal pathway in
poliomyelitis lias received the attention of investigators
for many years. In 1912 Flexner and Clark 1 showed
that monkeys might be experimentally infected by the
application of virus into the nose and that in such
cases the virus localized first in the olfactory bulbs.
Faber and Gebhardt 2 demonstrated the orderly P r0 ‘
gression of the virus through the netiraxis, following
intranasal instillation, in a manner consistent with the
hypothesis of nerve spread. If the nasal pathway is
interrupted, instillation of virus is without effect. Brodie
and Elvklge 3 and Schultz and Gebhardt 4 proved t it
effectiveness of surgical interruption, while Armstronl?
and Harrison and others 5 showed a similar P r0 ^ !!f

From the Deportment of Animal and Plant Pathology of the Foe
feller Institute for Medical Research. , _ . . pJnii*

Read before the joint meeting of the Section on PathologJ * ...
ology and the Section on Nervous and Mental Diseases at me
Annual Session of the American Medical Association, cn. 1
19, 1939. , ... «_ Tnfec*

1» Flexner, Simon, and Clark, P. F.: A Note on the 'W o, l0 . U
tion in Epidemic Poliomyelitis, Proc. Soc. Exper. Biol, ct
(Oct.) 1912. _ .. .. _ virus of

2. Faber, H. K., and Gebhardt, L. P ■p^r3?> t * c

Poliomyelitis in the Central Nervous lf (/one)

Period, After Intrancsal Instillation, J. . ■' ■

3. Brodie, Maurice, and Elvidge, A. R.: The Portal
Transmission of the Virus of Poliomyelitis, Science

(March 9) 3934. Polio*

4. Schultz. E. W.. and Gebhardt. L. P.:

myelitis, Proc. Soc. Exper. Biol. & Med. „i: 728-/I0 (** . > (

5. Armstrong, Charles, and Harrison, T..- TffLT ,,f AI“« ‘ r,w

nasally Inoculated Poliomyelitis of Monkeys by Instillation t

the Nostrils, Pub. Health Rep. 50 : 725-730 (May * Vinw*

of Experimental Intranasal Infection with Cert, in },emr,tnp . j03-2l. s
by Means of Chemicals Instilled into the l b 05 Vflk, 1 |,,f j £ ncepbah ,! J
(Feb. 28) 1936; Prevention of Intranasally . Inoeulat™ r c (
(St. Louis Type) in Alice and of Pdinmyelitts in Mmike.'^ 1 ; , 9 y,

Chemicals Instilled into the Nostrils, ibid. 51s 1105-1113 (Am,

Schultz. E. \V„ and Gebhardt, L. P Prevention .of witi

lated Poliomyelitis in Monkeys by Previous IiUranaal Irri c,

Chemical Agents, Proc. Soc. Exper. Biol. & iM- 3* • nl3 i IYI£

1936: Zinc Sulfate as a Chemoprophylattic Agent in fcxpe , b 13
myelitis, ibid. 35 : 524-526 (Jan.) 1937 ; Zinc Sulfate irop:

Poliomyelitis, J. A. M. A 108:2182-2184 «*£«
a TJ . DiheW P TT and Cox. If. R.; I roteeme Pfir

and Sabin. A. uomparnuyc p V nm J ; t j $ ’

in Protecting Monkeys Against Nasally Instilled Poliomyel.
Soc. Exper. Biol. & Med, 30:532-53$ (Maj) 19J/.

N

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r '. n,t,c °sa and fr4 e f m 'a fi r « , worfr

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swallnu ■ a -’ occn rr :, "' 4 Vjrnc c rec ° v ered r that

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1942

NEUROTROPIC VIRUSES— KING

} OHS. A. Jf. A,
Nov: 25, 19j)

In the olfactory mucosa it is possible that virus- injected into the eye is active in high dilutions Infec-
charged nerve cells in the epithelium m some way tion by the ocular or nasal route, while less effective than
discharge the virus into the secretions, while the by the intracerebral pathway, is far more virulent than
nonnervous portion of the epithelium plays no part, any other mode of peripheral inoculation. With the
A little reflection shows that the quantity of virus so fresh, recently isolated strain tin's difference does not
discharged must be enormous if, say, enough is going exist.

to persist unchanged through the intestinal tract and In guinea pigs , 22 fixed virus injected into the eye
be recovered in the stools. Considering the enzymatic could be traced with utter constancy along the appro-
action and the />, H alterations encountered on such a priate nerve paths in the brain. When injected into
voyage, and considering the lack of sensitivity of the the eye, the fixed virus first infects the ganglion cells
test animal, the amount of virus produced must origi- of the retina. Once the cell body has become involved,
nally be very great. If the virus multiplies only in the virus, in a manner yet unclear, passes along the
nerve cells, the problem of excretion by nerve cells axons constituting the optic nerve,
into a fluid medium is raised. One of the principal The anatomic considerations of the olfactory system
objections to accepting this point of view is that in provide a similar explanation of the effectiveness of

the cranial cavity, where nerve tissue has free access intranasal instillation of virus. The cells of origin of

to the cerebrospinal fluid, the virus can be demonstrated the olfactory nerve are located directly in the olfactory

in this fluid only with the utmost difficulty'-, if at all. mucosa, so that virus applied to the mucosa ini eels

Considering the relative number of nerve cells in the the cell body first. The axon, the prolongation of the

brain and the ease with which concentrated spinal fluid cell body', becomes secondarily involved,

may be gathered, it does not seem likely that nerve Primary' infection of the axon with subsequent
cells exude virus into their fluid environment. The rela- involvement of the cell body rarely occurs. Injection
tively few nerve cells in the olfactory mucosa (and the of fixed virus directly into the sciatic nerve produces
greater technical difficulty of collecting nasal secretions infection infrequently, even with high concentrations of
to demonstrate virus) make it seem unlikely that the virus . 20

virus in the olfactory mucosa is restricted to the neural With fixed virus, the heightened susceptibility to
elements. This problem also awaits further investiga- intranasal as compared with, say. subcutaneous moni-
tion. It seems to me that there is no natural disease Iation is due to several factors. "One is that this strain

which can be called strictly neurotropic and that polio-
myelitis, to some extent at least, is a systemic disease.
In this connection Brodie and Elvidge , 3 while claiming
that experimental poliomyelitis is entirely a central ner-
vous system disease, held it not proved that the natural
disease is equally so.

The work so far presented indicates that in experi-
mental poliomyelitis special ease of infection by the
olfactory route, together with the general importance
of this portal of entry, is a property of certain strains
of the virus, But with fresh strains the subcutaneous
route may be highly effective, a property that is readily
lost. Since the monkey is at best a poor host, the
production of disease by moderate doses given intra-
cutaneously appears of great significance. Of equal
significance is the fact that cutaneous infectiveness is
impaired by repeated passage. It is possible that the
relative importance of the nasal route in experimental
poliomyelitis is purely an artificial condition, brought
about by some degree of change in tire virus and with-
out necessary relation to the natural disease. There
are other diseases which furnish suggestive analogies
and parallels on this point.

Recent work 20 with equine encephalomyelitis virus
may be briefly summarized. Both fresh and fixed 21
strains of virus were used, both highly virulent after
intracerebral inoculation. But with peripheral inocu-

lation the behavior is different.

In adult mice, with the fresh strain, any peripheral
route of inoculation is effective. Injections into the
peritoneum, subcutaneous tissue or eye and instillation
into the nose result in-infection, with but little difference
in virulence for any of these routes. On the other
hand, fixed virus injected subcutaneously is nonpatho-
genic, although the same virus placed in the nares or

l s * Studies on Equine Encephalomyelitis: IV- Infection
in "the Mouse with Fresh and Fixed Virus, to be published- #

21. Traub, Erich, and Ten Broeck. Carl : Protective Vaccination of
Horses with Modified Eqmne Encephalomyelitis \ trus. Science SI: 572

(June ?) 1935.

of virus, to infect the nervous system with any but
enormous doses, must first involve the cell bodies of
the neurons ; the second, that in the nose the cell bodies
are superficial in the olfactory mucosa, with correspond-
ing ease of infection. Similar considerations apply 10
intra-ocular injections. Nerve filaments or endings,
such as are encountered with subcutaneous injections,

are not the equivalent of nerve cell bodies.

Ease of infection by the nasal route, in the face o
relative refractoriness of other peripheral sites, is fo> im
with other viruses. The neurotropic strain of yellou
fever virus, produced by passage of the natura virus
through mice, behaves similarly. Adult mice, demon-
strated by Theiler 23 to be refractory to intraperitonea
inoculation, will succumb only if there is simultaneous
brain injury .* 4 Recently, however, Findlay and Clar <e
showed that intranasal instillation of virus without irm
injury is readily followed by encephalitis. Loupmf
has been shown by Webster and Fite 26 to he inlec io -
for mice when given intranasally, hut subcutaneous
intravenous inoculation is without pathologic e c •
In the intact mouse the virus of St. Louis cn cep w
infects only with difficulty after intraperitoneai moc
tion but readily by the nasal route . 28 . .

When, however, the natural diseases are studied >
direct nasal portal of entry is of no apparent sig
cance. Looping ill in nature is transmitted by

22. King. L. S.: Studies on Eastern E<]uine EncepM ' myehM

Intra-Ocular Infection with Fixed Virus in the Guinea f, a
Med. 69 : 691-704 (May) 1939. . r Fever V'W

23. Theiler, Max: Studies on the Action of Yellow

Mice, Ann. Trap. -Med. 21:249-272 (July) 1930. fewy

21. Sawyer, W. A., and Lloyd. Wray: The jir'.ss; (Orf> |5 T
Immunity Against Yellow Fever, J. Exper. XeiirW'T;

25. Findlay, G. 31., and . CJarbe, L. . T . : . ^ iu^ Coa ,,.ef

VeUow Fever Virus Following Instillation , . .

[low' never virus rouuw„, K

al Sac, J. Path. & Bact. 40:55-64 (Jan.) 1935-

>6. Webster, L. T., and Fite, G. L.: Ex l r l Bit*- %r "

sal Instillation of Looping 111 Virus, Froc. Soc. fcxpe ( __

asai insemar/an * t ^

D: 656*657 (Feb.) 1933. D R-. x

27. Greig. J. R.; Brownlee, AfeMnder; Wilson, ^ 0{3tC i . )
S-: The Mature of Loupmg JU, Vet. Kec. * ^ ^

Is. Webster, L. T., and Clow, A, 11. : h

ter of the Encephalitis Virus (St. Louis Type) ■" b
:per. Med. (33: 433-448 (March) 1936.

u

Volume 333
Number 22

NEUROTROPIC VIRUSES— ICING

1943

Ixodes ricinus . 20 Equine encephalomyelitis, with over-
whelming probability, is carried by mosquitoes . 30 Yel-
low fever in nature does not produce encephalitis, but
the usual viscerotropic virus may be neurotropic for
mice , 23 and for monkeys the virus has been shown to
harbor a neurotropic component that can be disclosed
by a suitable experimental method . 31 Yellow fever, of
course, is also insect borne. The mode of transmission
of the St. Louis encephalitis B is not known ; mosquitoes
may be artificially infected but have not been shown
to transmit the disease by biting . 32 But the Japanese
encephalitis B, which, though serologically distinct from
the St. Louis type, has many points of similarity, has
been shown susceptible of transmission by mosqui-
toes . 83 These few examples suffice to show that certain
viruses which in their natural condition are highly
infectious by subcutaneous inoculation may with altered
conditions show a predilection for the olfactory pathway.

It is of interest that in fox encephalitis, which was
studied in its natural host, strong evidence has been
adduced by Green and his associates 34 that the nose,
or at least the respiratory tract, may be the natural
portal of entry for the virus. This evidence only shows,
however, how the virus may gain access to the body.
The modes by which it then reaches the brain have
not yet been demonstrated.

Experimentally, under conditions not yet understood,
the olfactory neurons may at times furnish an indirect
mode of entrance into the nervous system. But at
present there is little evidence that in naturally occur-
ring virus diseases of the nervous system the nose is
the direct portal of entry from which viruses pass into
the brain. Under the conditions of experimentation
this pathway has received great prominence, but the
necessarily artificial character of the data must be kept
in mind.

THE HEMATO-ENCEPHALIC BARRIER

There are relationships discernible between the action
of certain viruses and that of certain vital dyes. With
the acid dyes, such as trypan blue, it has been abun-
dantly shown that the adult brain does not stain vitally
under normal conditions. But brain trauma allows the
dye to penetrate the injured tissue. Furthermore, in
infant animals the dye will penetrate more easily into
the brain than is the case with adults. This entire
subject has been discussed at length elsewhere , 35 and
certain exceptions to the statements just made have
been noted.

29. MacLeod, J., and Gordon, W. S.: Studies in Louping III: II.
Transmission by the Sheep Tick, Ixodes Ricinus L, J. Comp. Path. &
Therap. 45 : 240-256 (Sept.) 1932.

30. Kelser, R, A.: Mosquitoes as Vectors of the Virus of Equine
Encephalomyelitis, J. Am. Vet. M. A. 82: 767-771 (May) 1933. Merrill,
M. H.; Lacaillade, C. W.> Tr.» and TenBroeck, Carl: Mosquito Trans-
mission of Equine Encephalomyelitis, Science 80:251*252 (Sept. 14)
1934. Merrill, M. H., and TenBroeck, Carl: Multiplication of Equine
Encephalomyelitis Virus in Mosquitoes, Proc. Soc. Exper. Biol. & Med.
32: 421-423 (Dec.) 1934; The Transmission of Equine Encephalomyelitis
Virus by Aedes Aegypti, J. Exper. Med. 62: 687-695 (Nov.) 1935. Ten-
Broeck, Carl; Hurst, E. W., and Traub, Erich: Epidemiology of Equine
Encephal omyelit i s in the Eastern United States, ibid. 62:677-685 (Nov.)

31. Findlay, G. M., and Stern, R. O. : The Essential Neurotropism of
the Yellow Fever Virus, J. Path. & Bact. 41: 433-438 (Nov.) 1935.
i enna, H. A.; The Production of Encephalitis in Macacus Rhesus with
Viscerotropic Yellow Fever Virus, Am. J. Trop. Med. 16: 331-339 (May)
1936.

32. Webster, L. T.; Clow. A T \, and Bauer, J. H.: Experimental

Studies on ’ " val of Encephalitis Virus (St. Louis

%) . , J. Exper. Med. 61: 479-4S7 (April)

33. Mitamura, T.; Kitaoka, M.; Mori, K. ; Okubo, K., and Tenjin, T.:

1 ransmission of the Virus of Japanese Epidemic Encephalitis by Mos-
? l, ^ oe ^ Tr ' Soc - Jap/ 2S: 335-145, 1938; Biol. Abstr. 13:97

(ref. 952) 1939.

34. Green, R. G.; Green, B. B.; Carlson, \V. E., and Shillinger, J. E.:
fcquzootvc Fox Encephalitis: VIII. Tbe Occurrence of the Virus in the
Upper Respiratory Tract in Natural and Experimental Infections, Am. J.
Hsr 24:57-70 (July) 1936.

35. Xmg, L. S.: The Hemato-Encephalic Barrier, Arch. Neurol. &
Psychiat, 41:51-72 (Jan.) 1939.

There are striking parallels between these facts and
the action of certain viruses. These may be considered
under two headings :

The Facilitating Action of Brain Trauma, — Certain
viruses are harmless if injected intraperitoneally into
adult mice ; but if at the same time there is a nonspecific
brain injury, such as the injection into the brain of
a weak starch solution, the intraperitoneal inoculation
results in fatal encephalitis. This was shown for yellow
fever virus by Sawyer and Lloyd . 24 A similar phe-
nomenon occurs with the virus of St. Louis encepha-
litis . 28 Here, although the concentrated virus is lethal
when given intraperitoneally, significant dilutions are
fatal only after concomitant brain injury.

With other hosts and other viruses, comparable data
are available. With poliomyelitis virus, Flexner and
Arnoss 30 first demonstrated the facilitating effect of
meningeal irritation in producing infection after various
routes of inoculation. Others 87 have shown that paren-
chymatous damage to brain tissue was similarly effec-
tive. German and Trask 13 found that peripheral injury,
such as operations on the extremities, may facilitate
infection. Here the central nervous system was not
directly involved.

With Borna disease virus, Zwick, Seifried and
Witte 28 showed that cutaneous inoculation was regu-
larly infective only after nonspecific brain trauma.
Similarly, in rabies 80 there is a facilitating effect on
peripheral inoculations if spinal fluid is pumped back
and forth.

However, not all viruses show this behavior. V esicular
stomatitis and equine encephalomyelitis are highly infec-
tious with direct intracerebral inoculation. Yet when
injected peripherally their encephalitogenic power is
not increased by concomitant brain injury . 40

Increased Susceptibility of the Infant Organism . —
With certain viruses infant animals, especially mice,
are much more susceptible to peripheral inoculation
than are adults of the same species. This was first
shown by Theiler 28 for the virus of yellow fever and
by Andervont 41 for certain strains of herpes virus.
More recently the phenomenon has been studied by
Olitsky and his associates 42 with vesicular stomatitis
viruses, in which the disparity between infants and
adults was marked with the particular strains employed.
Equine encephalomyelitis virus has also been studied
from this standpoint . 48

That injury facilitates the passage of virus and of
trypan blue into the brain, and that the infant brain

36. Flexner, Simon, and Amoss, H, L.: Tbe Relation of tbe Meninges
and Choroid Plexus to Poliomyelitis Infection, J. Exper. Med. 25: 525-
537 (April) 1917.

37. Lennette, E. H>, and Hudson, N. P. : BJood-CNS Barrier in Experi-
mental Poliomyelitis, Proc. Soc. Exper. Biol. & Med. 34: 470-472 (May)
1936. Clark, P. F.; Lemmer, K. E., and Rasmussen, A. F.*. Influence of
Sterile Inflammation on tbe Nasal Portal of Entry in Poliomyelitis, abstr,
J. Bact. 36:290-293 (Sept.) 3938.

38. Zwick, W.; Seifried, O,, and Witte, J. : Weitere Beitrage zur
Erfcrschvmg der Bomaschen Krankbeit des Pferdes, Arch. f. ivissensch.
u. prakt. Tierh. 59: 511-545 (June 18) 1929.

39. Jovvelew, B. M.: Ueber emige Bedingungen der Impfung mit
Tolhvut aus dem Blute, Ztschr. f. d. ges. exper. Med. 74:217-223, 3930.

40. Olitsky, P. K.; Cox, H. R„ and Syverton, J, T,: Comparative
Studies on the Viruses of Vesicular Stomatitis and Equine Encephalo-
myelitis, J. Exper. Med. 59: 159-171 (Feb.) 1934. King.* 5

41. Andervont, H. B.:. Activity of Herpetic Virus in Mice, T, Infect.

Dis. 44: 383 -393 (May) 3929. # J CCX ‘

42. Ohtsky, P. K.; Sabin, A. B. f and Cox, H. R.; An Acquired Resis-

tance of Growing Animals to Certain Neurotropic Viruses in the Absence
of Humoral Antibodies or Previous Exposure to Infection, T, Exner Meet
64: 723-737 (Nov.) 1936. Sabin, A. B.» and Olitsky, P. K.T Influence
? S F ?T ors on ,£ e “/°'Inyasi« n c5s of Vesicular Stomatitis Virus:

I Effect of Age on the Invasion of the Bram by Virus Instilled in the

66:15-34 (July) 3937; II. Effect of^Age on the Invasion of
the Peripheral and Centra! Nervous Systems by Virus Injected into the
Le ^ M c U l C - C ®S th £ Ey V&& ?6: 35-57 (July) 1937. C

43. Sabin, A. B., and Olitsky, P. K.: Age of Host and Capacity of

\%ir&*h CKS - Proc - s ~ ^

1944

NEUROTROPIC VIRUSES— KING

Jotra. A. M, A
Nov. 21 , 1911

is more receptive to some viruses and to trypan blue under experimental conditions, nerve cell damage
than is the adult organ, are rather surprising parallels, been shown to precede any inflammatory change This

which may be merely unrelated coincidence or may damage may take the form of inclusion bodies as for

suggest some deeper uniformity. example, in poliomyelitis ,' 14 where changes in anterior

the reasons^ why a cerebral trauma facilitates infec- horn nerve cells may precede any inflammation; or
tion after peripheral inoculation are not at all clear, there may be extensive loss of neurons without sig-
The simple explanation of a “barrier” which has been nificant reaction, such as occurs in the cerebellum in
broken down, as if a hole had been knocked in a fence, louping ill . 45 The whole subject has been well reviewed
seems scarcely tenable. If such a rupture in the “bar- by Hurst . 48

i ier were correct, one would expect that brain trauma, There are observations, however, which do not fisr-
with peripheral injection, such as by the intravenous monize with the view of primary attack on neurons,
route, would allow any virus to pass in readily, making In experimental St. Louis encephalitis 58 and equine
a situation comparable to intracerebral injection of encephalomyelitis 47 the first alterations are clearly
virus. With some viruses this does not occur. The inflammatory and interstitial. This is of special interest
situation is undoubtedly much more complicated. in equine encephalomyelitis, for this virus may invade

With vital dyes, the most satisfactory explanation for the brain directly through the blood stream but may
staining of an injured area is a change in the binding also travel along nerve paths . 48 It may attack the tissue
power, or “affinity,” of the tissue toward the dye . 35 after axonal transmission or attack through the blood
It seems likely that a comparable explanation may apply vessel wall, but in either case it provokes an interstitial
in the case of certain virus infections. As a substrate reaction as the first response,

for virus activity, tissue which has been altered by With reference to the cell damage found in virus
injury presents different properties from normal tissue, encephalitides, it is important to remember that selective
Virus in contact with this altered tissue may behave neuronal necrosis occurs in nonvirus diseases such as
differently from virus in contact with normal healthy various circulatory and toxic disturbances. The most
tissue. But experimental work is necessary to estab- familiar examples include the selective loss of pyram-
lish the validity of this speculation. idal cells in the hippocampus, the granule cells of die

With respect to the special behavior of infant animals, fascia dentata remaining intact; the selective destruction
especially mice, toward some viruses, differences in the of Purkinje cells in the cerebellum, and the scattered
tissue must also be kept in mind. From the anatomic areas of neuronal loss, or “verodungsherden," in the
and biochemical standpoint the immature nervous sys- cerebral cortex. To this type of damage inflammatory
tern of infant animals of most species is distinctly d if- response may be absent or insignificant. The occasional
ferent from the adult stages. The role of these factors inflammatory cells that are inconstantly seen in suc»
for vital staining has been emphasized elsewhere . 35 The reactions are considered by neuropathologists as sec-
intrinsic differences between immature and mature ondary” inflammation, in the sense of a reaction o
nerve tissue may constitute the alterations in substrate necrotic tissue however produced. In marked contra?
required to explain the variation in behavior of infant to this is the vigorous inflammatory change seen in
and adult animals toward some viruses. various forms of encephalitis, even where there is 11

Although this subject is clearly in need of detailed
study, one fact stands out, namely, that some change
in the character of nerve tissue is the one connecting
link between (a) the increased susceptibility of infants
as compared with adults and (b) the increased sus-
ceptibility of injured as compared with normal animals.
The changes in the two instances are obviously not
the same. It is possible that there is nothing in com-
mon between the two sets of phenomena or between
the action of some viruses and that of certain vita!
dyes ; but the parallelism between virus and dye action
exists and should be pointed out. Only future work
can determine the significance of this parallel.

CONSIDERATIONS ON HISTOPATHOLOGY

There are three cardinal points in the pathology of
virus diseases of the nervous system : inclusion bodies,
cellular necrosis and inflammation. These three need
not all be present. In pseudorabies in the rabbit, for
example, inclusion bodies may be the only sign of
disease, and inflammation as well as frank necrosis may
be absent. Furthermore, none of these features are in
any sense specific for virus diseases. Nevertheless
they furnish a constantly recurring pattern which must
be explained.

Viruses are generally considered as obligatory intra-
cellular parasites. The question has been raised whether
neurotropic viruses primarily attack the nerve cells.
Many viruses have been shown to travel along nerve
paths. Injury to the cells harboring the virus might
logically be expected as the first step. In some cases,

necrosis of tissue. .

When forms of virus encephalitis are compared w 1
other forms of pathologic alteration of the brain, i
clear that cellular necrosis and inflammation may u “-
quite independently of each other. Either one iin)
occur with little or no indication of the other, ds
class, the virus encephalitides are primary inflanirna o .
conditions. The degree of neuronal damage is 0 <
inadequate to account for the mesodermal re 5 P° ns ^ f
the basis of a nonspecific reaction to injury
produced. The distinction between a secondary in ^
mation clearly dependent on extensive necrosis
primary inflammation which may be quite mdepen

of necrosis is valid. . j-.o

It might be suggested that in virus encep w ‘
there are both inflammatory and necrotizing c
nents. It would be misleading to call either one p
and the other secondary. Although, of cours
:ient inflammation however produced — -

44. Co veil, W. P.: Nuclear Changes of Nerve

nyelitis, Proc. Soc. Exper. Biol. & Med. 27. 9.7 9^^ t j, s >c!
lurst, E. W.: The Occurrence of Intranuclear Indu'we ^

Cells in Poliomyelitis, J. Path. & Bact. 34: 331-333 1 (0 if*

45. Hurst, E. W.: The Transmission of Rouping U Co n r . D;

nd the Monkey: Histology of the Experimental Dis x „„,ai»
t Therap. 44 : 231-245 (Dec.) 1931. Findlay, G. M. . l « , J6 <J«
f Looping 111 to Monkeys, Brit. }. Exper. Path. 13.^ ^ ^

? 46. Hurst, E. W.: The. Newer Knowledge : of JTf
iervous System: A Renew and an Jmerpreiation,

L. S.: Studies on Eastern
. Histopatbology of the Nenmus System in the Gu
led. 08:677-692 (Nov.) 1938. . F „ e -,lnIom7« , A‘. r;l

48 King, L. S.: Studies on Eastern Equine i. cep , (ti 00-
athogenesis of the Disease in the Guinea Fla. }■ - 9
70 (May) 1939.

Volume 113
Number 22

NEUROTROFIC VIRUSES— KING

1945

injure cells, while extensive necrosis from whatever
cause may provoke a slight inflammatory reaction,
nevertheless these two components have no necessary
connection with each other. In some diseases and in
some hosts one type may prevail ; in another host the
same virus may provoke an entirely different response.
This is well illustrated in louping ill, with which, accord-
ing to Brownlee and Wilson , 49 the pig shows an intense
inflammation with insignificant cellular necrosis, while
in other hosts abundant necrosis is present. The dif-
ference in behavior can only be ascribed to host factors.
These two components must be considered as correlative
in their action, one predominating under certain con-
ditions, the other under different circumstances.

In relation to the neuronal changes found in many
virus diseases, the reaction produced by a nontransmis-
sible nonviral agent is of considerable significance. This
agent, present in monkey bone marrow as well as in
other tissues of other animals, is widely known as a
result of the Gordon 50 test for Hodgkin’s disease. On
injection into guinea pigs or rabbits it causes a char-
acteristic encephalopathy . 01 The principal and invari-
able feature is a selective loss of Purkinje cells of the
cerebellum. In the early stages cells show well marked
intranuclear acidophilic inclusion bodies, indistinguish-
able from those described for poliomyelitis or equine
encephalomyelitis. At a slightly later stage ectodermal
glial nuclei also show acidophilic inclusion bodies. A
change less constant than Purkinje cell loss is a sym-
metrical necrosis of the pyramidal cells of the hippo-
campus, again with absent or insignificant inflammatory
changes. It is of interest, then, that a nonviral agent
can cause selective necrosis of nerve cells, with forma-
tion of inclusion bodies as a stage in the process, by
action that appears to be indirect.

Comparison may be made with certain virus diseases.
Hurst 40 commented on the frequency with which hippo-
campal necrosis occurs in rodents in a variety of dis-
eases. Selective loss of Purkinje cells is pronounced
in louping ill 45 and somewhat less marked in many
other diseases. The similarities between some virus
diseases and the encephalopathy from bone marrow
extract are striking.

Although it is not known how viruses act on the
brain, a tentative separation into direct and indirect
action seems plausible. By direct action is meant the
immediate interaction between virus and tissue. The
nature of this reaction varies according to the animal
host. With equine encephalomyelitis virus in the
guinea pig, for instance, the direct action would be
exemplified by disseminated focal lesions, in which
inflammatory changes appear first with more or less
cell necrosis later.

By indirect action is meant the initiation of a train
of events leading primarily to cell necrosis, effected, by
means shared by nonvirus agents. The type of massive
hippocampal necrosis, for example, found after intra-
cerebral injection of equine encephalomyelitis is too
similar to that produced by normal monkey bone mar-
row to be dismissed as a coincidence. An underlying
common factor, not specific to either, must be assumed.

49. Brownlee, Alexander, and Wilson, P. R,: Studies in the Histo*
193^° 85 louping HU J- Comp. Path. & Therap. 45 : 67-92 (March)

50. Gordon, M. H : Remarks on Hodgkin’s Disease, Brit. M. J. 1: 641-
644 (April 15) 1933.

51. Kelscr, R. A,, and King, L. S.: Studies of a Paralysis Syndrome
l roduced in Rabbits and Guinea Pigs by Extracts of Normal Primate
Bone Marrow, Am. J. Path. 12: 317-332 (May) 1936. King. L. S.:
Encephalopathy Following Injections of Bone Marrow Extract, j. Expcr.
Med. 70: 303-314 (Sept.) 1939.

Similar considerations may apply to the sequence of
intranuclear inclusions followed by neuronal necrosis,
as shown, for example, by poliomyelitis and this same
bone marrow agent, or to tire phenomenon of selective
Purkinje cell necrosis.

It would be premature to speculate on the underlying
bases of such changes. It is worth noting, however,
that in many virus encephalitides there occur dissemi-
nated areas of damage that may' be called primary and
other types of injury that may be called secondary and
indirect. Such a distinction may not be valid for all
viruses or for all susceptible hosts, but the possibility
of such a distinction must be kept in mind in the study
of any virus pathology.

conclusion-

The material of this paper does not lend itself to
summary. From all the data here presented, the only
conclusion that can satisfactorily be drawn is that but
little is known of the interaction between viruses and
the nervous system. As yet there is only fragmentary
evidence. Only future work, with unremitting critical
examination of data and doctrine, can lead to a sound
basis of understanding.

ABSTRACT OF DISCUSSION
Dr. Robert G. Green, Minneapolis : The problem of deter-
mining the mode of passage of the viruses into the central ner-
vous system has been well considered by Dr. King. The reverse
process also has a critical bearing on the subject. A virus,
like any other biologic parasite, after reproduction must escape
to a new host to perpetuate its species. It may be that many
viruses which produce disease of the central nervous system
grow sufficiently for species perpetuation in some surface area
such as the upper part of the respiratory tract and that
invasion of the central nervous system is entirely accidental.
Regardless of whether or not a virus must escape from the
central nervous system, a demonstration of its actual passage
to the exterior and of the manner in which it progresses must
be valuable in the solution of this problem. From a dosed
intramuscular or intracranial injection, the virus of fox enceph-
alitis soon appears in the nasal cavity. Since the virus is found
in the blood stream and since it does not attack nerve tissue,
the virus must be blood borne to the nasal location. The
complexity of the hemato-encephalic barrier is clearly' shown
in the special case of the fox encephalitis virus. In the natural
disease this virus is destributed throughout the brain but only
in association with endothelial cells. It never penetrates suffi-
ciently to involve the ependymal cells lining the cerebrospinal
circulatory system. If the virus is introduced into the cere-
brospinal fluid, it at once attacks the ependymal cells. It may'
be that the early inflammatory reaction of viruses discussed by
Dr. King is, as he suggested, an extracellular effect of viruses ;
or the early growth of -the virus in the cell may produce dis-
turbances in the cell metabolites which call forth an inflam-
matory response. In my experience the same virus may produce
cell destruction with no inflammatory response in some animals
and in other individuals of the same species may provoke an
intense inflammatory response with few cells showing any
specific effect of the virus. However, as viruses seem to be
incomplete microbes, some of those less highly adapted and
simplified might be considered to carry on their parasitic
processes between cells in close proximity to the ceil mem-
brane rather than within the host cell protoplasm.

Da. Richard B. Richter, Chicago: I am gratified at the
remarks about the significance of the olfactory pathway. In this
country, at least, the experimental evidence that suggested the
olfactory pathway to be the significant one in natural disease has
been emphasized at the expense of the evidence against it, espe-
cially' for poliomyelitis, I think Dr. King’s conclusion that this
route is unimportant in the natural disease is valid for the
group of diseases which he is considering, particularly polio-

1946

SYPHILIS-REIN AND WISE

Jour, A. XI, A.
Nov. 25, mi

myelitis, St. Louis encephalitis and equine encephalomyelitis.
These are diseases which have similar epidemiologic manifesta-
tions, which are seasonal in late summer and in which there is
virtually no evidence of any contact communicability. But the
possibility of natural infection by way of this pathway may be
of great significance for other types of encephalitis, notably for
lethargic encephalitis, a disease attacking by preference in the
winter months and notoriously associated with respiratory infec-
tions. There is some reason to believe that here direct contact
infection occurs. The speculation which Dr. King has made
about the hemato-enccphalic barrier is interesting. When Nissl
first introduced this conception his idea was that the barrier
was represented anatomically by the adventitia of the cerebral

MAPHARSEN IN TREATMENT OF
SYPHILIS IN OFFICE
PRACTICE

A STUDY BASED ON 2,3-12 INJECTIONS OF
113 PATIENTS

CHARLES R. REIN, M.D.

AND

FRED WISE, M.D.

NEW YORK

blood vessels and it is now spoken of as a brain-blood barrier
and the idea has been gradually formed that it is sort of a
mechanical wall. Undoubtedly the situation is more complicated
than this, but I do think that there are some considerations
which point to the pial-glia! apparatus of the brain as being a
true biologic barrier and the site of much of the defense of the
brain against toxins and infectious agents. I cite the older
experimental results of injecting micro-organisms into the blood
stream with and without concomitant trauma to brain or cerebral
vessels. Without such trauma there is relatively little involve-
ment of the brain. With it there is much and the infectious
process becomes precisely localized at the point of injury to the
tissue. Dr. King’s suggestions as to the nature of damage to
nerve cells from viruses is also of great interest. In the light
of such clear-cut experiments as those of Goodpasture, for
example, on the transmission of herpes and rabies virus along
axons with direct involvement of the nerve cells, it is hard for
me to give up the idea that such direct action is the most impor-
tant feature.

Dr. L. S. King, Princeton, N. J. : I am glad that Dr. Green
raised the point of the invasion of the central nervous system
as merely an incidental factor in infections. Poliomyelitis has
been given as an example of a purely neurotropic disease which
invades only the nervous system. I feel that Dr. Green does
not agree with this, and I do not agree with it. In all probability
there is no such thing as a purely neurotropic virus ; all encepha-
litides are systemic diseases, and the invasion of the nervous
system is more of an incidental factor which may occur in
some cases and may not occur in others. The reason the central
nervous system is involved in some persons and not in others
is as yet unknown. I am glad that Dr. Green does not believe
viruses are necessarily intracellular parasites. Viruses can
multiply only in the presence of living cells, but that is different
from saying that viruses can multiply only in living cells. I
feel that probably viruses are not necessarily intracellular para-
sites. They can multiply only in the presence of living cells,
but multiplication may, - of course, be extracellular. Dr. Richter
raised the point of von Economo’s encephalitis. The point he
has raised is a valid one, but this virus is lost, and there is no
way of carrying on experimental studies. The hemato-encephalic
barrier probably lias a locus in the sense of an interface. The
capillary endothelium marks the interface between the blood and
the brain tissue. But that is quite a bit different from saying
that the barrier consists of the capillary endothelium, which is
the point against which I wish to protest. The barrier, in my
mind, lies in an interaction between three substances : the blood,
the membrane (that is, the capillary endothelium) and the brain.
Obviously the membrane, the capillary, is the division between
the two systems. Although that is the site, it is not the barrier
in the sense of a structure which of itself keeps things out.
Concerning the transmission of virus along the nervous system,
demonstrated in the experiments of Goodpasture and others, the
property of living only inside nerve tissue is frequently a
property only of a fixed virus. Viruses which primarily travel
up nerves are those which, by modification, can multiplx* only
inside of nerve tissue. Some viruses will multiply in many
kinds of tissue. Under certain altered conditions, such viruses
retain the faculty of multiplying only in nerve tissue and have
lost the power of affecting other tissues. The strains of herpes
virus which travel up nerves seem to be precisely those strains
which have lost the faculty of multiplying in non-nervous tissue
and multiply only within the nerve tissue.

Our purpose in this paper is to discuss the value
of mapharsen in the treatment of syphilis by the physi-
cian in his private practice.

It is known that the majority of syphilitic patient'
undergoing treatment in prix'ate practice are in the late
asymptomatic stage and that the diagnosis of syphilis
is frequently made solely on serologic evidence.

Now that most states have, or soon will have, legis-
lation requiring routine premarital and antepartum
blood tests, many more latent asymptomatic syphilitic
persons will be detected and will undergo treatment
in clinics or in private practice. It lias been estimated
that between 50 and 90 per cent of syphilitic patients
treated in private practice are asymptomatic. It is
especially with regard to this large group that the
determination of the diagnosis rests, in large measure,
on the outcome of the serologic examination.

One of the great difficulties encountered in private
practice is to convince patients with latent syphilis I® 1
sustained treatment must be carried out. Aside from
economic considerations, one of the most important
reasons for irregular and haphazard attendance and
eventually for complete relinquishment of treatmenl
is the production of various untoward reactions by m (
standard arsenical preparations in common use. Sud
reactions — often alarming and at times dangerous-
in patients who before therapy had no symptom-'
relative to their infection play an important role m
discouraging them from continuing the necessary trea
merit.

It is therefore an indispensable part of treatmen
avoid the therapeutic reactions which so often are s »
bling blocks in the path of an otherwise uneven ^
series of injections and handicap the practitioner
tlie free use of the arsenicals. If, for these asymp 0
atic patients, a preparation that produced a 1111,11 { j
of untoward reactions was used, it would be an a
inducement toward faithful adherence of the P a

:o the prescribed courses of therapy.

Such a preparation is available in the form o n ^
imino-parahydroxyphenylarsine oxide hydrocli on ’
rivalent arsenical identical with arsenoxidc an ‘ JJ.

lated by Tatum and Cooper 1 as mapharsen. 1 1,5 1 v
iration has been thoroughly investigated an 1 v
eports harm been published to attest its eflectn -- .

iroducing early sterilization and disappearance - ^
ochetes in open primary lesions, with rapid 1C ' b
oncomitant and later clinical manifestations^ — — ■

The mapharsen used in (his study was supplied h> Parte, ^

Dr. Cirsch Astrachan and Dr. Samuel B. Frank furnished s ^

Aerial used in this study. Post-Graduate Jtf- >

From the Skin and Cancer Unit, New Aork Tost ora
hool and Hospital, Columbia Umvers.ly.

Read before the Section on Uermatolosy \« 0 cialion, St. U'
netieth Annual Session of the American ->Ie« c f ^

iy 17, 1939. * * Meta-Ammo C 3r3 cjt^(

1. Tatum, A. L., ami Cooper, 9,vi a Science 75s Ml :
;eml Arsine Oxide as ™ « an

) 1932; An Expenment.il Study of Maphar n
lent. J. Pharmacol. S: Exper. Therap. -O: 196 Uch.J

ll 3

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TheV es P°nse o f f ° n Method ° rded a s i f ta ^n

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1948

SYPHILIS— REIN AND WISE

Jour, A. SI. A.
Nov. 25, 19J)

tion, but all tests became strongly positive in forty-eight hours.
He received intravenous injections of mapharsen daily for six-
teen days. The dosage varied from 0.03 to 0.06 Gm. with a
total of 0.88 Gm. (0.055 Gm. per injection). Regression of
the chancre was very slow and the reduction of the serologic
titer was equally retarded. At this juncture, the patient received
five intramuscular injections of a bismuth compound and four
additional mapharsen injections. Even after the first injection
of bismuth a noticeable regression of the chancre was apparent.
At the termination of this concurrent series of mapharsen and
bismuth injections the chancre had healed completely and Kline
diagnostic and Wassermann tests were negative.

This isolated experiment, meager as it is in signifi-
cance, suggests two things : first, that mapharsen is rela-
tively nontoxic and may even be given daily without
producing serious untoward reactions; second, that
despite daily administrations of conventional doses,
when unsupported by a heavy metal it was not effective.

For two women with secondary syphilis, two methods
of treatment illustrating the efficacy of combined ther-
apy were employed. The first patient received three
injections a week of mapharsen for a total of thirty-
nine injections, with an aggregate dosage of 1.44 Gm.
(0.037 Gm. per injection). During this period she
received only two intramuscular injections of bismuth.
Although the cutaneous eruption disappeared within
the first two weeks, the blood tests were still positive
at the end of this course. She then received four weekly
injections of bismuth, at the end of which there was a
marked reduction of the reagin titer. After this she
received additional treatment of thirty-one mapharsen
injections (1.43 Gm., or 0.046 Gm. per injection) and
eight intramuscular bismuth injections, at the end of
which all the blood tests were negative, as they have
remained to the time of the last examination, i. e., for
an interval of sixteen months. Cardiovascular and
spinal fluid examinations also were negative. This
patient with secondary syphilis therefore required a
total of seventy-one injections of mapharsen (2.85 Gm.
of mapharsen) and fourteen intramuscular injections
of bismuth to produce and maintain a complete sero-
logic reversal.

The second patient with secondary syphilis received
one intravenous injection of mapharsen and one intra-
muscular injection of bismuth concurrently once a week.
She received sixteen injections of mapharsen (0.58
Gm., or 0.036 Gm. per injection). At the end of the
twelfth injection all tests were completely negative, as
they have remained for the past twenty-eight months.

Two men with primary lesions also were compared.
The first, aged 29, had a chancre on the chin and posi-
tive blood tests. He received three injections of
mapharsen and one intramuscular injection of a bismuth
compound each week, for a total of twenty-eight injec-
tions of mapharsen (1.51 Gm., or 0.054 Gm. per injec-
tion). At the end of three weeks the primary lesion
was completely healed, but at the conclusion of twenty-
eight injections he developed an arsenical eruption
simulating pityriasis rosea. Mapharsen was stopped
temporarily. On resumption of mapharsen the derma-
titis recurred. He then was given eighteen additional
weekly injections of bismuth, at the. conclusion of
which all tests were completely negative; they have
remained so to the present time (twenty-one months).
The spinal fluid and cardiovascular examinations were
also negative.

The other patient, aged 34, presented a penile lesion
with a positive dark field examination and positive
blood tests. He received three injections of mapharsen
on three successive days and then concurrent injections

of mapharsen and bismuth, one of each once a week,
for a total of seventeen injections of mapharsen (05
Gm., or 0.053 Gm. per injection) and fifteen injections
of a bismuth compound. All the blood tests became
negative after the fourteenth injection of mapharsen
and have remained negative ever since (twenty-three
months).

. These five cases, although inadequate to permit defi-
nite conclusions, at least suggest that:

1. Mapharsen is relatively nontoxic and may be given
daily without producing serious untoward reactions.

2. Mapharsen alone in such frequent administrations
may produce rapid healing and disappearance of early
cutaneous syphilis but does not produce an early sero-
logic reversal.

3. Mapharsen used concurrently with a heavy metal
(bismuth) not only produces more rapid healing of
early cutaneous lesions but also effects and maintains
an early complete reversal of the serologic reactions.

We feel that the more frequent administration of
mapharsen (from three to seven injections a week),
although well tolerated by patients with normal renal,
cardiac and hepatic functions, does not add to the
efficacy of treatments as manifested by more rapid
sterilization and healing of early cutaneous lesions or
by producing and maintaining an early complete sero-
logic reversal.

Massive initial doses of mapharsen did not increase
the effectiveness of treatment in early syphilis, a fac
already'' noted by Foerster and his collaborators. 1

UNTOWARD REACTIONS

The majority of investigators draw attention to tbe
fact that mapharsen is relatively less toxic m an
commonly used arsenicals and stress the point
there has not been a single report of hernorr ' ?
encephalitis or of death attributed to the use of map '
sen. The toxic effects of mapharsen are comm
classified as immediate or delayed reactions. ^
former group consists of (1) venous spasm, (2)
gastrointestinal disturbances associated w™ na . j
vomiting and abdominal pain, (3) headache, ( ) '' ,

ness or collapse and nitritoid reactions, i “ c c ^
reactions include such conditions as (1) nauS , a , ■
vomiting, (2) fever and chills, (3) dizziness an
ing (4) precordial pain, (5) blood (lyscrasia , (
hemorrhagic encephalitis, (7) urticaria, ( )
(simplex and zoster), (9) dermatitis, (10) ^ uS
tions, (11) plaquelike eruptions (12) cmsi .
lesions, (13) jaundice, (14) delayed nitritoid ^
(15) exacerbations of preexisting e ru pti ' ' e ;,
ninth day erythema of Milian, (17) ocular di

( 18 ) renal damage and (19) neuritis. (V j ( |,

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mapharsen we noticed that several patient sn! ,

pain along the course of a vein due to \en .. injec*
This occurred during or immediately after ‘ c .
tion, especially if it was administered slowly. Ider;
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hours. When the drug was administered more 1 ^
this reaction was eliminated almost entire). ^
has shown that the application of cold vet
over the vein is rapidly effective. f<****^£ u of
tion and extravascular seepage of small a m_ ^

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1950

SYPHILIS-REIN . AND WISE

lowing morning she developed generalized giant urticaria. She
remained nauseated for twenty-four hours after the fourth
injection of mapharsen (0.06 Gm.). The fifth injection was
reduced to 0,02 .Gm. and was followed immediately by the
ingestion of S drops of compound solution of iodine in a glass
of water (in an attempt to prevent nausea). The patient
experienced no nausea after the injection. When the dose of
mapharsen was increased above 0.02 Gm. the injection was
followed by nausea., regardless of whether or not the compound
solution of iodine was administered. At no time was it felt
that the nausea was of sufficient severity to warrant the dis-
continuance of mapharsen. Following this first course of treat-
ment (thirteen injections of mapharsen and seventeen of a
bismuth compound) there was a marked reduction of the sero-
logic titer. The patient then received twelve more injections
of bismuth at weekly intervals (the last given on Jan. 19,
1938). On January 26 she received an injection of mapharsen
(0.02 Gm.), which was followed by slight nausea but no vomit-
ing. One week later a second injection of mapharsen (0.02
Gm.) was given, followed again by nausea but no vomiting.
When she returned the following week for her third injection

Table 3. — Results of Special Tests of the Patient with Fatal
Aplastic Anemia

Test

Kesulfc

Fragility tests

Initial hemolysis 0.45% NaCl

Complete hemolysis 0.20% NnCl

Bleeding time

4 minutes

Clotting time

5 minutes

Icteric index

5.5

Blood plasma

Albumin 4.2S%

Globulin 1.5S%

Fibrin 0.226%

Sedimentation rate

15 min., 10 min.; CO min., 130 mm.

Serology, Blood

Kahn 4--1-

Wnssermtmn strongly positive

Spinal fluid

Cells 3

Sugar 5S mg.

Globulin not increased

Colloidal gold, slight syphilitic curve

Alcoholio Wnsscrmnnn 4 plus

Cholestorinized Wassermann 4 plus

Kahn 4 plus

Blood chemistry

Normal

Friedman test

Negative

Cervical smear

Negative for gonococcus

Feces

Positive for occult blood

she was very pale and complained of marked weakness, dizzi-
ness and faintness. The hemoglobin determination on that day
was 30 per cent.

Immediate hospitalization was advised but the patient did not
enter the Metropolitan Hospital, Welfare Island, 0 until forty-
eight hours later (February 11), at which time she submitted
the aforementioned history of antisyphilitic treatment. She
stated that during the Christmas holidays of 1937 she had
influenza which lasted for one week and that since that time
she had never felt entirely well, always feeling tired and easily
fatigued but with no other specific complaints. One month
before she noted “black and blue’’ spots which appeared on
different parts of the body without relation to trauma. She
became progressively weaker, and several days before admis-
sion she became noticeably pale. Five days prior to admission
her weakness became so profound that she was unable to carry
on her occupation as a school teacher. She complained of a
slight elevation of temperature and of nausea but not of vomit-
ing. Her last menstrual period began on Dec. IS, 1937, lasting
the usual length of time with the normal amount of flow. Her
next period was due during the middle of January, at which
time she had her usual premonitory signs but no bleeding.
There was no history of rectal bleeding, hematemesis, sore
mouth, burning tongue or difficulty in walking. Dyspnea on
exertion had been present for weeks before admission, and
there had been a loss of 5 pounds (2 Kg.) in weight.

The patient was well developed and well nourished. She
showed profound pallor but did not appear acutely ill. Obser-
vations were negative with the following exceptions :

The

Jodi. A. JI. A
Nov. 25, 19!)

blood pressure was 85 systolic, 60 diastolic; the lower extremi-
ties showed several purpuric areas, and the axillary lymph
nodes on the left were slightly enlarged.

During the first two weeks in the hospital the patient
improved, with multiple transfusions as the chief form of
therapy. During her stay at the hospital she received nine
transfusions, as follows: February 22 300 cc., February!!
300 cc., February 16 250 cc., February 18 250 cc., February 20
250 cc., March 3 300 cc., March 7 250 cc., March 10 250 cc.
and March 11 125 cc. On February 13 several ecchymotic
areas developed on the right leg. On February 16 menstrua-
tion began and lasted for four days with normal flow. On
March 2, after two intramuscular injections of liver extract,
an abscess of the buttock developed. The symptoms noted on
admission reappeared (weakness, lassitude). On March 6 the
temperature rose to 105.2 F. and from then on until death it
persistently rose to about this level. On February 6 pain
developed in the right lower quadrant of the abdomen and soon
after in the left lower quadrant. The pain was accompanied
by tenderness in these areas but there was no rigidity. A
surgical consultant decided that the abdomen was not involved
in a discernible disease process. On March 10 the patient
developed difficulty in hearing and had blurring of vision. A
spinal tap done at that time disclosed clear fluid under normal
pressure. On March 11 the patient died.

Roentgenograms of the chest and abdomen were negative.
Electrographs, blood cultures, agglutination tests and sputum
and stool examinations were also negative.

Autopsy was performed on March 11. The anatomic diag-
noses were as follows :

1. Aplastic anemia due to arsenic treatment for syphilis.

2. Multiple petechial and ecchymotic hemorrhages of the
arachnoid, visceral pleura, epicardium, myocardium, endocar-
dium, renal capsules, ileum and cecum.

3. Toxic hepatosis.

4. Bilateral ovarian hemorrhagic cysts.

5. Hyperplastic splenitis.

6. Sanguineous peritoneal fluid (small amount).

Although this is the first reported case of the develop-
ment of a blood dyscrasia with a fatal outcome follov-ing
the use of mapharsen, it is interesting to note tin
Goldberg 10 reported a syphilitic pregnancy in 1
mapharsen prevented congenital syphilis and at (ie
same time did not cause a recurrence of a serious
hemopoietic complication (granulocytopenia), _
had occurred after treatment with another arsenical.

COMMENT

The majority of the patients in this series

tolerated

the mapharsen therapy well and presented no sen
untoward reactions, except for those described. . .
the 113 patients, who received altogether 2,342 mi
tions of mapharsen, sixteen had mild gastrointes
reactions (nausea), eleven had nausea and vo l’" ' s’
four complained of mild headaches and attacks o v
ness, three had pruritus, and one developed '1
simplex. Of these 113 patients, ten had similar
tions with other arsenical preparations, such as
arsphenamine, silver arsphenaniine and arspnena ,
Fifteen patients developed the more serious 7j
reactions; two had chills and fever; form c ' c( , r .
generalized erythematous eruptions; five had atl • ‘ . - c
bation of a preexisting dermatitis (three with sci .
dermatitis and two with a discoid vesicular tie *
two developed fixed eruptions; one coinplame
cordial pain, and one developed albuminuria. ; n

Mapharsen had to be discontinued for a short 1 ^

some of these cases. In three cases the drug ‘ ‘ j

stopped entirely because of the recurrence o nCC

reactions. In thirteen cases there was no r — -

o lire T vnn J Boyd and Van Alstyne Cornell, of the Metropolitan
Hospital. 'save remission to use the data obtained- while: the patient was
in the hospital.

1 0. Goldberg. -Mortimer: .Mapharsen .
phenamine in Agranulocytic Angina Followt
in a Pregnant Syphilitic Woman, Am- J*

79 (Jan.) 1 939.

os a Substitute tot ft'..;

,-ing NeoarspHenammc l „ z -

ypli., Conor. 1- A eh- v

Volume 113
Number 22

SYPHILIS— REIN AND WISE

1951

of the reactions when mapharsen therapy was resumed
at a reduced or a similar dosage. For two patients
treated by Dr. Girsch D. Astrachan (one with nausea,
vomiting and fever and the other with headaches, vomit-
ing and fever) the recurrence of these reactions was
prevented by the intramuscular injection of liver extract
from fifteen to thirty minutes prior to the injections of
mapharsen, as advocated by him in a recent publi-
cation. 11 We were not able to prevent the recurrence
of reactions by the oral administration of compound
solution of iodine prior to the mapharsen injection.

Some patients had a variety of untoward reactions
with the various arsenicals in the course of previous
antisyphilitic therapy but did not develop a recurrence
of these reactions when they received mapharsen. In
this group there were twenty patients with the following
reactions : Five had nitritoid reactions, eight had nausea
and vomiting sometimes associated with fever, chills,
headaches or attacks of dizziness, three had arsenical
dermatitis, one had urticaria, and one had angioneurotic
edema of the face and hands.

CONCLUSIONS

1. Mapharsen ' '* 1 ” adequate to control

early infectious 1 rapid sterilization

of active reactions.

2. The majority of syphilitic patients treated by the
physician in private practice are in the latent asymp-
tomatic stage. Mapharsen, possessing relatively lower
toxicity, is preferable in such cases to other drugs,
which have a greater tendency to produce untoward
reactions.

580 Fifth Avenue — 200 West Fifty-Ninth Street.

ABSTRACT OF DISCUSSION
Dr. Girsch D. Astrachan, New York: The main value of
this paper lies in the publication of a fatality which could be
attributed to the use of mapharsen. This report should draw
the attention of physicians to the potential dangers of mapharsen
and make them weigh carefully all the necessary indications and
contraindications. Dr. Wise and I came to the conclusion some
time ago that mapharsen should be preferred in late latent
syphilis. Mapharsen is useful also in cases of late congenital
syphilis, cases of cardiovascular syphilis and cases in which
drastic energetic therapy is not desirable. As a result of a
recent study on a limited number of cases (twenty-four) I
gained the impression that mapharsen is as efficient as neoars-
phenamine in cases of syphilis and pregnancy. Mapharsen has
a well deserved place among the efficient antisyphilitic remedies
but, regardless of its lower toxicity, it is a powerful arsenical
and may be very harmful if used without caution. This factor
is being ignored by some physicians, who in their enthusiasm
begin to use mapharsen in cases in which sensitiveness possibly
exists to the arsphenamines, or in which the arsphenamines are
contraindicated. A case is reported in which granulocytopenia
developed after the administration of neoarsphenamine and soon
after mapharsen was administered. Although this patient bene-
fited greatly from mapharsen therapy, I believe that no trivalcnt
arsenicals should be used again in cases in which there is a
history of a blood dyscrasia. I am also against the use of
mapharsen (especially in maximum doses) in cases of advanced
tuberculosis. Because of several reports of severe complications
following the continuation of arsphenamine therapy in cases of
ninth day erythema, I believe that as a matter of safety such
cases should be regarded as average cases of sensitivity to
arsenicals. Only after a blood count and liver function and
urine tests are found to be normal should the arsenical be
renewed cautiously, beginning with small doses. A blood count
was done in most of our cases before mapharsen therapy was
instituted and was repeated at the completion of a course of

11. Astrachan. G. D. : The Value of Administration of Liver in Patients
intolerant to Arsenicals, J. Invest. Dcrmat. 1 : 427 (Dec.) 1938.

treatment. This procedure helped to discover signs of beginning
dyscrasia of the hemopoietic system before clinical manifesta-
tions appeared. I agree with the authors that the efficacy of
mapharsen is greatly increased when it is given together with
injections of bismuth compounds.

Dr. H. M. Robinson, Baltimore : It is my impression, after
seven years' experience with mapharsen, that it is an adequate
antisyphilitic agent. Furthermore, mapharsen is almost the equal
of arsphenamine and is superior to neoarsphenamine. Never-
theless I am convinced that none of the generally accepted anti-
syphilitic drugs need be discarded from our armamentarium.
Each drug seems to have some place in our scheme of therapy.
In general, I believe that physicians should bear in mind the
fact that any of the reactions caused by the trivalent arsenicals
can also be caused by mapharsen. Also the patient should be
warned beforehand of the local, painful vein reactions. With
these provisos I think the drug would be preferable in an office
as well as in a clinic. The spirochetes are killed in from six
to seven hours by both arsphenamine and mapharsen. It takes
somewhat longer for neoarsphenamine to accomplish this result..
As for serologic reversal, the work of Moore and his co-workers
showed that the serologic reversal is about equal with neoars-
phenamine, mapharsen, silver arsphenamine and bismarsen, and
that arsphenamine caused a slightly quicker reversal to negative.
Several of our patients developed jaundice resulting from
mapharsen, a few of them quite serious. There have been two
cases of exfoliative dermatitis. However, we have encountered
several cases of mild exfoliative dermatitis due to arsphenamine
in which the patients could tolerate mapharsen. Sometimes it
is important to be able to continue with an arsenical in the
treatment of syphilis, especially in pregnancies and in early
syphilis, and it is my conviction that mapharsen should be tried
before all arsenicals are excluded from consideration. Knowing
that many practitioners and specialists are careless about the
preparation of the arsenicals, mapharsen comes nearer being
a foolproof arsenical than the arsphenamines. You can stir it
as much as you want to within reason. In fact, it is advisable
to stir it thoroughly in order to liberate the carbonate. If you
agitate the arsphenamines too strongly they become toxic. I
think mapharsen will probably supersede neoarsphenamine as a
drug of general usage, but not entirely, because there are still
some patients who cannot tolerate mapharsen but can tolerate
neoarsphenamine. Therefore, neoarsphenamine should not be
discarded but held in reserve.

Dr. William Becker, Chicago: I was gratified to hear the
authors and Dr. Astrachan give their preference for the con-
current method of treatment, because we have used that for
many years in our clinic. We have always thought that it had
advantages over the alternating system of therapy and we have
not experienced any increase in reactions from its use. In
mapharsen one has what is probably the active drug that is
liberated by arsphenamine in the body. Chemical methods as
yet are inadequate, so that we do not know how much arsenoxide
is liberated over a certain period of time from one of the
arsphenamines. It may even be that if mapharsen was given
in small doses, several times daily, we would be approaching
the optimal method of administration. I have always been
favorably inclined toward the use of bismuth. Levaditi and
certain French workers found that they could almost, but not
quite, cure syphilis with bismuth. Our treatment system is
incorporated on that principle ; that is, we use a lot of bismuth
and not a great deal of arsenical. When a patient comes with
ail early lesion, primary or secondary, instead of starting out
with a long series of arsenical injections we give bismuth right
from the start. We give the patient a small dose of mapharsen,
along with a small dose of soluble bismuth. This is repeated
two days later and again two days after that, after which we
give it once every five days or once weekly. I believe that this
combination therapy will have the advantage of preventing the
appearance of the so-called retractile cases. In other words, if
one starts out with a long series of arsenical injections, one
may find that pretty soon the lesions instead of becoming better
will become worse, but if you give bismuth right from the start
I think that this relapse will probably be prevented. I believe
that a great deal of bismuth and not so much mapharsen given
by the concurrent method is an extremely' good method for the
practitioner and is safer than the other’ methods.

1952

Jout. A. M. A.
Nov. 25, 1955

PARATRI GEM INAL LESIONS — DAVIS AND MARTIN

Dr, Leon Goldman, Cincinnati : In Cincinnati recently there
was a fatal case from mapharsen and this report is from the
Chronic Disease Hospital and is by several men in the medical
service there. The case will appear shortly in the literature.
A middle aged man developed hematuria and then renal insuf-
ficiency following mapharsen. To compensate for this some-
what, at this hospital we have been conducting a study purely
for academic purposes on the effect of mapharsen on late and
latent syphilis in patients who are 70 and 80 years old.

Dr. Charles R. Rein, New York: Although a number of
the patients in this series showed a satisfactory serologic
response following mapharsen therapy, the incidence was not as
high as should be expected if a similar number of patients with
early syphilis were treated with the same preparation. In our
series the majority of patients had their infections for many
years and received an average maximum of only twenty injec-
tions per patient. Dr. Sharp, of Detroit, was kind enough to
review our report and made the following note regarding the
fatality which occurred during mapharsen therapy: “The
development of anemia, leukopenia accompanied by neutropenia
and thrombocytopenia in the patient receiving antisyphilitic
therapy are presumptive signs of chemical toxemia. Inasmuch
as similar hemopoietic patterns do occur frequently in nons 3 'phi-
litic patients not having received any drugs within a reasonable
period of time prior to acute hematologic manifestations,
unknown etiologic factors cannot be excluded from consideration.

I do not recall how many similar cases I have studied, but the
clinical picture is not uncommon and infection of a degree ordi-
narily regarded as inconsequential occasionally is the only dis-
cernible pathogenesis.” It is quite possible that the blood
dyscrasia in this patient may have been due to something other
than the mapharsen. Mapharsen should be used with a great
deal of discretion. If administered indiscriminately it may pro-
duce serious untoward reactions.

SURGICAL LESIONS OF THE
PARATRIGEMINAL AREA

LOYAL DAVIS, M.D.

AND

JOHN MARTIN, M.D.

CHICAGO

In 1923, one of us 1 called attention to the clinical
syndrome produced by lesions of the paratrigeminal
area. In this small anatomic space are located the
sensory and motor roots of the fifth cranial nerve, the
gasserian ganglion and its three branches, the carotid
artery and the plexus of the sympathetic nerve fibers
which surround it, and the oculomotor, trochlear and
abducens nerves which innervate the extra-ocular mus-
cles (fig. 1). Obviously, with all these important
structures crowded into a small area the potentialities
of many symptoms from even a very small lesion are

great.

In one of our two cases reported at that time there
were excruciating pain in that area of the right side
of the face supplied by the ophthalmic and maxillary
divisions of the trigeminal nerve and paralysis of the
sympathetic nerve fibers innervating the eyeball, as
evidenced by a small pupil which failed to dilate after
the introduction of cocaine solution, a narrowed palpe-
bral fissure due to an enophthalmos and an absence
of the ciliospinal reflex. Autopsy disclosed a small
aneurvsm of the internal carotid artery. A second
patient also suffered with pain of a similar excruciating
character but distributed in the area supplied by all three

From the Division of Surgery, Northwestern University Medical

School. .. Section on Surcerv, General and Abdominal, at the

NOnScfb Annunl th S%ssio C n o" the American Medical Association. St. Louts.

■j' 1 "] D’avds 3 Loyal E.: Lesions of the Paratrigeminal Area. J. A. M. A.
SO:3SO C Feb. 10) 1923.

divisions of the left trigeminal nerve. She prcsenloi
ptosis of the left upper eyelid, dilatation of the pup!
and paralysis of all the extra-ocular muscles supplied
by the left oculomotor nerve. This patient, too, proved
to have an aneurysm of the internal carotid artery at
autopsy'. The third case included in the original report
had been cited by Raeder - in 1918. In common with

Fig. 3. — Anatomic relations in the paratrigeminal area.

our cases there had been severe pain on one side of the
face in the area supplied by the trigeminal nerve,
small pupil, enophthalmos and paralysis of the miCCi
supplied by the motor division of the trigeminal nene
completed the clinical symptoms. Raeder stated
autopsy a small “endothelioma” was found origins 1 S
from the medial edge of the gasserian ganglion.

During the past sixteen years fourteen other as >
have been observed in which the symptoms ))»)
classified as belonging to this syndrome. W ■
instances the lesion was verified as an aneurysm
internal carotid artery either at autopsy or at opera {( J
in seven cases a small meningioma, wholly; con
the dural envelop which encloses the gasserian IP ? '

was removed at operation and verified nucrosc p ‘
and in the one remaining case neither an aneury
a tumor could be verified at operation, .althoug ^
ing the surgical exposure of the paratngemma a
symptoms have subsequently' all disappeared.

Attention is again called to the lesions ". ,c
in this area not only' because of the interesting _
sy'ndrome which is presented in any ° ne o t se% e ‘
binations of symptoms but because (1) the s 5. l
must be differentiated from those which occur
of major trigeminal neuralgia, the etiology fl (

is as yet unknown, and (2) because the sy P i; evC t|
one half of the patients in this group have he
by' operation. . ,

Without exception, all these patients P re = en /j- crc d
selves for relief of the severe pain which they - , c>

in the area of distribution of the ttigem . .

Failure to obtain relief from this persistent ■ . • £C .

pain by' the usual analgesic drugs or by a cf fk

tions had led them, directly or by rcferci > ?v[T];) .
surgical attention. This pain is one o r : cnc c L 5
toms noted by the patient and in i our - P - as e C riai>
occurred in one. two or all branches o .: s ; 0 n has
ganglion, but without fail the ophthahm ^^

always been involved. A trigger zone, f° Pf ® B prC sent
of trigeminal neuralgia, may or ma} __ — , — ■ —

2. Rrcdcr, G-: Report of *** ^ ^

Enal Area, Norsk, mag. f. Isgevidensk. /?.

Volume 113
Number 22

PAR AT RIG EM INAL LESIONS— DAVIS AND MARTIN

1953

Though sharp and severe the pain seldom has had the
paroxysmal character of true trigeminal neuralgia, nor
is it as shocking and terrifying to the patient. Often
the pain seems to radiate peripherally from an origin
located indefinitely by the patient as “somewhere behind
the eye.” Several patients have complained of a severe,
dull headache localized to a point deep within the
anterior portion of the cranium on the affected side.

Without exception we have found that when this
syndrome has been due to a small meningioma, origi-
nating within the dural envelop which encloses the gas-
serian ganglion, there have been small patchy areas
of paresthesia, numbness and even complete loss of
sensation to pin prick and touch stimuli in the oph-
thalmic and maxillary areas of the face on the side of
the lesion. This is so constant an occurrence, if
examined for carefully and meticulously, that we have
come to regard it as pathognomonic of the presence of
such a tumor. Raeder did not comment on a loss of
sensation by his patient who had an “endothelioma,”
which we assume is the term commonly in use twenty
years ago for this same type of tumor. Involvement of
the motor division of the trigeminal nerve, as noted
by Raeder in his case, was also present in two of our
cases (both with tumors) but the paralysis of the ptery-
goid and masseter muscles was only partial.

Accompanying these symptoms of involvement of the
trigeminal nerve have been the signs produced by
involvement of the third, fourth and sixth cranial nerves,
which innervate the extra-ocular muscles. As might be
expected, these nerves may be affected singly or in any
possible combination. The most common manifesta-
tions have been those which pointed to the oculomotor
nerve and have been characterized by a dilated pupil,
an actual ptosis of the upper eyelid and divergence of

the eyeball to the
outer canthus. In
two cases, in which
there was a menin-
gioma, there was a
complete paralysis
of the external rec-
tus muscle, point-
ing to a lesion of
the abducens nerve,
and in another case,
in which there was
a large aneurysm
of the internal ca-
rotid artery, a com-
plete ophthalmople-
gia was present. In
no instance in which
a meningioma was
found and removed
at operation have
the extra-ocular
muscles failed to
recover their func-
tion. In fact, the
marked ocular
symptoms have been more characteristic of the cases in
which there were aneurysms of the internal carotid
artery.

When the sympathetic nerve fibers which surround
the carotid artery and accompany the ophthalmic
division of the trigeminal nerve are involved, a typical
Horner’s syndrome is produced with enophthahnos, a
narrowed palpebral fissure and a small pupil which will

fail to dilate after the introduction of cocaine solution.
Under these circumstances, which most often occur with
aneurysms of the internal carotid artery, the ciliospinal
reflex is also absent.

That surgical help can be given to at least one half
of these patients in our experience and that a shrewd
guess can be made that a small meningioma rather than

Fig, 3. — Low power section showing characteristic microscopic appear-
ance of the meningiomas found in the paratrigeminal area.

an aneurysm is present and that these patients come to
the surgeon for relief of the severe pain in the face
is illustrated by the following case :

A woman aged 50 first complained of a jabbing, knifelike
pain in the left eye in June 1937. This was not present con-
stantly but came in attacks and soon involved the left frontal
and the left maxillary areas. Cold air, rubbing the left tem-
poral area or touching the site of the removed left canine
tooth brought on the pain. At frequent intervals diplopia
would be present for hours or days at a time.

On examination, stimulation of the zones described by the
patient produced a sharp increase in her pain but it was obvious
that she was never entirely free from a pain described as “deep
in the left eye.” No impairment of the extra-ocular muscle
movements could be elicited on examination. There was a loss
of sensation to light touch and pin prick stimuli over the left
upper lip, left ala and left side of the nose which extended
laterally about 2 cm. The left upper and lower eyelids were
also insensitive (fig. 2).

At operation the gasserian ganglion enclosed in its dural
envelop appeared coarse, large and red. When the envelop
was opened a purple soft mass was found occupying the site
of the ganglion and wholly enclosed within its dural envelop.
The mass was removed completely and the sensory root divided.

The patient has had no recurrence of her pain, and no new
symptoms have developed during the past year following her
operation.

This story is quite typical in the six other cases in
y\ Inch a tumor in the same location, with the same gross
appearance and with the microscopic characteristics of
a meningioma, has been removed. In each instance

Fig. 2.-~Loss of sensation in the face
caused by meningioma in the paratrigeminal
area.

1954

PARATRIGEMINAL LESIONS— DAVIS AND MARTIN

there has been severe pain in the trigeminal area and
except for the last three cases an operation was devised
for the relief of trigeminal neuralgia. The presence
of small, scattered areas of sensory loss in the trigem-
inal area on the side of the pain has led us to the correct
diagnosis in the last three cases.

These tumors are not tumors of the gasserian gan-
glion and show none of the microscopic characteristics
of such tumors, which are not uncommonly found.

Joint, A. y.A
Nov. 25, IS?

As is shown in figures 3 and 4, the tumor tissue is
composed of a uniform epithelioid type of cells with
central round, granular or reticular nuclei, which are
arranged in poorly defined whorls about central blood
vessels. Other more elongated endothelial-like cells are
present and mitoses are fairly common.

These are not the large tumors which Cushing has
described in his monograph “The Meningiomas” as
“sitting like a saddle astride the anterior end of the
peti'ous ridge.” That, if allowed to go unrecognized
for an}' length of time, they would eventually grow to
extend into the middle and posterior fossae of the skull
is quite probable. However, in these seven instances
the severity of the pain has forced early surgical inter-
vention and as yet we have seen no evidences of recur-
rence of the tumor though the first operation was
performed eleven years ago.

The story of the patients with an aneurysm which
produced paratrigeminal symptoms and signs is not a
happy one, but in view of the potentialities of the
lesion it may be of much longer duration than one
would at first imagine:

A woman aged 47 had a severe pain in the right eye followed
by a terrific generalized headache while attending a funeral in
1932. Her vision was dim and she had a diplopia. The head-
ache, present since the onset, was described as a sharp, con-
tinuous pain over the right temporal area which varied in
intensity. This pain seemed to “shoot through the right eye
in attacks and when this occurred, as it did about once a week,
she became nauseated, vomited and had a true vertigo. A

boiling, drawing” pain bad been present over the verier c;
the skull since 1934. Although she had diplopia from i>
onset, she did not notice that her right eye was turning to lit
left and that the pupil was large until a year later.

In 1937 it was noted that the right upper eyelid was “dw;-
,n S and she could not open her eye easily. Simultaneous';
a. tingling, fiery, sharp pain occurred frequently in the risk
side of the face and would last about fifteen minutes, to le
followed by numbness in the right side of the tongue, the tail
and gums on the right side.

There was a definite ptosis of the right upper eyelid, an

the right pupil was larger than the left and reacted slug]

gisrJ

to light. The visual fields and acuity were normal in beta
eyes. In looking upward and to the left and right, the rift:
eye did not move at all but did move on looking down (fig. 5).
There was diminution to pin prick and touch stimuli over fe
right maxillary area and on the right side of the tongue.

At operation an enormous aneurysm of the internal carotid
artery extended upward and laterally into the middle fossa.

Although it has been assumed that the majority ot
such intracranial aneurysms are the result of sj'pbife
the serologic reaction of this patient and the other live
patients has been negative. Seven years since the onset
of her first symptoms and one year since operation, the
patient continues with her household affairs with Se-
quent attacks of pain which incapacitate her.

In 1937 Dandy 3 reported a case in which there to
an intracranial aneurysm of the internal carotid artery
He operated and was able to put a silver clip on the neck
of the aneurysm. The symptoms were very similar
to those we have found in our cases. As Daw!)
properly remarks, one cannot be sure that even alter an
aneurysm is disclosed at operation it will prove to
amenable to surgical attack. As in our case just aW
the aneurysm was far too large for one to he able o
disclose the point of its origin. On the other nm 1 ■

■ t m. - .-s,

Pig. 5, — Appearance ot patient tvth an aneurysm of tbe interna!
artery, showing ptosis of the pupil and ophthaimopicffi

Dandy’s report is of considerable interest ‘ ( |.,

these cases can be diagnosed early enoug i
aneurysm is small, the situation is not entire )
Extensive paralysis of the extra-ocular mu- ^
been quite characteristic of the cases of aneu . - ^ (y

internal carotid artery and in our experien ^ ( j. ;

motor nerve has been more constantly invoh ea —

/ntracraniaJ Aneurytm of tSc Intern-
,0: IS, 1937.

3. Dandy, Wafter E-f
Artery, Tr. South- S. A.

Volume 113
Number 22

CONTACT DERMATITIS— JORDON AND OSBORNE

1955

other nerves to the extra-ocular muscles. With respect
to the pain, it is our opinion that in the cases in which
there is an aneurysm the character and distribution
of the pain does not resemble the pain of trigeminal
neuralgia as closely as it does in the cases in which
there are meningiomas of the dural envelop of the
ganglion. Neither have we found the presence of a
sensory loss as constant in the instances of aneurysm.

CONTACT DERMATITIS FROM OPIUM
DERIVATIVES

WITH SPECIAL REFERENCE TO OCCUPATIONAL
ASPECTS

JAMES W. JORDON, M.D.

AND

EARL D. OSBORNE, M.D.

SUMMARY

A group of patients who seek relief from severe,
excruciating pain located in the distribution of the
trigeminal nerve also present symptoms pointing to
involvement of the other structures located in the para-
trigeminal area. Paresis or paralysis of the extra-
ocular muscles or intrinsic muscles of the eye should
direct attention to the possibility of a lesion in this area.
Small tumors confined within the dural envelop of the
gasserian ganglion verified as meningiomas and aneu-
rysms of the internal carotid artery have been encoun-
tered in sixteen cases in which there were various
combinations of symptoms characteristic of a pathologic
condition in the paratrigeminal area. The prognosis in
the cases of intracranial aneurysm has been uniformly
poor but on the contrary in each instance the tumors
found have been removed successfully.

54 East Erie Street.

ABSTRACT OF DISCUSSION
Dr. Erxest Sachs, St. Louis : This paper deserves a great
deal of attention because the differential diagnosis comes up
not infrequently between a true tic douloureux and pain in the
face due to a tumor in the region of the gasserian ganglion.

I operated in a case of this sort in 1915 and at that time I
attempted to differentiate between the symptoms of true tic
douloureux and tumors arising in this region. One of the
points that I feet fs particularly important is that whereas in
true tic douloureux the patient has intermittent attacks of pain,
in this disease it is constant. That is one of the important early
differential points; and the other is that the motor root of the
fifth nerve is involved; whereas in true tic douloureux I have
never seen involvement of the motor root. When I operated
in this case I was under the impression that X was dealing with
an endothelioma. The patient, however, had a recurrence after
one year and died. I did not attempt to reoperate on her. I
believe that this should properly be called a malignant tumor.
The six cases of Dr. Davis were aneurysms, meningiomas and
benign tumors. As a rule, they are benign, and I have recently
had two cases similar to the ones he has described, but in
neither of them were the third, fourth and sixth nerves involved.
I believe that it may be possible to diagnose this condition at
an earlier stage if one is so fortunate as to see them early, the
important differential point being that in this condition the pain
is constant and there is involvement of the motor root, which is
not found in trigeminal neuralgia. In one of my cases the
meningioma lay on the posterior root of the ganglion and was
so small that it had not yet pressed on any of the neighboring
nerves. This is unusual ; as a rule the meningioma is larger and
involves some other nerves, as in Dr. Davis’s cases.

A Method Imperfectly Understood. — Tiic healthiest trend
of modern medicine — and let it be said at once that tt is a
trend which is anything but universal — is to dispense as far as
possible with special methods of investigation in dealing with
the everyday patient. The special method is for the investigator
into pathological processes ; it is not for the pure clinician. The
use of special devices, of special tests, almost always leads one
way: the devices and tests are employed by men who cannot
have the training, cannot afford the time fully to understand,
and a method imperfectly understood is, generally speaking,
worse than useless. — Lewis, Sir Thomas : Research in Medicine
and Other Addresses, London, H, K. Lewis & Co., Ltd., 1939.

BUFFALO

Drug eruptions from the ingestion of or parenteral
use of morphine, codeine and other opium derivatives
are well known to dermatologists. Most American
authors of textbooks on dermatology include opium and
its derivatives as a cause of drug eruptions. Scheer
and Keil 1 in 1934 called attention to codeine as a cause
of dermatitis medicamentosa. Touraine 2 in 1936
exhaustively described drug eruptions from opium
compounds. Many morphologic types of eruption have
been produced by the ingestion of or parenteral use of
opium compounds. The most common are urticarial,
morbilliform or scarlatiniform, but eczematous erup-
tions in which the chief allergic response is at the same
site as in contact dermatitis have been described. Thus
opium compounds are capable of producing not only an
urticarial and scarlatiniform eruption but also an
eczematous response when taken internally by ingestion
or injection.

Eczematous dermatitis from opium compounds used
externally in the form of lotions, suppositories and the
like has been recorded in the foreign literature for many
years. Touraine 2 thoroughly reviewed this literature
and stated that Comanus reported the first case in 1882.
Since then Bodin in 1901 and Bourges in the same year
recorded similar observations. To our knowledge two
analogous cases have been reported in the American
literature. In one of these, reported by Heller in 1931, 3
lead and opium wash was applied externally to the
genital area. Tin’s resulted in a severe eczematous
dermatitis. In the second case, reported by Cummer, 4
also in 1931, ethylmorphine hydrochloride had been
used in the eye with resulting dermatitis of the lids.

Reports pf occupational dermatitis due to opium and
opium derivatives have appeared sporadically in the
European literature. Teuton, 5 in Jadassohn’s Hand-
book, recorded six cases. Pignot 0 reported eighteen
such cases at the sixth International Congress of Indus-
trial Diseases. Touraine and Scematna 7 reported a case
in 1936. Cranston Low, 8 in his book Anaphylaxis and
Sensitization, stated that dermatitis from opium com-
pounds is commonly seen in workers engaged in the
manufacture of these drugs. We have been unable to
find a report of occupational dermatitis due to morphine

From the Department q£ Dermatology and SyphHology, University of
Buftaio School of Medicine.

Read before the Section on Dermatology and SyphHology at the
Ninetieth Annual Session of the American Medical Association. St. Louis,
May ir t 1939.

1. Scheer, Max. and Keil, Harry*. Skin Eruptions of Codeine, T. A.

M. A. 102:908 (March 24) 1934. J

2. Touraine, A,: Les dermatoses do 1 'opium, Rev. de med., Paris S3;
449*460 (Nov.) 1936.

\ t,* V rt C « ute ^P e /^ atit ‘ s t0 Preparations,

Arch. Derma t. & Sypfe. 24:417 (Sept.) 1931.

4. Cummer, C. L : Dermatitis of Eyelids Caused by Dionin: Bevel*

opment of Local Hypersensitiveness After Eleven Years* Use, Arch.
Dermat. & Syph. 23:68 (Jan.) 1931. *

5. Cited by Touraine. 2

6. Pignot, M.: Dennatose eruptive chez des ouvriers fahriquant de

3CCiden ‘ S £t d “ ™' 3di « du

7. Tour-nine, A., and Scemama: Deraatite professioneile p 3r derives
dc 1 opium, Lull. Soc. frani;. de derroat. et sypb. 43: 169" (Nov.) 1936.

and Son?ltd:, C f 924 , A p a fsz XiS 3nd Scnsit!zalion ’ Edinburgh, W. Green

1956

CONTACT DERMATITIS — IORDON AND OSBORNE

Jour. A. M. A.
Nov. 25, 1939

or other opium derivatives in the American literature.
Likewise we have been unable to find any record of
occupational dermatitis in nurses, pharmacists, phy-
sicians or other workers who come in contact with these
substances in the course of their professional duties.
Our discovery of three such cases in nurses and one in
a young woman who was employed in the manufacture
of morphine tablets has prompted us to present this
subject. We believe that opium and its compounds
may be an important though unrecognized cause of
dermatitis in nurses, physicians, pharmacists and
workers engaged in the manufacture and handling of
these compounds.

Opium contains two chief classes of alkaloids : 9
benzyliso-quinolene derivatives, of which papaverine
and narceine are examples, and phenanthrene deriva-
tives, of which morphine, codeine and cibane are natural
alkaloids and from which synthetic compounds are
manufactured, such as ethylmorphine hydrochloride;
apomorphine, a dehydrated morphine compound ; heroin,
or diacetylmorphine, and many others. Most cases of
contact dermatitis that have been proved to be due to
opium compounds have been due to the phenanthrene
derivatives. For example, Lewin 5 reported a case due
to apomorphine. Low believes that codeine is the most
common cause. Pignot’s eighteen cases occurred among
workers with morphine, codeine and heroin. He noted
dermatitis most commonly in workers engaged in the
purification of diacetylmorphine or heroin and its
hydrochloride. Touraine and Scemama obtained posi-
tive intradermal tests to both narceine, a benzyliso-
quinolene derivative, and codeine, a phenanthrene
derivative. However, the results of intradermal tests
are of little value since, as Pilcher and Sollmann 10 have
shown, most normal persons have a positive intradermal
reaction to morphine.

REPORT OF CASES

Case 1. — E. B., a student nurse aged 21, was first seen in
1930, at which time she complained of an eruption of one week’s
duration on the third and fourth fingers of the left hand. The
eruption was confluent and papulovesicular and was accom-
panied by considerable itching. The condition was tentatively
considered to be ringworm but no proof was established. The
eruption partially subsided at the end of a week; three weeks
later it recurred in greater severity on the hands. She was
advised to discontinue work and at the end of a week was much
improved. The condition at this time was considered plant
dermatitis. Three weeks after the patient’s return to work a
new attack of dermatitis appeared on the hands and face, with
marked swelling of the eyelids. At the end of a week the
dermatitis on the face subsided, but the eruption on the hands
persisted. During the next month she continued to have slight
exacerbations, with periods of quiescence. She was patch tested
to all the plants with which she came in contact in the wards,
with negative results. One month later she had another severe
outbreak and she was tested to chloroform, solution of for-
maldehyde, grain alcohol and rubbing alcohol, all reactions
being negative. She continued to have exacerbations and periods
of relative quiescence during the next two years. We then
patch tested her to morphine in dilutions of 1 ; 100, 1 : 1,000,

1 -. 10,000, 1 : 100,000 and 1 : 1,000,000. She showed a strongly
positive eczematous response to all these dilutions. She was
then tested to apomorphine, papaverine, ethylmorphine hydro-
chloride and codeine, all in a dilution of 1 : 1,000. With this

9 Small L F-: Chemistry of tJie Opium Alkaloids, Supplement 103
to Public Health Reports, U. S. P. H. S„ 1932. Sollmann, Torald:
A Manual of Pharmacology, ed. 5, Philadelphia, W. B. Saunders Com-
pany, 1937, p. 273.

10. Pilcher, J. D., and Sollmann, Torald: Skin Reaction to Morphine,
Arch. Int. Med. 33:516 (April) 1924.

dilution the reactions were moderately positive to apomorphine,
papaverine and ethylmorphine hydrochloride but not as strongly
positive as. they had been to morphine 1 : 1,000,000. Codeine
gave negative results. At one time the patient was away from
work for one year, during which time she had no recurrence of
the dermatitis. It promptly recurred when she returned to her
regular duties. She was therefore transferred to the outpatient
clinic in dermatology and had no dermatitis during the week, but
after week ends, when she was required to perform relief duties
in the wards, each Monday she reported a mild recurrence in
spite of the fact that she did not actually, to her knowledge, come
in contact with opium or its derivatives. The problem was
solved by having her work in the x-ray department, where no
morphine or other opium derivatives were used. Subsequent
observations showed that the air of the general ward where
morphine was used produced itching and burning of the exposed
skin when she was in the room for a few minutes. Attempts at
desensitization, using baths of morphine sulfate in dilutions
greater than 1 : 1,000,000,000, produced general erythema and
had to be abandoned.

Case 2. — F. A., a student nurse aged 20, first developed an
eruption on the hands in July 1934. At this time she had been
in training for about a year and was working in the surgical
clinic. She applied fungorex, a proprietary remedy, and the
eruption disappeared. She then went to work in the hospital
diet kitchen and two days later the eruption recurred. She was
first seen on August 4, at which time she had a confluent
erythematous vesicular dermatitis about the nails of both hands
and a few lesions on the palms and backs of the hands. She
was patch tested to the soap she was using and to solution ol
formaldehyde U. S. P. diluted 1 to 400. Reaction to the former
was negative but the formaldehyde gave a strong positive
reaction. During the next four months she continued to have
recurrences in spite of the fact that she was not exposed to
formaldehyde. She was not seen again until November W
at which time she had a papulovesicular eruption involving It
fingers and dorsum of the hands, which had been present or
several months. She gave no history of contact with forma
dehyde. Two months prior to the visit in 1936 she had ta.'tn
a codeine tablet and the next day had a generalized eruption-
This disappeared in a few days. She was patch tester
codeine 1:100 and morphine 1:100. Both tests were strong
positive. During the past four years she had noted that cac
time she handled a morphine tablet the dermatitis recur L
She had no recurrences when she was not exposd to morp «

Case 3. — V. M., a student nurse aged 19, when firs 1 -' c “'
n January 1937 had a discrete deep-seated vesicular erupt
nvolving the left palm and wrist, with an area o con ^
icaling dermatitis at the base of the right fourth finger.. ^
iruption had been present approximately ten days. At ■* ( . £
he had been in training about a year and a half.
nfection was suspected and under treatment the er , up '° jj et
.ppeared. During this period she was working in
ritchen. In December 1937 a severe recurrence develops
he was working in the surgical ward. Patch tests vve ^
with L100 dilutions of mercury bichloride, atropm - Jc ; nc .,
rocaine hydrochloride, morphine sulfate, papaverine 99
nd with thymol iodide powder, saturated solution o
per cent boric acid ointment, zinc oxide, face P°" ’ . K p !

owder, hand lotion, alcohol, three different j soaps,
enzoin and theobroma oil, all of which she l 9 ^

ourse of her work. There was a strong > posi - cn t0
j morphine and papaverine and a weakly posin
odeine. During the next week she careful!) av then

nd other opiates, and the dermatitis disappeared.
ms required to take care of a patient receiving fprA

ons and developed another severe recurrence on ^ d ,..
lecause of the dermatitis she discontinued
latitis did not completely disappear for sc ' paring lh:!
ad no recurrence for one and a halt ) • g(, c tfcei

nerval she did not come in contact with notf" ,s4
ave one hypodermic injection of mor P ’ s;1 „- rc d on t -
le next day an acute vesicular dermatit PP^ 1

Volume 113
Number 22

CONTACT DERMATITIS— JORDON AND OSBORNE

195 7

hands, accompanied by erythema and edema of the face. She
had used precautions to avoid direct contact with the morphine
tablet.

Case 4.— F. G., a woman aged 48, a medicinal tablet molder,
first seen in October 1938, had worked ten weeks molding
morphine and strychnine tablets for a drug company. Three
weeks after she began this work an eruption appeared on
the flexor surface of the arms, particularly about the ante-
cubital areas. The eruption spread to the back of the neck,
the hands and the eyelids. In the course of her occupation
she came in contact with powdered morphine and powdered
strychnine. She continued with her work for three weeks after
the first appearance of the dermatitis, during which time the
eruption became more severe. She discontinued work on
August 24, approximately six weeks before we first saw her.
During this time she had received treatment from her family
physician. Her skin had gradually improved, so that when we
first saw her she had a mild dermatitis about the face with
slight swelling of the eyelids, a dry scaling dermatitis in both
antecubital areas, and discrete papulovesicular lesions on the
forearms and the dorsum of the hands. She was patch tested
to morphine, ethylmorphine hydrochloride, papaverine, apomor-
phine, codeine and strychnine, all in a dilution of 1 to 100.
At the end of twenty-four hours morphine and ethylmorphine
hydrochloride gave a moderately positive reaction and papav-
erine and apomorphine weakly positive reactions. At the end
of forty-eight hours the reactions to morphine and ethylmorphine
hydrochloride were still moderately positive, while the test to
papaverine was slightly less positive and the test to codeine
had become mildly positive. The test to apomorphine was
now negative, and strychnine at no time showed any results.
She was referred back to her family physician and has not
been seen since.

COMMENT

The three cases of dermatitis in nurses and the case
of dermatitis in a worker with morphine, in addition
to the reports of European observers, demonstrate that
morphine and other opium derivatives are potential
eczematogenous agents. The opium alkaloids, like
many other alkaloids and other plant derivatives such
as quinine and strychnine, are capable of producing
the allergic contact type of dermatitis and should be
borne in mind when one sees an eczematous type of
dermatitis in nurses, workers in drug houses or others
whose occupation or profession requires them to be
in contact with these substances. We believe a suspicion
of morphine and related compounds as a cause of occu-
pational dermatitis in this group of workers will result
in the discovery of many more cases in this country.
The eruption in our three nurses appeared first on the
hands, with a clinical appearance easily confused with
that of ringworm infection. In the case of the morphine
tablet molcler, if the history was correct, the eruption
first appeared in the antecubital areas, probably because
the morphine was in powdered form. Other exposed
areas were involved subsequently. In all three nurses
the dermatitis first appeared on the hands and in cases
1 and 3 later involved other exposed cutaneous areas.
Morphine dermatitis, therefore, may remain localized
to the hands and thus simulate ringworm infection or
contact dermatitis due to other causes such as solution
of formaldehyde and soaps. It may primarily involve
other areas than the hands and simulate a dermatitis
due to plants, dyes or dusts. Extreme degrees of sensi-
tization may be encountered, as in case 1, in which
dilutions of 1 : 1, 000,000 produced a strongly positive
patch test and exposure to the air in the wards produced
clinical symptoms. Our attempts at desensitization in
morphine dermatitis have proved a complete failure, as
have our attempts at desensitization in other cases of
the contact type of dermatitis.

SUMMARY

1. Opium and its compounds, particularly phenan-
threne derivatives, deserve more attention as eczematog-
enous agents and as a cause of the contact type of
dermatitis.

2. This group of drugs should be suspected as a cause
of eczematous dermatitis of unknown etiology in nurses,
physicians and pharmaceutic workers.

417 Delaware Avenue.

ABSTRACT OF DISCUSSION
Dr. M. B. Sulzberger, New York: The striking fact in
this report is that it concerns not an isolated instance but tiiree
cases of contact-type eczematous dermatitis caused by opium
derivatives. That brings up the point as to the practical signifi-
cance of these substances as causes of contact-type dermatitis;
that is, how many cases per thousand are produced by exposure
to opium derivatives. The number may be more than was
previously believed but still not very great. However, we must
always at least think of this possibility, particularly when we
face contact-type eczematous dermatitis in physicians, nurses,
druggists, persons dealing with pharmaceuticals and their manu-
facture, and individuals receiving treatment with codeine, mor-
phine or other opium alkaloids. As the authors point out, a
few such cases have been reported in the foreign literature. The
question brought up by Drs. Jordon and Osborne’s paper is
also the route of the access to the skin. We know that allergens
which produce contact-type eczematous dermatitis may arrive
at the skin and produce eczematous reactions not only on expo-
sure from without but also when they are given by injection,
by ingestion or in any other way, provided the skin is suf-
ficiently sensitive and that enough of the agent gets to the actual
shock tissue. In Jordon and Osborne’s series there is one case
mentioned in which codeine given by mouth produced the
eczematous eruption on the skin but no interna! or mucous
membrane reactions. Now there are similar analogous situa-
tions in contact-type dermatitis to a great variety of allergens.
There are cases of eczematous eruptions due to solution of
formaldehyde after the ingestion of methenamine and in which
no mucous membrane reactions occur; there are cases in which
ana! suppositories containing contact-type excitants such as
resorcinol or ethylaminohenzoate or tars produced generalized
eruptions of the skin but no irritation of the anal or rectal
mucosa ; there are cases in which eye drops containing procaine
or atropine, and so on, produced no conjunctivitis but severe
dermatitis of the skin of the eyelids and of the face; there are
cases in which the allergenic excitants in vaginal tampons and
in vaginal suppositories produced no reaction of the mucosa but
contact-type dermatitis of the skin. I think we are forced to
the conclusion that, while in isolated instances there may be
a mucous membrane sensitivity associated with the eczematous
sensitivity of the skin, in many other cases the mucous mem-
branes are not sensitive to contact-type allergens. I should like
to ask Dr. Jordon and Dr. Osborne whether they found that
the phenanthrene derivatives of opium were more likely to
cause reactions than the oxyquinoline derivatives.

Dr. James W. Joroon, Buffalo: I believe the sensitizing
index of morphine is very difficult to determine because mor-
phine is handled by relatively few individuals. The drug is
handled chiefly by nurses, pharmacists and, to a lesser extent,
by physicians. When we see an eczematous eruption on the
hands in nurses, we think of a few things, among them solution
of formaldehyde, rubber gloves, soaps and mercury bichloride,
and, since the discovery of our first case, morphine. The sus-
picion of morphine as a cause of eczematous dermatitis in nurses
led to the discovery of two additional cases. As far as patch
tests are concerned, we had positive tests not only to phenan-
threne derivatives but also to benzylisoquinoline compounds. In
the latter case the tests were not so strongly positive and there
is some doubt in my mind whether there is not some contamina-
tion with a small amount of morphine. In our cases, at least
v,e believe that morphine was a responsible agent rather than
the other opium derivatives.

1958

EXCISION OF SCAPULA— RYERSON

Jobs. A. 3!. A.
Nov. 25, 1933

EXCISION OF SCAPULA

REPORT OF CASE WITH EXCELLENT
FUNCTIONAL RESULT

EDWIN W. RYERSON, M.D.

CHICAGO

Complete excision of the scapula is performed so
rarely that few reports of this procedure can be found
in the medical literature. The only reference in recent
years is an article by W akeley , 1 of London. His patient
was a young man whose right scapula was removed
because of an osteogenic sarcoma. After the excision
the trapezius muscle was sutured to the deltoid, and
the functional result was very satisfactory.

Nearly all of the reported operations were done for
sarcoma or for metastatic carcinoma, with a few
scattered cases of necrosis due to injury or infection.

REPORT OF CASE

The following case is of interest for several reasons :

A man of 56 from a neighboring state entered St. Luke’s
Hospital, Chicago, June 8, 1938, complaining of pain and
swelling in the right shoulder. Six years previously he had
undergone the resection of several inches of his transverse
colon for chronic obstruction, which was said to have been
due to carcinoma of the hepatic flexure. He made a rapid
recovery from this operation and enjoyed perfect health for
the next four years, but in 1936 he began to notice some vague
distress in the abdomen, and his appetite was not very good.
He continued to work, however, until August 1937, when his
right upper arm became painful, and the pain gradually grew
worse. His local physician treated him for neuritis with
intravenous injections, but the pain persisted, and in May 1938,
a month before the trip to Chicago, the shoulder became swollen
in the region of the scapula. This swelling was not particularly
tender to pressure, but the outer side of the arm was so painful
that the patient had to take sedatives three times a da.v. He
was thin and pale, with blood pressure of 108 systolic and

Fi „. i —Dense osteorlastic tumor of scapula.

?8 diastolic. There was no enlargement of any of the lymphatic
glands in the neck, axilla or inguinal, regttms.

Session of the American Medical A- .- gC:439 (Oct.) 1938 .

1. Wakeley, Cecil P. G.: Bnt. }■ surg.

none of the venous engorgement so often seen in sarcoma'.
Movement at the shoulder joint was much restricted in all
directions and caused pain which radiated down the arm as far
as the elbow. The tumor occupied all of the region below
the spine of the scapula and seemed to extend upward above
this level to the upper angle. It was firm and nonfluctuant
and was not particularly tender to pressure. The scapula
was not adherent to the chest wall, but its excursions were
distinctly limited.

X-ray examination by Dr. Hollis E. Potter showed a dense
enlargement of the body of the scapula, with a possible involve-

lent of the coracoid process. The lateral
idiating striations commonly seen in 0S T° B p jy not
luoroscopic examination of the chest by U . {, u (

sveal any evidence of metastatic lesions in
iveral calcified lymphatic glands were visible l —ijgnant
In considering the diagnosis, the history 0 ( jve, M
jstruction in the hepatic flexure was higi y ' a f (er the

le patient had been in perfect health for fo > * 5 ; n the

ilonic resection and had had only vagu ) suggested
idomen after that time. The x-ray appearances^^ ^
new growth of solid consistency and un,fo 5 m ' c i fl om 3 tous
me of the spotty areas commonly seen m m3 |ic-

letastases in the flat bones. The lesion wa sarco aa >*
int, and the patient was beyond the age rC ' £ m-

snerally encountered, but the x-ray appearance certai
ed an osteogenic sarcoma. _ •„,„r C ru>u!ar-th orac ! c

I considered the advisability of an i this-

notation, but the patient was unwilling to n ^ c „
msented to the excision of the scapula, ho^^j ^
ime 9 he was anesthetized with nitrous - de wcl ]A!'
n incision was made from the acromion and a i ^

ong the spine of the scapula to its mn c(c( ] a n<i the

awmvard to the lower angle. The flap wa^ ^ mug
cromioclavicular joint was separated. Thc w cdJ 5

■as then divided and the deltoid PU* hcd p . harp diss« lg '
id lower borders of the scapula were freed ^ mU5cic . fr-
itting the insertion of the s e "a‘us rriaE (hc tcrC5 ms-’
melons of the supraspinatus and infrasp'flat - „. cfC
ie subscapularis and the long

ivided, but it was difficult to separate th curvcd '

s attachments. The capsu « divided the

nd after the remaining muscles hao

auld be lifted up without further i_c 5^ opcrat ian.

There was considerable h eeding g Tw0 chromic ca A

MJ'Z. t

Volume 113
Number 22

EXCISION OF SCAPULA— RYERSON

1959

the clavicle, holding the humerus up in fairly good position.
The deltoid was loosely sewed to the trapezius, and the skin was
sutured with silkworm gut. No drains were inserted.

A blood transfusion was given, as the patient was beginning
to show considerable shock. A Velpeau bandage was applied.

The wound healed by first intention. Ten days after the
operation about 3 ounces (90 cc.) of blood was aspirated from
the lower angle of the incision. There was little discomfort
after the first two days, and the former severe pain disappeared
entirely.

The laboratory reported that the tumor was a metastatic
glandular carcinoma. Radiating from the original site of the
scapular bone were many linear spicules of bone between
which were soft gray regions. Histologically there was a basic
structure of necrotic bone trabeculae that enclosed marrow
spaces filled with granulation and fibrous tissues. The fibrous
tissue was extensively invaded by epithelium. The glandular
structure resembled that seen in a carcinoma of the colon.

Within three weeks after operation the patient was able
to move his arm freely through a range of about 20 degrees

Fig. 3. — Tumor and scapula divided sagittally and spread open.

in all directions. He used the arm in feeding himself and
in writing, and he considered that he was greatly benefited by
the operation. The former severe pain had entirely disappeared,
and he was able to sleep well without any of the sedatives which
he had for months been compelled to take. The humerus
remained in close apposition to the clavicle, and the deformity
was not particularly noticeable. He returned to his home a
few days later, and no further pictures were taken, although
he came back to the hospital several times for roentgen therapy
over the abdomen. He used his arm surprisingly well. The
abdominal mass gradually increased in size, and digestive dis-
turbances began to appear. In a few months the opposite
shoulder became painful, but no metastasis to the scapula could
be discovered. From this time his condition became worse,
and by March 1939 he was practically bedridden.

His attending physician reported that on April 8 death
occurred from generalized carcinomatosis and that postmortem
examination had not been permitted by his family.

Here, then, is a metastatic carcinoma of the scapula,
developing five and a half years after the resection of a
portion of the colon, with an interval of perfect health
lasting four years and with a picture resembling an
osteogenic sarcoma. From a survey of the recent litera-

ture on bone metastases from carcinoma in various
organs, it is evident that metastasis to the scapula is
relatively uncommon. Ghormley and Vails 2 report one
such case in forty-three cases of gastrointestinal car-
cinoma with bone metastases and state that the incidence

Fig. 4. — One month after excision of entire scapula. Note good approxi-
mation and range of active abduction.

of all bone metastases in such cases is from 0.2 to 0.5
per cent, with the highest rate for cancer of the rectum.

Geschickter and Maseritz 3 report 356 bone metas-
tases in 5,739 cases of carcinoma of various organs.
In five of these 356 cases the scapula was involved.

Probably if I had been certain that the scapular con-
dition was due to metastatic carcinoma the operation

Fig. 5. — One month after operation.

might not have been performed, but the relief from
the unbearable pain was so great that it seems to have
been justified. The injection of alcohol around the
scapula might have given some relief and would per-
haps be worth trying in a similar case.

122 South Michigan Avenue.

74 (ja)Tm R ' K " Md VallS ' J - E - : J - Bonc & Joint Surg. 31:
SX?31 G "(ApriTi9?9 . K ' 3nd L H " J' & ^int Surg.

1960

venous obstruction— McLaughlin and ■ popma

Jour. A. M. A.
Nov. 25, 1939

ABSTRACT OF DISCUSSION

Dr. W. B. Carrell, Dallas, Texas: I observed a patient
40 years old with a tumor of the scapula from childhood, evi-
dently an osteochondroma. During the past four or five years
there had been definite increase in growth, although no special
discomfort with the arm. He came in principally because of
the massive tumor on the shoulder and the inconvenience it
caused. The case was one of a definite osteochondroma with
sharp detail, and nowhere could I find any evidence of a malig-
nant condition. Believing that this was benign, I attempted to-
preserve as much function as possible and to save the acromion
and a part of the coracoid with the glenoid. I believed that I
could save the acromion and perhaps gain stability for the
shoulder joint later. At the operation it was found when I
had gotten in under the tumor that there was a fairly good
section of the glenoid and coracoid process, which I was able
to leave. As a result I obtained not only good function but
excellent stability of the shoulder. The trapezius and the deltoid
muscles were left attached. This patient has excellent function,
good general position and practically all the motions of the
shoulder joint. It is important in excision of the shoulder to
preserve the mechanism of attachment of the trapezius and of
the deltoid front below so that one gets not only satisfactory
position but also stability.

Dr. J. Albert Key, St. Louis : I believe that had this patient
of Dr. Rverson’s lived and had an opportunity to develop a
pseudarthrosis around the head of the humerus he would have
had considerable abduction and considerable strength in that

Fig. 6. — Active abduction one month after operation.

shoulder. I have seen one patient with a total excision of the
clavicle. She had very little deformity, the shoulder did not
drop as would be expected, she had good abduction, and she
returned within about two months to regular duty as a trained
nurse and has been doing it ever since. Sometimes it is amazing
what good results can be obtained after removal of what one
customarily thinks of as an extremely important bone. With
no clavicle at all, this woman can get her arm up and do her
hair.

Dr. Edwin W. Ryerson, Chicago : There are several people
in Chicago who were born without any clavicles and they can
do a fair day’s work. Of course, their shoulders are narrow
and the heads of the humeri are in a forward position. A few
weeks ago an elderly woman came into my office who twenty-
three years ago had a real sarcoma of the clavicle in the middle
portion of it, and I excised all except the two ends of the
clavicle and put in a bone graft from her tibia. I lost track of
her and had not seen her for at least twenty years until she
came into my office the other day. She is working in a neighbor-
ing town as a beauty specialist, and she says that she can do
all the facial work that women require and do it without much
difficulty except that her arm gets tired. A fairly good clavicle
resulted from the bone graft. I am surprised that Dr. Key
did not put a bone graft in that clavicle, although he says he
really did not need to.

Clinical Notes, Suggestions and
New Instruments

INTERMITTENT OBSTRUCTION OF THE
SUBCLAVIAN VEIN

Charles IV. McLaughlin Jr., M.D., and A. M. Popsia, M.D., Omit

Intermittent obstruction of the subclavian vein is very uncom-
mon. Venous obstruction is rarely a factor in cases of cervical
rib with arterial compression and associated paresthesias. Swell-
ing of the arm following radical mastectomy is frequently seen
as a result of venous or lymphatic obstruction, but it is usually
constant, permanent and due to scar tissue or recurrent malig-
nant growth. Matas 1 recently reviewed the subject of primary
thrombosis of the axillary vein following strain. Marked swell-
ing of the involved extremity is usual in this condition, but with
its development a firm tender thrombosed axillary vein is always
associated.

The following report represents an instance of intermittent
obstruction of the right subclavian vein developing in a healthy
young man and persisting for two years. The absence of any
history of trauma or venous thrombosis at the onset of the
illness, together with the operative observations and the clinical
result following section of the scalenus anticus muscle, warrant
presentation of the case in some detail.

report of case

C. M., a farmer aged 24, married, entered the University
Hospital, Omaha, for the first time on Feb. 2, 1938. He com-
plained of intermittent swelling and cyanosis of the entire right
upper extremity following exertion for the past two years.

The family history was essentially negative except that the
patient’s father died at the age of 58 with diabetes mellit^
There was no history of tuberculosis, syphilis or heart disease
in the family. The patient had been married four years. There
were two children living and well. The wife had had no mis
carriages. , , .

Prior to the onset of the present illness the patient a
enjoyed excellent health and carried out all his duties as a
farmer. Eight years previously both bones of the right jj 1 *®
had been fractured and reduced without x-ray studies. Hea
was normal, and there was no residual deformity or wea ijjL-
There were no other injuries or operations except a mm
procedure which will be mentioned. , ,j ]t

Two years before admission while doing heavy wor'
patient for the first time noted that his right hand, ok
and arm became swollen and blue. This condition ai'k^ ^
suddenly and without any inciting cause and subside
few moments of rest. In the succeeding months these * j ce j
of swelling with cyanosis recurred on the average o ^
day, although when the arm was unusually active tic ^
persisted most of the day. It would always disappear .
or on rest of the extremity. _ ; nu tcs

A typical attack could be precipitated in about . \
if the patient chopped wood, drove nails or did sin"

He would then note that the hand, forearm and. an trerrl ;ty
rapidly swollen, with the skin tense and the cntire , ( j' ( j cv c!o?
increased in size. Pain of a severe aching type "°“ c er! t;re
in the entire arm and demand immediate rest. •
extremity became blue and definitely cooler than ■ s r^c\ori\
the superficial veins of the hand, forearm, arn ' P jjjstention
region would become distended and prominent. 1 cervical
of the veins was seen to extend up into the r,s . at ti:«
region on occasions. If the arm was perrmtte 0 , ; j z , js

side it would lose its blue color and assume a no

ten to fifteen minutes. Musician,

e year before entry the patient consulted a P ’ > 0 use!*

d the arm over the anterior surface ot the o »
is reported that a ganglion was remov e ii ott -ed l ' r '
igh no i mprovement in the general condition

,m the Departments of Surgery and Radiology, ^ t

ka College of Medicine. - . , *!,_ Axillary Veia

Matas. Rudolph: Primary Thrombosis of the Ax

lin. Am. J. Sure. 24 : 642-667 (June) 1934.

Volume 113
Number 22

venous obstruction— McLaughlin and popma

1961

operation. In recent months the entire extremity and shoulder
region had become sore and painful after being swollen inter-
mittently during the day, interfering with the patient’s rest. The
local application of heat did not benefit these symptoms.

There had been no loss of strength or sensory changes and
no associated numbness or tingling while the arm was swollen.
The major complaints were a full tight feeling during the
period of swelling, associated with intense pain of a muscle
fatigue type, and a throbbing sensation followed by intense ach-
ing which would persist for some hours.

There was nothing else of import in the systemic history that
had any bearing on the present illness.

The patient was powerfully built and well nourished, appeared
to be in excellent health and had no complaints other than those
already noted.

The skull showed no abnormality and the pupils were round
and equal, responding to light and to accommodation. The
sclera was normal. The ears and nose were normal. The teeth
were in good repair, the tongue was clean and the tonsils were
small and atrophic. The thyroid was not palpable. A few small
submaxillary and submental glands were palpable. Careful pal-
pation of both cervical regions gave no suggestion of a cervical
rib.

The heart was not enlarged, the sounds were of good quality
and regular and the pulse rate was 72 per minute ; there were
no murmurs. The blood pressure was 120 systolic and 76
diastolic in the right arm and 110/70 in the left when the

vie. 1. — Appearance o i patient five minutes after moderate enlargement
of the right arm. The gross enlargement of the arm is readily seen.

extremities were hanging at the side. The chest was clear to
percussion and auscultation. The abdomen was normal. The
reflexes in all the extremities were normal.

Examination of the two upper extremities disclosed that the
right arm was somewhat better developed and more muscular
than the left, and the superficial veins on the right side were
slightly more prominent while in the position of rest The entire
right upper extremity appeared to be slightly larger than the
left. The skin was smooth and elastic, and there was no pitting
edema. Palpation of the radial, brachial and axillary arteries

showed that the pulsations on the two sides were present and
grossly equal. After five minutes of active exercise, including
flexion and extension of the forearm, and abduction and adduc-
tion of the arm, the right upper extremity became definitely
enlarged, appearing to be approximately one third larger than
the left (fig. 1). The superficial veins on the dorsum of the

Fig*. 2. — Appearance at the completion of injection of 4 cc. of colloidal
thorium dioxide. The vein is grossly dilated and appears narrowed where
it crosses the first rib.

hand, the forearm, arm and the right pectoral region became
distended and prominent, and the veins in the right cervical
region were noticeably enlarged. The entire extremity became
dusky blue and cold to touch. During this time the patient
complained of intense muscle fatigue incident to the exercise,
and a definite diminution in the muscle power of the extremity
was seen to develop. After ten minutes’ rest the arm had
returned to approximately normal sire, the veins again became
collapsed and the color returned to normal. The muscle power
and grip at this time were essentially normal on both sides.

Table 1. — Blood Pressure Determinations

Right Left

Systolic Diastolic Systolic Diastolic

First 320 CO 10G CO

Second 124 00 112 03

Third 124 5S 112 53

Fourth 120 00 US 02

Fifth 124 01 112 00

The clinical impression was that this patient presented an
example of a vascular obstruction on the venous side in the
right cervical region, probably at the point where the subclavian
vein crossed the first rib. Special investigative procedures
were then outlined and carried out in an effort to confirm this
impression more definitely.

Blood study showed 88 per cent hemoglobin, 4,850,000 red
cells and 7,600 white cells, with 57 per cent polymorphonuclears,
31 per cent lymphocytes, 9 per cent staff cells and 3 per cent
monocytes. The urine was amber, with specific gravity of
1.020, and acid reaction. It contained no sugar, no albumin
and an occasional white blood cell. Serum Kahn and Kline
tests were negative.

The right upper arm measured 12(6 inches before exercise
and 13(6 inches after exercise. The right lower arm measured
11(6 inches before exercise and 12(6 inches after exercise.
Repeated blood pressure determinations were then made on both
arms at one minute intervals with two sphygmomanometers and
the pressure in the two arms was recorded simultaneously
(table 1).

It was observed that the pressure on the right side remained
consistently at a higher level than on the left.

Skin temperature studies were carried out at rest under basal
conditions after vasodilatation had been induced bv immersing
the lower extremities in water at 43 C. (109.4 F.) for twenty

1962

venous obstruction— McLaughlin and poem a j™*. <uu

' Nov. 25, 1!!!

minutes. Readings were also made after active exercise suf-
ficient to produce swelling of the right arm.

This investigation demonstrated a satisfactory skin tempera-
ture response in both upper extremities following the release
of all vasoconstricting influence. However, readings taken at
the same points after exercise demonstrated a marked drop in
the skin temperature readings of the right hand, which was in
keeping with the clinical observations.

Histamine studies done by the intracutaneous method showed
a satisfactory wheal and flare at all levels on both sides.

A study of the venous pressures in the veins of the upper
extremities was carried out by Dr. A. L. Bennett of the depart-
ment of physiology and Dr. Ross MacIntyre of the department
of pharmacology. An attempt was made to record venous pres-

Table 2 . — Skin Temperature

Midarin

Jlidforearm

Dorsum of
Hand

Right upper extremity, F.

Before exercise

79.7

85.8

84.G

After peripheral vasodilatation..

82.8

83.2

87.8

After exercise

89.0

8G.2

79.0

Left upper extremity, 3?,

Before exercise

83

SO

S4.0

After peripheral vasodilatation,.

SC

SC

SS. 2

After exercise

84

ss

91.0

sure in the median basilic vein of each arm during the time of
iorceiul rapid gripping o( the hand. The patient, however, was
unable to produce the typical swelling of the right arm by such
limited movements of the hand muscles with the needles in
place, and the results obtained from these studies were incon-
clusive.

X-ray studies revealed that the chest and cervical spine were
essentially normal and the mediastinum was dear. The lower
end of the right radius showed some cortical thickening at the
site of the old fracture, about 4 cm. proximal to the wrist joint.

An anteroposterior study of the right shoulder showed no
evidence of pathologic change in bone or soft tissue. There was
no evidence of cervical rib.

A film of the right shoulder exposed after the injection of
4 cc. of colloidal thorium dioxide into the median cubital veins
showed the cephalic vein to be well visualized to the point of
its entrance through the costocoracoid membrane into the axil-

Fig. 3.— A second exposure, made sixty seconds after the completion of
the injection of colloidal thorium dioxide, shows the vein less well tilled
v;ith the opaque medium although the same degree of ddatahon exists.
Roentgenograms made post operatively three seconds after injection ot
10 cc. of diodrast showed none of the contrast medium to be present m
the vein.

Jary vein. Further study made after injection of the basilic
vein showed it to be visualized to slightly above the point where
it pierces the deep fascia, about i inch below the axillary fold.
These observations suggested partial occlusion of the axillary
vein, possibly due to thrombophlebitis.

Further studies of the axillary vein showed it to be well
visualized from the level where previous visualization stopped

upward to the first rib (figs. 2 and 3), This indicated that ft;
obstruction was intermittent and not the result of thrombo-
phlebitis. There appeared to be a zone , of narrowing where ft;
vessel crossed the first rib. The cephalic vein was not visualized
at this time. In summary, the right axillary vein, 6 to 18 m
in diameter, was well visualized to the level of the first rib,
with relative narrowing where it crossed the first rib.

Fig. 4. — Condition ten days after operation. The arm 'v« ^

vigorously for fifteen minutes prior to the taking of the prow / ' c jj,
right arm remained slightly larger than the left, but there was
and no pain.

On the clinical assumption of partial or intermittent o
ion of the axillary vein at the point where it crossed ^
ib, surgical intervention was decided on and carrtc
tfarch 2. ccl j a

Cyclopropane anesthesia was administered. The P™
vas exploration of the right subclavian triangle and sea
in the right. . ra ij e |ir

An incision S cm. in length was made above and p. y ul
he right clavicle. The platysma was severed an
lissection a large vein measuring at least 1 cm. m ^
ecame apparent in the base of the wound. From 1 . 5I) t
uperficial position it was felt that this could not e ^
lavian. On further dissection it was seen that >
ugular vein emptied into it and that farther dow
zith the internal jugular vein, which identified i “ t
s the subclavian vein. Just distal to the point w ’ er * s
re first rib the vein was seen to be definitely di a e •> ^
last 2 cm. in diameter. As it crossed the rib i
arrower, but no definite mechanical obstruction IV [,3

Arable at this point. The vein seemed rather o , ( -a

tretched over the first rib at its point of crossing. . ft,
thickening in the venous wall in this^ evidence e

. in

istence of an old thrombosis, nor was there a
[ blood pigment about the vein. The subclavian a ^ ( j.,
its normal position and showed no Stoss : m jgh:
;umption that the first rib in its rather high P° of vt! y>
isibly be producing a partial, mechanical obs r tll£ r ?

ism of the subclavian vein, it was decided f Pf an#’"
assume a lower position by section of the lcp3 tn'P :
isde. This was done after carefully heemga -^^
phrenic nerve. After section of the muscle sss vtf J

slip downward, allowing the subclavian art - . ,j,e vrf
re anterior position on the first rib and per ® ev) V.< !
cross the superior surface of the rib witfio

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str ‘ctp r - r " '"or e r ’ Cccs sarif S
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c Orj s

1964

shapes attached to a fiber and guided by a swallowed thread

nrnh l M r0dU f Ce ^- tear eSSly by pers!stent adherents. They are
probably safest m expert hands. We have seen under the fluoro

cope an apparently taut cord loosen, the bougie fail to engage
the cardia and pass blindly into a dilated esophageal pouch
Because of this as well as of other obvious liS oL thev
must be reserved for the expert endoscopist. ’ they

ma!iuanv r o a r hv I 31 ' 0 " f* T , UCker ’ S instr " a " d Avulsion
manuaHy or by forceps from the gastric side are major surgical

BS S™ 1 f0r ,h0,e f ™ » "«ch

Hurst introduced his mercury filled bougies in 1913 Thev
arc, rubber tubes varying in diameter (from 21 to 40 English)

3 inches long and each containing the same quantity of me r -
1 ounces). These are carried and guided through the

The'se 111 3 dfiatis e,r - We,Sht ’ ° Pening " paSSagewa >’ b >' their size,
these dilators, _m our experience, are the easiest passed •

. ey cause !ess discomfort and are unquestionably the safest
instruments available in properly indicated cases Sue ess. vely
arg r tubes are passed at a single sitting, and in mostTnstanct

the "* h “ ,r ”<*« than

fcltaS"'l , ,he ”1 ° f l-ffe include the

to tint ft tlJ 1 ! instance of narrowing at sites, in addition

one passage i pl! T ^ ‘° the same extent b Y the
m selected ms^rSf t

hll T °/ h- h,S pr ° cedure - 4 - It is obvious that these bougies
ave limitations and are best employed when the cardiac opening

emams dependent and the existing pathologic condition has
not brought about a great sacculation at a level below the

severe f s Tl T? ^ emp,0y * d them Quite successfully in
severe cases 5. The large size, No. 40, often proves annovino-
to patients because of the bulk in the pharynx ' * *

woTk e of IS 189S °T,! h i e i g f d r'r dat “ baek J- C. Russel’s
uork of 1S9S. In 190 6 at the Mayo Clinic Plummer modified

Russel’s instrument

SSOPHAGOSPASM— BROWNS AND McHARDY

foot. A. JI. A
Nor. 25, IS?

It rendered fluoroscopic control of divulsion dilation ptjefal

ever dlstinction from ^ Plummer dilator, fe

ever, is that it is pneumatic.

intend, ZT S h . as 4 pass « d since Smithies' pneumatic bougie »

instramen d ts an T f , here t, ha \ been ”° further n0tab,e advMceb
mstruments. There have been minor modifications of the par

matic bougie and advocates of a barium bag, but none of the
have been of great value. Prior to perfecting the combine

apparatus which w
now introduce we use
equipment similar t
Smithies’, eliminatir;
the objectionable site
shaft, thus increase:
the safety factor hot
still having to resort
to a swallowed threat
for reassurance arid
guidance in most in-
stances. In Septem-
ber 1938 work to
started on the instru-
ment which we now-
present, and the final
plans and specifications
were forwarded to
George P. Pilling k
Son Company in Jan-
uary 1939.

This new dilator
and divulsor combines
the principles oi Hunt,
Plummer and Smithies
and achieves a post-
tion of maximal effi-
ciency and saiefy.

Dilator in place and distended
with air. Arrow is at margin of pneumatic
bag, which is faintly outlined.

. Fig. 3. — Dilator introduced into stomach;
irregularity in outline as marked by arrow
represents the metallic ring at each extreme
of the pneumatic bag.

and introduced into
prominence the rubber
covered silk balloon
using hydrostatic pres-
sure. Moersch and
Vinson, with their ex-
cellent work and sta-
tistical accumulation,
have sustained their
preceptor’s teachings.

The instrument is a
rubber tube supported
by a whalebone staff
tipped with an olive
just behind which is
a rubber covered silk
balloon which is di-
lated by hydrostatic
pressure regulated by
special adapters. All
dilations are carried
out over a previously
swallowed silk thread
(5 yards) held taut,
which the Mayo group
feels eliminates all
danger of perforation.

ciency and saieij.

It is a number 21 Hurst mercury tube; on the distal end, W
cm. from the tip, has been incorporated a rubber covered s®
. bag 11 cm. in length to which a small catheter runs through
the mercury filled tube. By this means distention, under tf>'
control of a sphygmomanometer, may be effected.

The distinct advantages of this instrument are that: i-A
swallowed guiding thread is not required; it is easily
being the size of the small Hurst dilator. It is carried through
by virtue of its contained 21 ounces of mercury, which i>
sufficient to force the closed sphincter and which is in >t se * *
guide but which is not sufficiently forceful to traumatize &
perforate the esophagus. 2. This type dilator is most easily
passed with less discomfort than any other type and does ,!f
show any tendency to coil in a dilated prediaphragmahe dila-
tation, as might be suggested by some. 3. Only a sl ®
instrumentation is required, as contrasted to the passing o a^
olive prior to the use of a Plummer dilator and the use ?
graduated Hurst bougies. 4. It offers controlled pneuma i
divulsion, which is more practical and safer than
dilation, and this in combination with the bougie qua!: nea 'o
of the Hurst dilator. 5. It is applicable to x-ray
as is illustrated here.

examinati®
ilicabk

It requires a source of running water and is not portable and
for this reason is not as practical as could be wished. Failure
to place the dilator, unsatisfactory results due to improper tech-
nic, considerable pain and a mortality percentage are a'dmitted;
however, it has a definite advantage in that divulsion is achieved
by its use.

In 1929 Frank Smithies designed the pneumatic dilator modifi

This dilator is not presented with the idea that it is a PP .
in all instances, any more than other instruments may ^
all emergencies, but rather that it fills a need most treque
encountered.

1520 Aline Street.

Number of Persons Infected by One Mosquito-
important to know whether an Anopheles once infect
malaria) can infect more than one person without again (f
on infective blood. ... In a most instructive st
experiments conducted by Mayne he reports that one u;trrrJ :r -
proved to be the sole infecting agent in three casts. - 1 jj,
used Anopheles punctipennis (Say) with Plasmodium

Volume 113
Number 22

COUNCIL ON FOODS

1965

■' r-

.i '<?■

Council on Foods

ACCEPTED FOODS

The following troducts have been acceeted bv the Council
on Foods of the American Medical Association and will be listed

IN THE BOOK OF ACCETTED TOODS TO BE PUBLISHED.

Franklin C. Bing, Secretary.

HEINZ STRAINED PEARS AND PINEAPPLE

Manufacturer. — H. J. Heinz Company, Pittsburgh.

Description. — Canned strained mixture of pears and pineapple.

Manufacture . — Fresh pears are sorted, peeled by mechanical
peelers, by scalding, or by hand peeling. The. peeled pears are
cored, trimmed, washed and precooked with direct steam under
light pressure. Definite proportions of canned or fresh crushed
pineapple are added and the mixture is strained in an atmosphere
of steam, filled into enamel-lined cans, vacuum sealed and heat
processed.

Analysis (submitted by manufacturer). — Moisture S4 .9%, total
solids 15.1%, ash 0.4%, salt 0.05%, protein (N X 6-25) 0.4%,
fat (ether extract) 0.04%, crude fiber 1.0%, total carbohydrate
other than crude fiber (by difference) 12.9%, sucrose (Munson
and Walker Method) 10.1%, starch (by difference) 2.8%, acidity
as citric 0.37%.

Calories. — 0.54 per gram; 15.3 per ounce.

Vitamins . — Protocols of biologic assay submitted by the manu-
facturer indicate that Heinz Strained Pears and Pineapple has
the following approximate vitamin content:

Vitamin A, 1.7 U. S. P. units per gram ; 50 per ounce.

Vitamin Bl (thiamin), 0.24 international unit per gram; 7 per
ounce (equivalent to 0.21 mg. of thiamin per ounce).

Vitamin G (riboflavin), 0.17 Sherman-Bourquin unit per
gram ; 5 per ounce.

It is further reported that the product contains 0.03 mg. of
ascorbic acid per gram, 0.85 per ounce (equivalent to 0.6 inter-
national unit of vitamin C per gram, 17 per ounce) as determined
by chemical titration.

TURKEY BRAND GOLDEN SYRUP

Manufacturer. — J. Stromeyer Company, Philadelphia.

Description . — Corn syrup flavored with refiners’ syrup.

Manufacture . — Formula proportions of the two ingredients are
blended and packed in tins.

Analysis (submitted by manufacturer). — Moisture 22.6%, total
solids 77.4%, ash 1.2%, fat (ether extract) 0.1%, protein
(N X 6.25) 0.2%, reducing sugars as invert sugar 32.4%,
sucrose 9.7%, dextrin 28.3%, crude fiber none, carbohydrates
(by difference) 75.9%, Baume 41°.

Calorics. — 3.05 per gram; 87 per ounce.

PRUDENCE BRAND ROAST BEEF HASH

Manufacturer . — Boston Food Products Company, Boston.

Description . — Canned roast beef hash prepared from cooked
potatoes, roasted beef, roasted beef juices; seasoned with salt
and pepper.

Manufacture . — Selected beef (boneless chucks, shoulders and
rounds) U. S. Inspected and Passed by the Department of
Agriculture, is cut in small pieces, sinew, bristle and excess fat
are removed, and it is roasted until well done without the
addition of water. Potatoes are mechanically peeled, trimmed,
washed and cooked. Formula proportions of the ingredients are
mixed, mechanically chopped and filled into cans, which are
heated, sealed and heat processed. The product is manufactured
under the supervision of the Bureau of Animal Industry.

Analysis (submitted by manufacturer). — Moisture 70.0%, total
solids 30.0%, ash 2.4%, fat (ether extract) 6.4%, protein
(N x 6.25) 9.5%, crude fiber 0.3%, carbohydrates other than
crude fiber (by difference) 11.4%.

Calorics. — 1.41 per gram; 40 per ounce.

SA VERY-SAVORY BRAND MUSHROOMS,
BUTTONS, SLICES, AND STEMS
AND PIECES

Manufacturer .— The Great Western Mushroom Company,
Denver.

Description . — Hothouse mushrooms, canned as buttons, slices
and stems and pieces, slightly seasoned with salt.

Manufacture. — Mushrooms, grown under sterile conditions
from mushroom spawn, are cultured on trays in a thin layer
of moist rich top soil covering a mixture of dirt and manure
in dark houses maintained at a constant temperature. The
mushrooms are picked by hand, conveyed to the cannery,
trimmed, and sorted by hand. Stems and buttons are graded
mechanically and some mushrooms are sliced mechanically. The
mushrooms are immersed in boiling water for five minutes,
weighed into cans which are filled with hot water, salt is added,
and the cans are sealed and heat processed.

Analyses (submitted by manufacturer).-

Buttons,
per cent

Slices,
per cent

Stems and
Pieces,
per cent

Moisture

91.7

93.4

92.2

Total solids

8.3

6.6

7.S

Ash

3.6

1.5

1.6

Sodium chloride (NaCl)

0.9

1.1

3.2

Fat (ether extract) .....

0.2

0.2

0.2

Protein (N X 6.25) ....

3.1

2.6

2.7

Crude fiber

Carbohydrate other than

0.7

crude

0.7

2.9

fiber (by difference) . .

2.7

1.6

0.4

Calorics. — Buttons, 0.25 per gram; 7 per ounce.

Slices, 0.19 per gram ; 5 per ounce.

Stems and pieces, 0.14 per gram; 4 per ounce.

(1) BRUCE’S JUICES BRAND ORANGE

JUICE, UNSWEETENED

(2) BRUCE’S JUICES BRAND ORANGE

JUICE, SUGAR ADDED

Manufacturer. — Bruce’s Juices, Inc., Tampa, Fla.

Description. — (1) Canned, unsweetened orange juicei .

(2) Canned orange juice with added cane sugar.

Manufacture. — (1) Sound, tree-ripened oranges are washed
and mechanically cut in half and the juice is extracted by
reamers operated by hand or mechanically. The juice is strained,
deaereated, pasteurized and filled into cans. The cans are sealed
and cooled.

(2) The juice is prepared and canned as described for Bruce's
Juices Brand Orange Juice, Unsweetened. A small amount of
sugar is added after the juice is strained.

Analyses (submitted by manufacturer).— (1) Moisture 87.5%,
total solids 12.5%, ash 0.4%, 'fat (ether extract) 0.1%, protein
(N X 6.25) 0.4%, sucrose 1.9%, reducing sugar as invert 6.9%,
crude fiber 0.1%, carbohydrates other than crude fiber (by dif-
ference) 11.5%, titratable acidity as anhydrous citric acid 1.2%,
vitamin C 51.4 mg. per hundred cubic centimeters. (2) Moisture
84.6%, total solids 15.4%, ash 0.3%, fat (ether extract) 0.1%,
protein (N X 625) 0.4%, sucrose 5.0%, reducing sugar as
invert 6.7%, crude fiber 0.1%, carbohydrates other than crude
fiber (by difference) 13.3%, titratable acidity as anhydrous citric
acid 1.2%, vitamin C 50.3 mg. per hundred cubic centimeters.

WINDSOR BRAND EVAPORATED MILK

Manufacturer . — Windsor Evaporated Milk Company, Cleve-
land (an associate of the Telling-Belle Vernon Company,
Cleveland, and subsidiary of the National Dairy Products Cor-
poration).

Description . — Canned unsweetened evaporated milk.

Manufacture . — Selected milk is inspected, tested, preheated,
evaporated under vacuum, homogenized, cooled, standardized to
meet government requirements for butter fat and total solids,
filled into cans, sealed and sterilized.

Analysis (submitted by manufacturer).— Moisture 73.7%, total
solids 26.3%, ash 1.6%, fat (ether extract) 7.8%, protein
(N X 6.38) 6.9%, lactose (by difference) 10.0%.

Calorics. — 1.38 per gram; 39 per ounce.

1966

EDITORIALS

Joust. A. Jf. A.
Nov. 25, HjJ

THE JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION

535 North Dearborn Street - - - Chicago, III.

Cable Address - - - “Medic, Chicago”

Subscription price

Eight dollars per annum in advance

Please send in promptly notice of change of address , giving
both old and new; always state whether the change is temporary
or permanent . Such notice should mention all journals received
from this office. Important information regarding contributions
will be found on second advertising page following reading matter.

SATURDAY, NOVEMBER 25, 1939

The Platform of the American
Medical Association

The American Medical Association advocates :

1. The establishment of an agency of the
federal government under which shall he
coordinated and administered all medical and
health functions of the federal government
exclusive of those of the Army and Navy.

2. The allotment of such funds as the Con-
gress may make available to any state in actual
need, for the prevention of disease, the promo-
tion of health and the care of the sick on proof
of such need.

3. The principle that the care of the public
health and the provision of medical service to
the sick is primarily a local responsibility.

4. The development of a mechanism for meet-
ing the needs of expansion of preventive med-
ical services with local determination of needs
and local control of administration.

5. The extension of medical care for the
indigent and the medically indigent with local
determination of needs and local control of
administration.

6. In the extension of medical services to all
the people, the utmost utilization of qualified
medical and hospital facilities already estab-
lished.

7. The continued development of the private
practice of medicine, subject to such changes as
may be necessary to maintain the quality of
medical services and to increase their avail-
ability. '

S. Expansion of public health and medical
services consistent with the American system
of democracy.

THE PLATFORM OF THE AMERICAN
MEDICAL ASSOCIATION
In the various actions of the House of Delegates
during the special session held in Chicago in September
last year, and again at the meeting in St. Louis, certain
constructive proposals were made which had the full
approval of the House of Delegates. Now the Board
of Trustees of the American Medical Association lias
formulated these concepts into a constructive platform
for the American Medical Association. This platform
is set up as a guide to indicate the trend which the
American Medical Association believes should be fol-
lowed in the development of health activities and med-
ical care for the people of the United States.

1. The establishment of an agency of federal
government under which shall be coordi-
nated and administered all medical and
health functions of the federal governmenf
exclusive of those of the Army and Navy-
Today the medical and health functions of the
United States are divided among a multiplicity of
departments, bureaus and federal agencies. Thus, the
United States Public Health Service is in the Federal

Security Agency ; the Children’s Bureau in the Deport'
ment of Labor; the Food and Drug Administration in
the Department of Agriculture; the Veterans’ Admin-
istration and many other medical functions are separate
bureaus of the government. The WPA, CCC an
PWA are concerned with a similarity of efforts m
the field of preventive medicine. The Federal Wor
Administration and the Federal Housing Administra
tion also have some medical functions.

Since 1875 the American Medical Association has
urged the establishment of a single agency in the fe
government under which all such functions coul ^
correlated in the interest of efficiency, the avoidance o
duplication and a saving of vast sums of money. u j
a federal health agency, with a secretary in the ca in
or a commission of five or seven members in u
competent physicians, would be able to administer •
medical and health affairs of the government wit
more efficiency than is now done.

2. The allotment of such funds as the Com
gress may make available to any sta c
actual need for the prevention of disea
the promotion of health and the car
the sick on proof of such need.

The physicians of the United States have gi' en
af their time and of their funds for the ® rc ...
jick. Their contributions to free medical service a
o at least $1,000,000 a day. The physicians
:ountry have urged that every person » eell,ng , ^
rare be provided with such care. They h^ e ^ crr: J
he allotment of funds for campaigns a 5 ain . j nV cfti-
nortality, against venereal disease and for
ration and control of cancer. The medica p

Volume 113
Number 22

EDITORIALS

1967

does not oppose appropriations by Congress of funds
for medical purposes. It feels however that, in many
instances, states have sought aid and appropriations for
such functions without any actual need on the part of
the state, in order to secure such federal funds as might
be available. It has also been impossible, under present
technics, to meet actual needs which might exist in
certain states with low per capita incomes, with needs
far beyond those of wealthier states, in which vast sums
are spent.

It is proposed here simply that Congress make
available such funds as can be made available for
health purposes; that these funds be administered
by the federal health agency, mentioned in the first
plank of this platform, and that the funds be allotted
on proof of actual need to the federal health agency,
when that need is for the prevention of disease, for
the promotion of health or for the care of the sick.

3. The principle that the care of the public
health and the provision of medical ser-
vice to the sick is primarily a local respon-
sibility.

Obviously if federal funds are made available to the
individual states for the purposes mentioned in the
second plank of this platform, there might well be a
lessened tendency in many communities to devote the
community’s funds for the purpose and, in effect, to
demand that the federal government take over the prob-
lem of the care of the sick. Hence it is suggested
that communities do their utmost to meet such needs
with funds locally available before bringing their need
to the federal health agency, and that the federal health
agency determine whether or not the community has
done its utmost to meet such need before allotting
federal funds for the purpose.

4. The development of a mechanism for
meeting the needs of expansion of pre-
ventive medical services with local deter-
mination of needs and local control of
administration.

The medical profession is not static. It wishes to
extend preventive medical service to all the people
within the funds available for such a purpose. Obvi-
ously, this will require not only a federal health agency
which may make suggestions and initiate plans but
also a mechanism in each community for the actual
expansion of preventive medical service and for the
proper expenditure of funds developed both locally and
federally. In the development of new legislation, such
mechanism may be suitably outlined.

5. The extension of medical care for the
indigent and the medically indigent with
local determination of needs and local
control of administration.

The medical profession does not yield to any other
group in this country in its desire to extend medical

care to all those unable to provide themselves with
medical service. The American Medical Association
through its House of Delegates has already recognized
the possible existence of a small group of persons able
to provide themselves with the necessities of life com-
monly recognized as standard in their own communities
but not capable of meeting a medical emergency. It is
recognized, however, that only persons of the same
community fully familiar with the circumstances can
determine the number of people who come properly
under such classification and that only persons in actual
contact with such instances are capable of administering
suitably and efficiently the medical care that may be
required. Hence it is the platform of the American
Medical Association that medical care be provided for
the indigent and the medically indigent in every com-
munity but that local funds be first utilized and that
local agencies determine the nature of the need and
control the expenditure of such funds as may be
developed either in the community or by the federal
government.

6. In the extension of medical services to all
the people, the utmost utilization of quali-
fied medical and hospital facilities already
established.

In the so-called National Health Program it is
asserted that one half the counties of the United States
are without suitable hospitals, and vast sums are
requested for the building of new hospitals. In con-
trast, reputable agencies within the medical profession
assert that there are only thirteen counties more than
30 miles removed from a suitable hospital and that in
eight of those thirteen counties there are five persons
per square mile. In the United States today the per-
centage of hospital beds per thousand of population is
higher than that of any other comparable population
in the world. This fact is completely' ignored by those
who would indulge in a program for the building of
great numbers of new hospitals.

Moreover, it seems to be taken for granted that
hospital building has languished in recent years, whereas
considerable numbers of hospitals have been built with
federal funds by various state agencies and also by the
PWA, the WPA and the Federal Works Admin-
istration.

Analyses may indicate that in many instances such
hospitals were built without adequate study as to the
need which existed or as to the possible efficient func-
tioning once it was erected. Moreover, there is evidence
that in recent years many of the hospitals of the United
States known as nonprofit voluntary hospitals have
had a considerable lack of occupancy, owing no doubt
to the financial situation in considerable part. It seems
logical to suggest then that such federal funds as may
be available be utilized in providing the needy sick with
hospitalization in these well established existing institu-
tions before any attempt is made to indulge in a vast

1968

EDITORIALS

Jot-'K. A. M. S
Nov, 25, 155)

building program with new hospitals. In this point
of view the American -College of Surgeons, the Amer-
ican Hospital Association, the Catholic Hospital Asso-
ciation, the Protestant Hospital Association and prac-
tically every other interested voluntary body agree.

Again, it has been argued that the demands for
medical care in some sections of the country might
require the importation of considerable numbers of phy-
sicians or the transportation of numbers of physicians
in the areas in which they now are to other areas. In
this connection it would seem to be obvious that a
change in the economic status of the communities con-
cerned would result promptly in the presence of physi-
cians who might be seeking locations. The utilization of
existing qualified facilities would be far more econom-
ical than any attempt to develop new facilities.

7. The continued development of the private
practice of medicine, subject to such
changes as may he necessary to maintain
the quality of medical services and to
increase their availability.

In the United States today our sickness and death
rates are lower than those of any other great country
in the world. This fact was recognized by the Presi-
dent of the United States when he sent the National
Health Program to the Congress for careful study.
The President emphasized that a low death rate may
not mean much to a man who happens to be dying at
the time of tuberculosis. The medical profession recog-
nizes the importance of doing everything possible to
prevent every unnecessary death. At the same time it
has not been established by any available evidence that a
change in the system of medical practice which would
substitute salaried government doctors for the private
practitioner or which would make the private practi-
tioner subject to the control of public officials would in
any way lower sickness and death rates.

There exists, of course, the fact that some persons
are unable to obtain medical service in the circumstances
in which they live and that others, surrounded by good
facilities, do not have the funds available to secure such
services. Obviously, here again there is the question of
economics as the basis of the difficulty and perhaps lack
of organization in distribution of medical service and a
failure to utilize new methods for the distribution of
costs which might improve the situation.

The medical profession has approved prepayment
plans to cover the costs of hospitalization and also pre-
payment plans on a cash indemnity basis for meeting
the costs of medical care. It continues, however, to
feel that the development of the private practice of
medicine which has taken place in this country lias led
to higher standards of medical practice and of medical
service than are elsewhere available and that the main-
tenance of the quality of the service is fundamental in
any health program.

8. Expansion of public health and medical
services consistent with the American sys-
tem of democracy.

Careful study of the history of the development of
medical care in various nations of the world leads to
the inevitable conclusion that the introduction of meth-
ods such as compulsory sickness insurance, state medi-
cine and similar technics results in a trend toward
communism or totalitarianism and away from democ-
racy' as the established form of government. The inten-
sification of dependence of the individual on the state
for the provision of the necessities of life tends to
make the individual more and more the creature of the
state rather than to make the state the servant of the
citizen. Great leaders of American thought have
repeatedly emphasized the fact that liberty is too great a
price to pay' for security'. George Washington said
“He who seeks security through surrender of liberty
loses both.” Benjamin Franklin said “They that can
give up essential liberty to obtain a little temporary
safety' deserve neither liberty' nor safety'.”

In these times, when the maintenance of the Amer-
ican democracy seems to be the most important objec-
tive for all the people of this country, the people may
well consider whether some of the plans and programs
that have been offered for changing the nature of med-
ical service are not in effect the first step toward an
abandonment of the self reliance, free will and personal
responsibility that must be the basis of a democrats
system of govertment.

THE SECRETARIES AND EDITORS
CONFERENCE

The Annual Conference of Secretaries of Constituent
State Medical Associations and Editors of State J e *
cal Journals, held in Chicago on November 17 ai ' ’
proved to be one of the most inspiring and stimu ah o
sessions thus far held under the auspices of the Ame ^
can Medical Association. Among the highlights o
program arranged by Dr. Olin West were the rep ^
on “The Study of Medical Care in the United Statc^
read by C. E. Nyberg, of the Bureau of Medical
nornics; the analysis of present legislation lor
National Health Program by Dr. W. C. ’’A' 00
of the Bureau of Legal Medicine and Legislation, •
the report of the Board of Trustees relative !0
platform of the American Medical Association, " 1
appears in this issue of The Journal.

The remaining sessions were devoted large y 0 ^ ^
sideration of actual reports on plans non su T ^
experiment in various states, particularly that o ^
Jersey presented by X. M. Scott, of
L. Fernald Foster, of Washington by V. >'• ^
and of Pennsylvania by M . F. Donaldson. - 0 ^ „
there were discussions of rural medical service >)
Crockett, of the Committee on Legislative -• cm

VoUJME ns
Number 22

1969

EDITORIALS

the American Medical Association, and an analysis of of the patient or guardian is one of the most important
the way in which the state of Indiana meets legislative

problems, by Thomas A. Hendricks, executive secre-
tary for that state. These reports proved to be clinical
sessions dealing with economic experiments. Exhaus-
tive discussions of experiences not only with these plans
but with various federal and other agencies now inter-
ested in this field brought to light important informa-
tion. Extensive abstracts of this material will be
published in the Organization Section of forthcoming
issues of The Journal.

Similarly, the dinner for state editors, which was
attended by practically all of the secretaries as well,
proved to be an editorial clinic in which the demonstra-
tor was Dr. Samuel J. ICopetzky, of New York, who
spoke on “The Role of the State Medical Journal in
Organized Medicine.” The discussion on this topic
concerned not only the actual preparation of editorials
but also the relationship of the state journal to public
relations for state medical societies and even such
minute problems as the proper use of the editorial “we.”

These meetings serve particularly to coordinate the
work of the headquarters office of the American Medical
Association with the constituent state medical associa-
tions, whose secretaries and editors are the chief func-
tioning units in the work of the American Medical
Association.

WHY ACETARSONE FOR SYPHILIS?

The use of acetarsone as an antisyphilitic drug which
could be taken by mouth has been reviewed recently by
Pillsbury and Perlman, 1 who studied 187 cases of con-
genital syphilis at the Sigma Clinic of the Children’s
Hospital, University of Pennsylvania School of Medi-
cine. Their conclusions corroborate the previous
statements made by the Council on Pharmacy and
Chemistry 3 concerning the use of acetarsone in the
treatment of syphilis. The investigators emphasize that
acetarsone, although an active antisyphilitic agent by
mouth, is less rapid in action than arsphenanrine and
is inferior to both arsphenamine and bismuth prepara-
tions in arresting congenital syphilis. In their series of
cases they found a high incidence of reactions. They
concluded, indeed, that adequate experimental back-
ground for determination of the toxicity and spiro-
cheticidal effect of individual lots of acetarsone is not
available. In addition they observed that regularity of
attendance of patients at the clinic was not increased by
the use of oral therapy as compared to the injection
method of administration and that acetarsone is probably
not administered as directed to patients treated at home.
They stressed that the evaluation of the responsibility

1. PilHIntry, D. XI,, and Perlman. H. H. : Acetarsone Therapy in
One Handled and Eighty-Seven Cases of Congenital Syphilis, Arch.
Dermal. & Syph. 39 : 969 (June) 1939.

2. Stovarsol (X. X. R. description). J. A. XI. A. S4: 1917 (June 20)
1925. Late Congenital Syphilis <Q. & XI. X.), ibid. 103: 1471 (Xov.
10) 1934. Skin Reaction with Arsenicals (Q. & XI. X.), ibid. 10G:726
I Teh. 29) 1936.

features of oral therapy and that lack of cooperation
is a contraindication to the use of acetarsone. The
authors indicated that for newborn infants the use of a
system of dosage based on weight is essential and stated
that the system of Bratusch-Marrain 8 seems the best
available.

Pillsbury and Perlman believe that the convenience
and time-saving advantages of oral therapy are not suf-
ficient to substitute for the administration of more
effective, less dangerous compounds which must he
given parenteral!) 1 , granted that this may sometimes
prove difficult. It might be argued that the high per-
centage of Negroes among their patients might account
for the lack of cooperation or irregularity of attendance.
The fact remains that in the case of children the
responsibility of adequate and subtoxic dosage is depen-
dent largely on the parent of the patient treated orally
at home. This responsibility might also be obviated
by insisting that the patient receive the prescribed oral
medication from the physician in his office, in which
case the advantage of time saving would be lost, plus
the inconvenience of frequent visits.

The ease of administration of an oral spirocheticide
is sufficiently desirable to encourage the search for an
effective antisyphilitic drug which can be given by
mouth. Every preparation must be considered, how-
ever, in relation to others as to its effect on syphilis,
irrespective of the mode of administration required.
Because of its inferiority of effectiveness, acetarsone
cannot be recommended for general use in the treat-
ment of syphilis. Although there have been numerous
favorable reports * of the value of acetarsone for
syphilis, there are also others 5 which criticize its use
severely. Whipple and Dunham 0 state that the period of
observation for any adequate evaluation of acetarsone
has been sufficient in only four studies. In most reports
the ease of administration has been emphasized as an
important advantage of acetarsone therapy. This should
not excuse the critical examination of the results
obtained, which thus far seem to be poorer with
acetarsone than with other arsenicals of lesser toxicity.

In addition to the inferiority of results obtained in
congenital syphilis with acetarsone, it has been found
to be undesirable from the point of view of toxicity.
The evidence concerning this is conflicting but lias been
adequately summarized by Rosahn and Kemp, 7 They
were unable to establish any definite dosage range as
safe for rabbits and found that the drug in therapeutic

3. Bratusch-Marrain. Alois: Method and Value of Spirocide Treat-
ment of Syphilis in Childhood, Arch. f. Kinderh. ? >2: 26 (Nov, 28) 1930,

*?. Traisman, A. S.: The Use of Antisyphilitic Remedies, J, A. M, A,
10S: 825 (March 6) 1937. Rosenbaum, H. A.: Acetarsone in the Treat-
ment of Syphilis, J. A. M. A. 108: 1280 (April 10) 1932,

5. Cole, H. N.: The Pharmacopeia and the Physician: The Use of
Antisyphilitic Remedies, J. A. M. A. 107:2123 (Pec. 2$) 1936 ; The
Use of Antisyphilitic Remedies, ibid. 10S:S25 (March 6) 1937.

6. Whipple, D. V., and Dunham, E. C.: Congenital Syphilis : II.
Prevention and Treatment, J. Pediat. X3; 101 (July) 1938.

7. Rosahn, P. D., and Kemp, J. E.: The Oral Administration of
Stovarsoi m the Treatment of Experimental Syphilis of the Rabbit, Am.
J. Syph,, Conor. & Ven. Pis. 21; 180 (March) 1937.

1970

CURRENT COMMENT

Jocj. a. y. ,i

Nov. 25, 155 !

doses was sometimes lethal. There was also variation
in the toxicity of various lots of the commercial drug.
The small difference between the toxic and the thera-
peutic dose constitutes an additional objection to
acetarsone.

Current Comment

THE COLLEGE OF SURGEONS AND THE
AMERICAN MEDICAL ASSOCIATION

One of the most important conferences to be held
for the promotion of efficiency in the administration of
medical affairs in this country took place in the head-
quarters office of the American Medical Association on
November 16, when the Board of Regents and some of
the headquarters officials of the American College of
Surgeons met with the Board of Trustees and the
headquarters officials of the American Medical Asso-

OHIO HEALTH DEPARTMENT
REORGANIZED

The health department of the state of Ohio haste
reorganized “to enhance its efficiency by removing it,
so far as possible, from political interference.” 1 Ohh
Public Health 1 reports the appointment of a public
health council provided by a new law passed by tie
last session of the Ohio general assembly. 2 The tier
council consists of six members/ of whom three are
physicians, one is a dentist, one is president of the Ohio
Congress of Parents and Teachers, and one is a sani-
tary engineer. The former public health council con-
sisted -of five members all appointed by the governor.
The new organization provides that the director of
health shall be appointed for five years instead of being
removable at the pleasure of the governor. He cannot
now be removed by the incoming governor except by
written request of a majority of the public health coun-

Board of Regents of American College of Surgeons, Board of Trustees of American Alcdical Association, and headquarter j) r . Fie./,

from left to right: Dr. Olin West, Miss Eleanor K. Grimm, Dr. Malcolm T. McEachern, Dr. James R. Bloss, Dr. Isathan B. ' Hotner F*

A. Besley, Dr. James Monroe Mason, Dr. Austin A. Hayden, Mr. Will C. Braun, Dr. W. D. Cutter, Dr. Irvin Abe**, * * Them 2 *

Dr. Gilbert J. Thomas, Dr. George P. Muller, Dr. R. L. Sensenich, Dr. Walter S. McClellan, Dr. Rock Sleyster. Front rry Cr* l .;
Gardiner, Miss Jewel Whelan, Dr. Ralph A. Fenton, Dr. E. L. Henderson, Dr. H. H. Shoulders, Dr. Alton Ocnsner, D * • , racr . Dr.
Howard C. Naffziger, Dr. Morris Fishbein, Dr. Arthur M. Shipley, Dr._ Arthur W» Booth, Dr. Fr^d Caller, Dr. Herman L. h

B. Cullen, Dr. Alphonse McMahon, Dr. Roger I. Lee, Dr. George W. Crile.

ciation. The session was devoted largely to a con-
sideration of increasing efficiency', avoiding duplication,
and enhancing the importance of the inspection of hos-
pitals, not only for their utility' in caring for the sick
but also in relationship to their work in surgery and
their availability as institutions for the education of
interns and for the establishment of residencies in the
specialties. The many years of experience of the
Council on Medical Education and Hospitals and of
the Hospital Section of the American College of Sur-
geons, which are now cooperating in these efforts,
warrant the placing of full reliance on this joint effort.
Consideration was given also to many questions con-
cerned with the appointments of the staffs of hospitals
and the manner in which the two organizations could
function together in the maintenance of the quality
of medical service in our country.

cil. The enactment of legislation to remove pi> lC ^
departments from politics is always encourag !t V^ ^
course the functioning of the new law wi e P
how it is administered, but even in the han s ^
seeking politicians such laws have a tendency to p ^
the tenure of office of a competent official an ’ ^ {

continuity and integration to public health "or ^
state. The presence of physicians and dentis s ( .-
senting the organizations of these professions
representatives of civic organizations on P ,1J 1
boards or councils tends to discourage politics tn ^
which has been one of the most discourager, ^
with which sincere public health officia s
forced to contend.

Ohio TuMic Health 3:3 (Sept.) 1939.
Latvs of Ohio. 1939, approved May 1/,

introduce*! as

Ifas** ZZ*‘*

Volume 313
Number 22

MEDICAL NEWS

1971

Association News

THE SCIENTIFIC EXHIBIT

Application blanks for space in the Scientific Exhibit at the
New York Session, June 10-14, 1940, are now available.
Requests for blanks and for information concerning the Scien-
tific Exhibit should be sent to the Director, Scientific Exhibit,
American Medical Association, 535 North Dearborn Street,
Chicago.

MEDICINE IN THE NEWS
The seventh season of broadcasting by the American Medical
Association over the facilities of the National Broadcasting
Company and affiliated stations opened Thursday November 2 at
4 : 30 p. m. eastern standard time (3 : 30 central standard time,
!:30 mountain time and 1:30 Pacific time). The title of the
irogram will be Medicine in the News.

True to their title, the programs consist of dramatizations
rased on what is happening in the world of medicine. Each
program will include a principal news item from The Jotnot al
ar some other reputable medical source or from Hygcia. This
will be followed by one or more highlights on current medical
news. Each program will close with a question of the week
drawn from the question and answer correspondence of Hygcia.
A question will be asked each week and answered the following
week.

Medical News

(Physicians will confer a favor by sending for

THIS DEPARTMENT ITEMS OT NEWS OF MORE OR LESS
GENERAL INTEREST: SUCH AS RELATE TO SOCIETY ACTIV-
ITIES, NEW HOSPITALS, EDUCATION AND PUBLIC HEALTH.)

, CALIFORNIA

A Definition of Epilepsy.— At a meeting October 7 the
California State Board of Public Health defined “epilepsy"
as follows : Any condition which brings about momentary lapses
of consciousness, and which may become chronic, shall be con-
sidered reportable under the term “epilepsy." This action was
taken in view of recent legislation making epilepsy a reportable
disease. Physicians are now required to report cases to the
local health officers, who will in turn report to the state depart-
ment of health.

Society News. — A symposium on physical therapeutic meth-
ods was presented before the San Francisco County Medical
Society November 14 by Drs. Tilman Howard Plank, Harry
Glenn Bell, William C. Deamer, Alice Potter, William H.
Northway and Frances Baker. All are of San Francisco. — —
The medical and surgical aspects ot hypertension were dis-
cussed before the Alameda County Medical Association, Oak-
land, November 20 by Drs. Archibald A. Alexander, Hugh
Gordon MacLean and William Whitfield Crane, Oakland.

Postgraduate Assembly. — The Huntington Memorial Hos-
pital and the Stanley P. Black Memorial Association, Pasa-
dena, sponsored a postgraduate assembly October 2-7. Among
the speakers were:

Dr. Loren R. Chandler, San Francisco, Abdominal Surgery in Children.

Dr. Roy E. Thomas, Los Angeles, The General Management and Treat-
ment of Pneumonia.

Dr. Hans Lisser, San Francisco, Childhood and Adult Hypothyroidism
and the Proper Use of Thyroid Substance.

Dr. Frank S. Dolley, Los Angeles, Recent Advances in the Surgical
Treatment of Diseases of the Chest.

Chauncey D, Leake, Ph.D., San Francisco, Practical Aspects of Recent
Advances in Pharmacology,

Dr. Ludwig A. Emge, San Francisco, The Toxemias and Other Com-
plications of Pregnancy.

FLORIDA

Society News. — At a meeting of the Dade County Medical
Society recently the speakers were Drs. Elmer H. Adkins,
Miami Beach, on “Thyroglossal Duct Cysts and Fistulae” and
Iva C. Youmans, Miami, “Technical Requirements as Related

to the Growth of Medicine.” The Duval County Medical

Society was addressed in Jacksonville October 3 by Dr. Lin-
coln S. Laffittc on “Quinidine in Some Maniiestations of Heart

Disease.” At a recent meeting of the Pinellas. County Medi-

cal Society Dr. Nonie W. Gable, St. Petersburg, spoke on
ethmoiditis.

Basic Science Board Appointments. — Members of the
state board of examiners in the basic sciences for Florida
include the following recently appointed by the governor,
according to the Journal of the Florida Medical Association :
Mark Wirth Emmel, D.V.M., professor of veterinary science,
University of Florida, Gainesville, chairman; John Ferguson
Conn, Ph.D., secretary, professor of chemistry, John B. Stetson
University, Deland ; Ezda May Deviney, Ph.D., professor of
zoology, Florida State College for Women, Tallahassee; Jay
F. W. Pearson, Ph.D., professor of zoology, University of
Miami, Coral Gables, and Donald D. Bode, Ph.D., professor
of chemistry, Tampa University.

District Health Units Abolished. — Newspapers report the
discontinuance of the five district health units in Florida estab-
lished to render emergency service in counties without full time
health units. Hereafter this service will be administered by
the state department direct from the central office at Jackson-
ville. The district units were located in Marianna, Jackson-
ville, Ocala, Bartow and West Palm Beach. According to the
report, abolition of the health districts was recommended by
the American Public Health Association in a recent statewide
survey of Florida's public health conditions. Concurring in
the recommendation, the U. S. Public Health Service has
refused to allow further use of federal allocations to Florida
for this type of service, .it was stated. It was also said that
the money used to finance these districts should be . devoted
to establishing full time health departments.

ILLINOIS

Personal. — Dr. Alfred S. Ash, formerly of Chicago, , has
been placed in charge of the Soldiers’ and Sailors’" Home" and
Hospital, Quincy, succeeding the late Dr. Chauncey. E. Ehle.

Dr. Charles E. Soule, Beardstown, was recently, guest of

honor at a banquet given by the Cass County Medical Society
in recognition of his fifty years in the practice. of medicine.
The Illinois State Medical Society presented him with "a cer-
tificate and medal.

• Report on Trachoma. — A total of 161,903 persons have
attended the five trachoma clinics of the ’ state' during the five
years of their existence. • These clinics, established about 25
miles apart in Shawneetown, Jonesboro, Eldorado, Herrin and
Vienna, give treatments each week to' about 700 persons of
all ages and in varying stages of trachoma. On August 12
there were 3,276 cases of positive trachoma under care at the
five clinics, with 1,295 suspects under observation. According
to Welfare , 191 operations were performed in the past year.
Of the 331 new patients with positive trachoma received for
treatment at the clinics in the year ended June 30, 1938, there
were thirty-three, or 10 per cent, who had beginning trachoma ;
fifty-five were in the second stage, sixty-six in the third stage
and_177 in the fourth stage. Many persons who came to the
clinics for diagnosis oid not have trachoma but suffered from
other eye conditions which threatened their vision. Of these,
eighty-eight were sent to the Illinois Eye and Ear Infirmary
during the past year and twenty-four more are waiting until
beds are available.

Chicago

. Hospital News. — The Illinois Eye and Ear Infirmary has
instituted a course of training for orthoptic technicians follow-
ing principles outlined by the recently organized American
Orthoptic Council. Four technicians will be taken for a six
months course beginning in January.

The Bacon Lectures. — Dr. Robert Meyer, formerly direc-
tor of Pathological Institute (Gynecological Clinic) and hon-
orary professor at Friedrich- Wilhelms University, Berlin, will
deliver the Charles Sumner Bacon Lectures for 1939-1940 at
the Medical and Dental College Laboratories Building, Uni-
versity of Illinois College^ of Medicine December 6-7. His
subjects will be “The Basis of the Histological Diagnosis of
Carcinoma” and “Diagnosis of Early Carcinoma of the Cervix.”

uranrs ior

a. AilDLilUlt Ul iUCUICmC oi

Chicago announces that the entire Elizabeth McCormick Child
Research Grant of §1,000 for 1939-1940 will be used for the
encouragement of research and that awards have been made to
Dr. Mda I Pierce Evanston, for work on leukemia; to
Dr. Heyworth N. Sanford for a study of the role of the quali-
tative platelet factors in the coagulation of the blood, and to
Dr. Clayton J. Lundy for a study of heart murmurs in children
with rheumatic heart disease^ utilizing a heart sound recording
machine simultaneous!}* with an electrocardiograph.

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Socie^ T ; nce ; President State 0 fp p ,tfsbu ^h, pre s "

Ew/ng \y r? °^est Jivlno- -^Peghenv J^^vania, and

Z’iS&j'T&Zzr *r*2s , . Mi * s

— , Tire ‘ cad w" Cef0 ."?h Mass. Tt, an

balding anc j , u mes ; n jgg^. . e Plf{ sburgh Jr 1,b rary

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^th Sfg^fr. Geo r~ e f f DAK0 ?A

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Ration and "> f C ° ,W " has bL ^ nivc .rsity Servcs a mong th e c- CC for tfvenVfi VSPapcr reporn ^’er, a

y o^reir." -fe&« ' a °“ s«1SSl« "

p °undati 0l , v'll n as fu ‘ure sturff USh foundation , a le Jate
f medicine W;m COnc ^ucted thr es sponsored b v t) n ^n 0tber
'"anatomy and GreuhM the univemlt ' e Br ush

School of "Ar P J- d - Physical anthr P h.D., resear i! 3 ’ S sc, 'ool

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,s a misdemeanor ff Ster "'«hi„

1974

MEDICAL NEWS

Jour. A, M. A.
Nov. 25, 1933

Health Service, “Practical Problems of Public Health,” and
Mr. John Carniody, administrator of the Federal Works
Agency, Washington, D. C., “The Meaning of Public Health
to the Nation.”

VERMONT

New Dean at Medical College.— Dr. Hardy A. ICemp,
professor of bacteriology and preventive medicine at Baylor
University College of Medicine, Dallas, Texas, has been
appointed dean of the University of Vermont College of Afedi-
cme, Burlington. Dr. Kemp succeeds Dr. James N. Jenne,
who died Sept. 9, 1937. During the period since Dr. Jennc’s
death Dr. Ernest H. Buttles, professor of pathology and bac-
teriology, has been chairman of a committee of administration
for the school. Dr. Kemp, who is 37 years old, graduated
from St. Louis University School of Afedicine in 1926 and
went to Baylor in 1928 as associate professor of bacteriology
and hygiene. Among new members added to the faculty are
the following :

Dr. Bird J. A. Bombard, Burlington, associate professor of clinical
surgery.

Dr. Avmer S. C. Hill, Winooski, assistant professor of clinical medicine.

Ur. Arthur R. Hogan, Burlington, assistant professor of clinical surgery.

Dr- Peter P. Latvlor, Burlington, assistant professor of otolaryngology
and rhinology and clinical instructor in opthtlinlniology.

Dr. Wilhelm Raab, formerly of Vienna, assistant professor of clinical
medicine.

WEST VIRGINIA

Changes in State Health Department.— Dr. John F.
Cadden, director of the bureau of industrial hygiene of the
state department of health, has resigned to become medical
director of the plant of the American Viscose Corporation at
Roanoke, Va. Dr. Charles N. Scott, director of the bureau of
venereal disease, has accepted a similar position with the
viscose plant at Nitro. Dr. John B. Hozier of the U. S.
Public Health Service, recently lent to the health department
to develop the venereal disease program, was named to succeed
Dr. Scott. Dr. Thomas H. Blake, director of county health
work, resigned to enter private practice at St. Albans. Dr.
Bruce H. Pollock, Point Pleasant, has been appointed to suc-
ceed Dr. Blake.

Society News. — Dr. Allen F. Voshell, Baltimore, gave an
address before the Ohio County Aledical Society, Wheeling,
November 3 entitled “A Discussion of Fracture Fundamentals

and Errors.” Dr. Stanley Weinstein, Huntington, addressed

tile Cabell County Medical Society, Huntington, October 12 on
the “Glandular and Hormone Treatment of the Menopause.”
The society adopted a resolution favoring the proposed creation

of a national department of health with a cabinet portfolio.

Drs. Thomas K. Laird and Robert Harold Jones, Montgomery,
addressed the Fayette County Medical Society, Montgomery,
October 17, on “Etiology, Symptomatology and Treatment of
Pelvic Infections in Women” and “Value of Gastroscopic

Study” respectively. Dr. Harold W. Jacox, Pittsburgh,

addressed the Kanawha Medical Society, Charleston, October

10 on “Lymphoblastoma.” At a meeting of the Lewis

County Afedical Society in Weston October 10 the speaker was
Dr. William R. Goff, Parkersburg, on “Diagnosis of Thyroid

Conditions.’’ Dr. Hugh W. MacMillan, Cincinnati, who is

also a dentist, addressed a joint meeting of the Logan County
medical and dental societies in Logan November S on “Deep
Abscesses of the Neck of Dental Origin.”

GENERAL

Special Society Election.— Dr. Charles W. M. Poynter,
Omaha, was chosen president-elect of the Association of Ameri-
can Medical Colleges at its annual meeting in Cincinnati
October 23-25 and Dr. Russell H. Oppenheimer, Atlanta, Ga.,
was installed as president. Dr. Eben J. Carey, Aliiwaukee, was
elected vice president and Dr. Fred C. . Zapffe, Chicago,
reelected secretary. Next year’s meeting will be at the Uni-
versity of Afichigan, Ann Arbor.

Another Swindler.— A man giving the name of Folger and
claiming to represent Folger and Company, St. Louis, recently
collected monev in advance from a Chicago physician for an
order of medical supplies. He claimed to be an expert on
repairing blood pressure apparatus and stethoscopes. Un
investigation it was found that Folger and Company do not
handle medical supplies and that this firm has no representative
in Chicago and no representative named Folger. This man is
about 55 vears old. 5 feet 4 inches tall, weighs about 13o pounds
and is well versed in medicine, according to the report.

Nobel Prize Goes to Professor Lawrence.— The 1939
Nobel prize for physics was awarded November 9 to Ernest
O Lawrence, Ph.D., professor of physics and director of the '

radiation laboratory, University of California, Berkeley, for
invention and development of the cyclotron and results obtained
with it, especially Jn disintegration of the atom and production
of artificially radioactive elements. Dr. Lawrence was born
in Canton, S. D., in 1901. He graduated at the University of
South Dakota in 1922, receiving an honorary degree of doctor
of science in 1936. Yale University awarded him the degree
of doctor of philosophy in 1925 and an honorary science degree
in 1937. Prior to joining the staff of the University of Cali-
fornia he was associated with Yale.

Symposium on Blood, Heart and Circulation. — The
Section on Aledical Sciences (N) of the American Association
for the Advancement of Science announces that its sessions at
the Christmas meeting in Columbus, Ohio, December 27-30,
will be devoted to a symposium on the blood, heart and circu-
lation. Topics for the separate sessions are: blood, physiology
of coronary blood flow, pathology of the coronary circulation,
cardiac failure, hypertension, heart and circulation in special
territories. Twenty-eight papers are listed on the program.
In addition, Dr. Carl J. Wiggers, Cleveland, vice president ol
the section, will deliver his official address on "The Physiology
of Coronary Blood Flow” and the Theobald Smith Award in
Afedicine is to be awarded to Dr. Albert B. Sabin, Cincinnati,
who will speak on “Constitutional Barriers to Involvement ot
the Nervous System by Certain Viruses."

Lalor Foundation Awards Available. — Applications are
invited for tile fourth scries of awards by the Lalor Founda-
tion for fundamental research in chemistry. The awards are
open to men and women for work anywhere. The Ph-D-
degree or training equivalent thereto is a requirement. Final
selections will be based on the previous training, demonstrated
competence and promise of the candidates in their fields of
work. Preference will be given for part of the awards to
candidates directing their research toward applying the prin-
ciples and discoveries of physical and organic chemistry to
problems in the fields of biochemistry and chemotherapy. 1"
the case of awards of this kind, renewals of the grants for an
additional year will be favorably considered. Time to be spent
in acquiring training in the medical studies necessary for a
thorough understanding of the clinical aspects of the subjects
will be considered acceptable as a part of the plan of t ‘ ie ''JL
of the candidate. Individual awards will range between Su
and $2,500 or according to the special needs of the Candida •
Inquiries and requests for application forms should be addres'
to C. Lalor Burdick, Secretary, Lalor Foundation, \\iIi"'"S'
ton, Del. Applications must be in the bands of the sccrcta j
by December 31. Appointments will be announced early M.
March.

Council on Problems of Alcohol. — A new executive co
mittce of the Research Council oil Problems of Alco
announced at a recent meeting a broad program for atta
the diseases of alcoholism. Dr. Karl AI. Bowman, dircc
psychiatry, Bellevue Hospital, New York, chairman o
committee, announced three grants of _ financial aid .

organization. The Carnegie Corporation has apP’jf’F ' ‘

$25,000 for a survey of work done to date on the e • .
alcohol on the individual, a project sponsored by the ■dep- .

i>f psychiatry, New York University College of AfecI'CJ >
die supervision of Dr. Norman H. Jolhffc, associate F •
of medicine. The American Philosophical Society is y c u'
i study of the toxic factors in alcoholism conducted a
i r ork Psychiatric Institute under the direction of U ' ■ ,. f3 |

A. Jervis. In addition, the Dazian Foundation lor ■ j

Research has granted funds for research on the role .. .’ s | t y
n liver cirrhosis, a project initiated by New Aork om ‘.
College of Medicine. Afcmbcrs of the new cxccu
nittecare: , ««ntsry.

Forest R. .Moulton, Ph.D., Washington. D. . C.. rj™ anc ’ _

American Association for the Advancement of betm cr. ]jo< r :!a!.

Dr. Winfred Ovcrliolser, superintendent of St. tnraic
Washington. . . , ... it. S. huh-

Dr. Lawrence Kolh, chief, division of mental hjgiene.
fealth Service. Washington. roltimhiii L'nivrU V

Dr. Hoi an D. C. Lewis, professor of psychiatrj, Co
iollese of Physicians .and Sun-cons, New \ orK. Urivtrl

Hans T. Clarke, D.Sc., professor of hiochcnu'trj , C

Luther II. Gulick, Ph.D.. director, Institute of Tul-hc Adnum <•

;w York.

Mr.' Leonard Harrison, director of the Committee on I oath

\ir Austin If. MacCormick. commissioner of c0 I r j

Mbert t! Fofrenberser, Ph.D., professor of r^olo^ Cel,

sity, New York. f .t,.. Greater }«c* *"

Robert \V. Searlc. D.D.. RcncraJ secretary of the

iteration of Churches. * or * ork. . Vationsl CV« nS ’

VIr. Albert \V. Whitney, constiltins director, . -

rcau. New York.

Vo&vue 3 53
Number 22

FOREIGN LETTERS

1975

Foreign Letters

LONDON

(From Our Regular Correspondent)

Oct. 25, 1939.

The Decadence of Science Under Nazi Rule
Sir Thomas Holland, principal and vice chancellor of Edin-
burgh University, presiding at a graduation ceremony, pre-
dicted a degeneration in German military efficiency as a result
of neglect of scientific research, which was evident in the last
six years. Sir Thomas, who is a past president of the Insti-
tution of Mining and Metallurgy, said that during those years
German universities turned out from their research laboratories
a gradually diminishing stream of products. Six or seven years
ago no scientific man in the world would have dared to pass
over the publications of the research institutions of Germany.
Not only were they great in volume but their quality was of
a kind that led the world. Today these volumes of output
have diminished to small fragments of their former size, and
their quality is negligible. One can predict from this fact
alone that the neglect of fundamental truth for its own sake
must be followed by degeneration in technical efficiency. What
is less important possibly, but immediately important to every-
body in Europe, is that this neglect certainly will be followed
by degeneration in military efficiency. It is now or never for
Germany, even from the military point of view. Referring to
the suggestion that Germany itself might soon save the situation,
Sir Thomas said that it was easy to destroy a great structure
but that it took many years to build another like it. Only the
very youngest in the room would live to see the time when
German universities would be restored to their old position in
the intellectual world.

Deaths from Road Accidents Doubled by the Black Out
The restrictions on street lighting rendered necessary by the
danger of air raids has doubled the fatalities from road acci-
dents. In the House of Commons the minister of transport
reported that the number of persons who died during September
as a result of road accidents was 1,130 against 554 in September
a year ago. Information as to the number injured was not
available. Since the first days of the emergency, efforts had
been made to achieve the maximum possible safety in road
conditions consistent with demands of defense against attacks
from the air. The public could help to secure a reduction in
accidents by increased care on the roads and refraining from
the use of automobiles after dark except when absolutely neces-
sary. Many accidents occurred to pedestrians crossing the
road, as the drivers could not see them before their cars struck
them. It is suggested that pedestrians should wear or carry
something white or of a light color and walk on the left side
of the pavement. The ‘‘Safety First Council" described the
foregoing figure as the most serious statement on road accidents
ever made in Great Britain. War time conditions have pre-
vented the compiling of the figure for the injured. If the
proportion to killed remains the same as before — a reasonable
assumption — more than 40,000 persons must have been injured
on the roads this September, 10,000 of them seriously.

The Danger of Radium Dispersal by Air Raids
The Emergency Measures Committee of the National Radium
Commission has issued a memorandum on the danger of radium
dispersal by aerial bombardment, by A. R. Greatbatch, of the
Research Department of the Woolwich Arsenal. He points
out that in considering dangers from aerial bombardment atten-
tion must be given to the disruptive action of a high explosive
bomb on radium containers and the probable dispersion of
radium dust over a wide area. Unprotected radium needles
would almost certainly be disrupted and the contents scattered

by the blast from the explosion of a 500 pound bomb within
a range of 20 feet. Any envelop surrounding the needle would
afford some protection. A reasonable protection would be
given by a steel container 3 inches thick. The danger from
fragmentation is of a different nature. The radium container
may be struck by one of the thousands of fragments hurled
by the force of the explosion at double or even treble the
muzzle velocity of a rifle bullet. This danger may extend to
more than a hundred feet from the bomb. A direct hit by a
fragment within this area would shatter a container unless
heavily protected in the manner described. The protective
value of the building housing the radium must be considered.
It should be related to the fact that bombs dropped from a
height of 10,000 feet or more can penetrate 5 feet of concrete
and 30 feet of earth. Thus for complete protection from a
500 pound bomb the radium should be covered by more than
30 feet of earth. The recommendation that radium should be
sunk 50 feet in the ground (which already has been done)
will therefore ensure safety from radium dispersal in all cir-
cumstances, including a direct hit.

Casualty Evacuation Trains for Civilians
The vast organization formed for the defense of the civilian
population against air raids has been described in previous let-
ters. Every possible contingency, even to the disposal of the
dead, has been the subject of careful planning. A new example
is trains specially adapted for the evacuation of air raid casual-
ties from hospitals in dangerous areas to base hospitals outside
them. There arc twenty such trains in London, eight in the
English provinces and two in Scotland. Their crews consist
of one medical officer, one hospital train officer, three trained
nurses and ten auxiliary nurses. Each train is made up of
nine parcel vans converted to take thirty stretchers in each
van. Brackets have been fixed to the sides of the vans, and
the stretchers are in two tiers. There is a coach with a kitchen
attached, so that the patients can have hot meals during the
journey. All the crews have been working on their trains for
some time, so that they now form organized teams.

Adaptation of the British Pharmacopeia to
War Conditions

The British Pharmacopeia Commission is engaged on modi-
fication of the pharmacopeia to the exigencies of war. The
strain imposed on the medical services of the country renders
necessary the utmost economy in the prescribing of drugs. At
the invitation of the Ministry of Health, the Medical Research
Council has formed a therapeutic requirements subcommittee
to advise the ministry and . the medical and pharmaceutic pro-
fessions on economy in the use of drugs. When there are sev-
eral remedies for a particular disease it may be desirable to
concentrate on the manufacture of a particular one. Difficulties
may arise from the fact that the raw materials for the manu-
facture of many remedies have to be imported from abroad or
because war conditions may cause an abnormal demand for
certain drugs.

The Conveyance of Disease by Airplane

At the Royal Society of Medicine, Air Commodore H. E.
Whittingham said that journeys by air from countries where
the major infectious diseases— cholera, plague, smallpox, typhus
and yellow fever— are endemic to uninfected countries are now
usually completed well within the incubation periods of these
diseases. The health control of traffic is based on the Inter-
nationa! Sanitary Convention for Aerial Navigation, 1933, which
specifics the maximum measures which may be imposed but
leaves their application to each country, the aim being to make
the regulations as uniform as possible, to lessen inconvenience
to passengers and cause. the minimum delay. Each govern-
ment has drawn up its own regulations for the sanitary con-

1976

FOREIGN LETTERS

trol of aviation. In the United Kingdom aircraft are permitted

desL°ated a ‘‘ f airdromes ‘ A aa "itary airdrome

s designated a local area if it is beyond all probable risk

of contamination from without No one must enter or leave
it without official permission. If a death, other than by acci-
dent, occurs on an aircraft arriving from abroad, or a case or
suspected case of infectious disease (other than tuberculosis or
venereal disease), the craft must notify the airdrome medical

Infected" PreferabIy ^ "'ireless, before arrival

nfected aircraft or those coming from places infected with

rodfn?’ d gUe ’ , SmaI ! P0X ’ typhus or y ell0 'v fever, or those with
rodents dying aboard, must not discharge passengers crew or

-go until the medical officer has inspected them and Sred

Lpiffil oT lnf6Ct r • The USUa ‘ Pr ° Cedure is * isolatein
a ospital persons showing evidence of infection, while the

contacts may be liberated after giving names and addresses of

locaT heahVffl 7 T? * UndCr tbe sur '' eil!a "« of the
inoculation 1 ° -"T u f eQUate vaccination a&ainst smallpox or

ation In T t r a . 0r yell ° W f6Ver fron, iso-

on In cases of infection the aircraft is disinfected In

i craft from the tropics and subtropics disinsection is per-
formed to prevent the introduction of mosquitoes carrying the

TL re "" » ■»!.*. H there iL'dl

area fi h a f° r - u airCraft haS C ° me fr0m a cholcra infested
area, fish, fruit and vegetables must not be unloaded.

Jors. A. M A
-Vov. 2i, i;;i

three physicians, six pharmacists and one veterinary surra-
were convicted of offenses against the Dangerous Dru^ct'
6 'J aS „ no e y ,dence of any organized illicit traffic.' &J

attlm r° 1 ‘ C n ! mP ° rt aS were dis covered were individual
attempts, usually by oriental seamen, to bring in small quantities

or eir own use or that of compatriots resident here Two
attempts to smuggle in small quantities of prepared opium tr
means of the newspaper post were discovered. No single seizure
of opium exceeded 12 ounces.

YELLOW FEVER

Special precautions are taken against yellow fever, as the

( f AedeS /* egypti) !s prevalent in the tropics and
subtrop.es. The fear of spread to India by air traffic is con-
sidered so great that the government has taken additional pre-
cautions. . Passengers from yellow fever areas in Africa are
not permitted to enter India until nine days has elapsed since
their departure, and aircraft are not permitted to fly direct to
India from such areas unless in possession of a certificate from
ie Egyptian Quarantine Board stating that the aircraft has
been dismsected. In common with the Dutch East Indies and
the Sudan, India prohibits the importation of yellow fever virus
even for research purposes. The danger is considered so great

that the following precautions are recommended: 1 Provision

of antiamaril airdromes in all yellow fever districts They
have, been established at Kano, Malakal and Khartoun. The
last is not in a yellow fever area but is a clearing place for
air traffic. 2. A campaign against Aedes aegypti. This has
already produced a marked decline along the air routes of
Africa. 3. Possible requirement that intending passengers mav
be required to go into isolation for six days before embarka-
tion. In Nigeria seven days’ notice of flight is demanded, so
that it can be decided whether quarantine in a mosquito proof
hut is necessary. 4. A change of aircraft during journeys,
which lessens the risk of transporting infected insects beyond
a certain point. 5. The destruction of mosquitoes in aircraft,
which has occupied the attention of experts in various coun-
tries. Deskito, a water-soluble pyrethrum concentrate, diluted
from ten to fourteen times, is used as a spray by Imperial
Airways. 6. Inoculation against yellow fever of all who intend
to travel by air through yellow fever districts.

The Blood Tests Bill

The report of the House of Lords select committee on the
oastardy blood tests bill recommends that it should become law.
The committee is satisfied that the risks of error have ken
reduced to negligible proportions and that the tests would
pi event injustice. Replying to the criticism that to make it
mandatory on the court to order a blood test would be ail inter-
ference with the liberty of the subject, the committee feels that,
in view of the possible injury to reputation, these cases require
special treatment. An “approved person” should be nominated
bj- the court to take tests. He should be a physician who i>
also a pathologist, but blood samples for the test could k
taken by a physician who is not an approved person. In view
of possible nervousness on the part of the woman, this ph; si-
cian should, if possible, be her regular medical attendant. In
all cases in which an applicant refuses to undergo a blood test
her application should be dismissed.

Evacuation of the Wounded by Air
Air forces will play a greater part in this war than in aitf
previous one, and a new development, which has already begun,
is evacuation on a large scale of the wounded by air. Tfe
British air force has in France complete units for the evacuation
to England of casualties and patients with all possible speed
by air. Up to the present all the casualties have been evacuated
in this manner. In addition the medical services have a com-
plete system whereby in an emergency the blood transfusion
units can be carried by air right into the front line. If nccty
sary, transfusion can be performed while the wounded nun 15
being carried in air transport.

PARIS

(From Our Regular Correspondent)

Oct. is, M

Occupational Diseases of the Skin

During the sessions of the Journees internationales dc P 3 *' 1 - 5 '

■ " t U

and

Little Traffic in Dangerous Drugs in Great Britain
The report on the traffic in opium and other dangerous drugs
m Great Britain, which lias been presented to the League of
Nations by the government, deals with the year 1938 and states
that drug addiction is not prevalent. The number of persons
known to the central office during the year as addicted to nar-
cotics was 519 — 246 men and 273 women. Of these 134 were
physicians, two were dentists, five were pharmacists and two
were veterinary surgeons. The percentages of addiction to
different drugs were morphine 78.7, diacetylmorphine 13.2,
medicinal opium 0.4, diliydromorphinone 0.6. During the vear

me acasiuiib ui tne journees inieriiauuna»v-

Iogie et d’organization du travail, held last May in Pan"’' 1

official report of which has just been published, plandin

Rabeau presented a paper on occupational dermatoses based

1,000 cases among workers of different trades. Occupation

diseases of the skin constitute from 40 to 70 per cent o

occupational diseases. Diseases of the skin are among 1 ®-

which incapacitate longest for work. Their etiology i» Cu “

obscure. In some cases diseases of the skin arc clearly 0® ^

by the occupation alone; in most other cases it is difficu ^

determine the particular toxic, infectious, mechanical or a

In other cases cutaneous diseases of a mycotic, r ‘ J "

■ ■ - "■ W

agent. luols ^ULtWicuuo vi ^

tional or diathetic nature may be modified by scratching or ^
local infections, syphilis, diabetes, tuberculosis, lichen, icht
and so on. In this confusion, recourse is finally had to
neous tests, which require much time. However, improve^
in technic will no doubt bring about a shortening of •

One of the great difficulties in applying these tests is 1 •-
number of allergens that have to be considered. Finn "
Rabeau described their modification of Bloch’s tecnnic.

T W

stress the need of attention to detail as well as the f j

required for the correct interpretation. The susccpti - ,l *
individuals changes in the course of the years and ever

Volume 113
Number 22

FOREIGN LETTERS

1 977

the seasons. There are also sensitization thresholds, activating
substances and physical factors such as heat, humidity and light
by which allergy is more or less aided in its evolution. Fifty
per cent of cutaneous diseases are purely exogenous; 30.35 per
cent in men and 19.74 per cent in women are designated as
seborrheas, a term used with reservation because of its possible
provisional nature ; 26.28 per cent of cutaneous diseases in men
and 25,28 in women are of bacterial or mycotic origin. Sub-
stances used for cosmetic purposes cause 20 per cent of eczemas
in all occupations.

Trachoma and Rickettsia

At a meeting of the Academie de medecine, Georges Blanc,
R. Pages and L. A. Martin brought to the support of the
analogies invoked between trachoma and Rickettsia infections
the results of new attempts to transmit trachoma to Macaca
svlvanus, an animal especially sensitive to the disease. They
were able to bring about five transmissions from monkey to
monkey and thereupon from monkey to man and from man to
monkey, the trachoma agent losing nothing of its virulence in
the course of its successive inoculations. The infections induced
in man by the virus of the baboon is of the acute type observed
by all investigators in the infection provoked by the human
virus. Of the three types of Rickettsia so far described in
trachoma infection, that of Busacca-Poleff, that of Cuenod-Nataf
and that of Foley-Parrot, only the last one was found by Blanc
and his collaborators. Prowazek's bodies were frequently but
not always observed in the experimental trachomas which they
caused. They appeared between the twentieth and the thirtieth
day and lived only a few days. Although they have the appear-
ance of “parasites,” the fact that they are relatively rare in
trachomatous monkeys invites caution in speculating on their
pathogenic role.

The Epidemicity of Acute Rheumatic Fever
Blechmann, at a recent session of the Societe medico-chirurgi-
cale des hopitaux fibres, reported the results of his observations
on acute rheumatic fever, a subject proposed by the military
health service for further study.

Epidemicity is one of the characteristics which render acute
rheumatic fever a disease entity. Its cause is not yet known,
or at least there is no proof of the part played by the different
germs so far isolated. However, cases of familial rheumatism
are sufficiently numerous and indicate a hereditary predisposition
or suggest a direct transmissibility. Besides, several outbreaks,
evidently of an epidemic character, have been reported, notably
during the World War, both in military circles and in isolated
groups in which soldiers were in prolonged casual contact with
civilians. The argument often advanced for the seasonal nature
of the disease cannot be entertained. The fact that the infection
is not fatal and that its mechanism is not known does not con-
stitute an argument against its infectiousness. Its transmission
seems to require a direct and prolonged contact. The port of
entry seems to be the pharynx. There is, at least according to
army medical statistics, a close parallelism between the curves
of acute rheumatic fever and angina, which is often considered
the only symptom of it. The connection between acute rheu-
matic fever and scarlet fever is still clearer. The effect of
salicylates on the manifestation of scarlet fever and rheumatism
emphasizes the community of origin between the two maladies.
Conditions such as humidity and overfatigue clearly are to be
reckoned among the inducing causes. Billings and Rosenow,
on the other hand, stress the role of focal infections of a buccal
nature. Many authors ascribe this rheumatic infection to a
variety of streptococci such as Streptococcus viridans or Strepto-
coccus haemolvticus. Others have described numerous germs
or associations of germs the specificity of which has not yet
been demonstrated.

BERLIN

(From Our Regular Correspondent)

Oct. 25, 1939.

War Closes Some Universities
Ail universities have been closed except those of Berlin,
Vienna, Munich, Leipzig and Jena. According to reports, these
five have been selected to continue their teaching and research
functions and to maintain their departments of physical culture
unimpaired. Several technical schools and art schools also will
remain open. The other universities will accelerate and com-
plete their examinations before closing. Students disqualified
for military service and those not yet called to the colors are
required to continue their academic studies at once. Medical
students who have passed the medical examinations but have
not served their year of training in the clinics, a training that is
still obligatory and a prerequisite to full medical recognition,
are to be granted their diploma at once. The same regulation
applies to druggists. The National-SoziaUstischc Partcikor-
respondenz now issues a special wartime service which it calls
"The Inner Front.” In this war time service Dr. Conti, state
leader of physicians, has announced that one third of the 38,000
physicians practicing in Germany have been mobilized for
military purposes. A noticeable shortage of physicians has set
in since the discriminatory policy against Jewish physicians was
enforced. This shortage has in no wise been corrected. The
remaining two thirds are to be distributed equally over the rest
of the country. All physicians with a private practice are
required to assume duties that may be assigned to them, such
as those connected with the sick funds and with public hygiene
and health. To prevent financial discriminations, physicians who
previously were not admitted to sick fund and public health
practice may now, and under certain conditions are required to,
serve where the sick fund medical association assigns them.
Moreover, the number of practicing physicians has’ been
enlarged by granting medical students completing their last
semester their diploma. In this way the government is able to
make 2,400 “physicians” available at once who are to assist in
military and other hospitals and thus make it possible to release
older physicians for home service ; many married female physi-
cians who were prohibited from practicing during the last years
have offered their services and are now in active practice.

Besides, hospital services of an auxiliary nature have been
organized in sufficient number according to Dr. Conti’s announce-
ments. Official appointments of physicians have also been
made for the "liberated and occupied” districts and the neces-
sary measures inaugurated to prevent the occurrence of epidemic
diseases. Dr. Conti admitted that, because of the withdrawal of
many physicians from ordinary life and their assignment to
military needs, medical services would here and there be cur-
tailed. He advised that physicians be called only if really
needed and that patients consult the physicians as much as
possible at their office.

Physicians also may establish themselves at new locations
only with official permission. This measure has been taken to
protect the interests of physicians called to the front. No per-
manent certificate is therefore granted for sick fund practice
during the continuation of the war.

The use of automobiles, prohibited during war times without
official permission, is conceded to practicing physicians. Official
permit is signalized by a red corner on the automobile plates
issued.

Membership in the sick funds is assured during war times
and members are relieved of paying assessments. Their needs
are taken care of at the front by military physicians, while their
families continue to enjoy the medical service provided by the
sick funds.

1978

MARRIAGES

Jour. A. JI. A
Kov. 25, IP

Hospitalization Figures for 1937
According to a report just issued, the average proportion of
hospital beds in the combined hospitals of the nation at the end
of 1937 was 92.7 per cent to 10,000 inhabitants, as compared
with 92.2 per cent in 1936 and 92 per cent in 1935. Likewise
the number of patients treated in the combined hospitals
increased by about 245,000, totaling about 5,400,000, equivalent
to 799.3 to 10,000 inhabitants. The number of hospitalization
days increased from 180,000,000 to 186,000,000, equivalent to
3.1 per cent, although the days for which the individual patient
was hospitalized fell, on the average, from 34.9 to 34.3 per
cent; in 1935 the percentage stood at 35.2. The higher figures
for hospital services in 1937, as compared with those of 1936,
are to be ascribed to increased patronage and not to a pro-
longed hospitalization of the average patient. The average in
percentages between 1932 and 1937 is represented by 71.6 as
against 81.1. Individual figures vary according to location, size
of the hospital, time of the year and the type of the hospital.
On an average, about 510,000 beds were in daily use in the
combined hospitals and 250,000 in the general hospitals. The
mortality rate for all hospitals was the same as that for the pre-
ceding year, namely 4.9 per cent. Of every 100 deaths occur-
ring in Germany in 1932, 26.7 per cent occurred in hospitals;
in 1937 the number rose to 28 per cent. Hospitalized obstetric
cases increased by 8 per cent over those of the preceding year.
Artificially induced miscarriages in hospitals had decreased in
1936 by about 28 per cent over those of 1935, manifestly in
consequence of a more rigorous diagnosis ; in 1937 there was a
further decrease of 16.4 per cent. The frequency of births in
hospitals showed a further increase, as discernible from these
figures : 251 per thousand in 1935, 270 in 1936 and 293 in 1937.

Tuberculosis and the Army
Serial x-ray examinations have been increasingly used in
Germany in the case of factory employees and members of
formations. They are also employed largely in the army.
Detailed information is now furnished by Surgeon Major
Dr. Deist in the National-Sozialistische Partcikorrcspoiidenz.
Serial x-ray examinations were begun in the army in 1931. In
38,041 tests there were found sixty-four cases of active (0.168
per cent) and sixty-six of inactive pulmonary tuberculosis (0.74
per cent). In the old national army of 100,000 men the greatest
number of active cases was not discovered in the first year but
in the fifth and ninth years of service. However, since the
introduction of general military service the picture has under-
gone some modifications so that men in the first and second
years of service are somewhat considerably involved. Besides
irradiations, prophylactic roentgenograms are to be taken of
every recruit immediately on admission into the army. A
medical check-up is made in his second year with special atten-
tion given to those with inactive or suggestive indications. On
discharge from military service at the end of the second year
another prophylactic test is made. Regular army soldiers are
to be given x-ray examinations annually. These plans and
measures may not be carried out during the present war condi-
tions but deserve attention for the principles of social service
involved.

Measures Governing Alcohol Control
Official regulations dealing with alcohol control were reported
in The Journal September 16, p. 1144. The new regulations,
designed to prevent traffic accidents, relate to employees of
street cars and require that every' employee report for duty in
a- sober condition; that is, free from the effects of alcohol or
other stimulants. The consumption of alcohol is prohibited
not only during working hours but while the employee gets
himself ready or performs official errands. New regulations
also prohibit any reference to the effects on health in the
advertising of brandy products. Health references prohibited
include reference to dietetic effects such as “promoting diges-

tion,” “stimulating the appetite,” and “beneficial." Pictomi
representations of this kind also are banned. Only in case c:
bitters and liqueurs that possess a sufficiently high content ti
herb extracts and ingredients of bitters, reference may be rah
to such an effect in the advertisements ; but it must be limits!
to moderate expressions.

Personals

As reported in The Journal Dec. 17, 1938, page 231J.
Franz Volhard, professor of internal medicine in Frankfort ci
the Main, retired at the end of 1938. Prof. William Jionnra-
bruch, director of the second medical clinic at the Germn
university in Prague, has been appointed as his successor.
Nonnenbruch was a pupil of Morawitz, director of the medical
clinic in .Wurzburg at that time. As early as 1917 Nonnec-
bruch made a reputation by his publication based on observations
of kidney diseases in army campaigns. His further work vis
chiefly in the field of the pathology and clinical studies of kidrer
diseases and of water metabolism. In 1928 Nonnenbruch was
called to Prague, where in addition to medical problem; k
devoted himself extensively to encouraging young men cl
German extraction to study medicine. Associate profc«cr
Schellong, of Heidelberg, was appointed- as his successor at
Prague.

ITALY

(From Our Regular Correspondent)

Sept. 30, 1939.

Congress of Medicine and Surgery
The fourth Congresso Medico-Chirurgico of Calabra
held recently; Prof. Rocco Jemma was president.

Prof. Roberto Falcone, who spoke on treatment of fractu^
made the following suggestions : 1. In all cases o rac

it is advisable to make a careful x-ray examination ln j’ 3 ? ..
projections before attempting any maneuver. 2. Anest esi^
indicated in certain cases in order to make an x-ray c - va *
tion of the fracture, and in all cases to obtain a per ec re
tion. 3. Early' reduction of the fracture has a av
influence on the healing process. 4. To apply lrac l0I J
contra-extension it is advisable to resort to apparatus am • ^
cial beds, as well as to apply direct traction on tic
certain cases. 5. The limbs must be relaxed to J >re ' * • (a ; nf d
cular tension. 6. A perfect coaptation shoul c n ' ^
as long as necessary and, when indicated, transos ca
should be resorted to. 7. If a cast is applie it 51 ^

no lining and should not interfere with the functions •

muscles and joints. 8. The use of the limb must ^ ar ^ cu !ar
as soon as possible to prevent muscular at ™P 1 7’ ^ ^
rigidity and edema. 9. Physical therapy can e a ,
attpr tl-ip infiammaforv reaction has completely isap

Marriages

’AUSBEE B. Beattv, Margaretvjlle, H Y-, to
ginia Wagnon of San Bernardino,- Calil.,

., September 24. ... petty A r '

tiCHARD S. Bloomer, Rockville, Ind., to M -

re of Greencastle in Indianapolis, October t . j fcrl

Ienrv Stuart Burem, Kingsport, Tenn., to -

non Gormley at Johnson City, October i . jjjr.li

Lav O. Fessev, Nashville Tenn., to Miss Foul

les of Columbia, Tenn., in October. £\\z^ u

ICHARD Boxlev Bowles, Dehaville, Va, to .

ups of Mathews, September 30. j Iar y Off-

EORCE Nugier Des Ormeaux to Miss K<*‘

i of Lafayette, La., October 14 v «vhoii‘«, °

[argaket L. Maisoll to Mr. Richard V«hoU-

-ristovvn, Ind., October 26. SpS - '-'

erman Anfaxyer, New York, to Miss
'rov, Miss., recently.

D eath,

DE 4Tm

1980

DEATHS

James Wiley Thomason, Midway, Ala.; University of
Alabama School of Medicine, 1910; member of the Medical
Association of the State of Alabama; for many years member
of the county school board; aged 59; died, September 12.

Herbert Piercy Nottage, Ontario, Calif.; Harvard Medical
School, Boston, 1886; member of the California Medical Asso-
ciation ; served during the World War ; aged 75 ; died, Septem-
ber 15, in the San Antonio Community Hospital, Upland.

Saul Alfred Cloutier, Reno, Nev. ; School of Medicine and
Surgery of Montreal, Que., Canada, 1901 ; served with the
Canadian Army during the World War ; aged 63 ; died, Sep-
tember 10 , of myocarditis and cerebral thrombosis.

Marcus Solomon Oliver ® Chicago; Northwestern Uni-
versity Medical School, Chicago, 1912; member of the Ameri-
can Urological Association; aged 54; died, September 11 , of
coronary thrombosis and chronic myocarditis.

Robert Moses Nichols, Sheboygan Falls, Wis, ; Hahne-
mann Medical College and Hospital, Chicago, 1887; served
during the World War; formerly postmaster; aged 76; died,
September 30, of aortic insufficiency.

David Archer, Oshawa, Out., Canada; Victoria University
Medical Department, Coburg, 1S89; University of Toronto
Faculty of Medicine, 1S90; L.R.C.P., Edinburgh, and L.R.C.S.,
Edinburgh, 1S90; died, September 20.

Glenn Russell Ford ® Endicott, N. Y. ; Syracuse University
College of Medicine, 1919; on the staff of the Ideal Hospital;
aged 46; died, September 9, of duodenal ulcer, bronchopneu-
monia, nephritis and myocarditis.

John Hiram Wilson, Keokuk, Iowa; Keokuk Medical
.College, College of Physicians and Surgeons, 1907; aged 56;
died, September 26, in St. Joseph's Hospital of an accidental
gunshot wound.

Charles Emonual Eugene Pannaci, Coral Gables, Fla. ;
Columbia University College of Physicians and Surgeons, New
York, 1900; served during the World War; aged 61; died,
September 1.

Henry Paul Rhode, Green Bay, Wis.; College of Physi-
cians and Surgeons of Chicago, 1894 ; aged 66 ; died, September
28, in St. Vincent’s Hospital of myocarditis and appendical
abscess.

Moses E. Haase, Cedar Rapids, Iowa; St. Louis Medical
College, 1882; member of the Missouri State Medical Asso-
ciation; aged 77; died, "September 10, of carcinoma of the
bladder.

Sydney Abraham Stein ® New York; College of Physi-
cians and Surgeons, Medical Department of Columbia College,
New York, 1891; aged 70; died, September 29, of heart disease.

James A. Sparks ® Ashland, Ky. ; Kentucky School of
Medicine, Louisville, 1900; on the staff of the King's Daughters’
Hospital; aged 63; died, September 27, of coronary occlusion.

John Abraham Hoffman, New Holland, Pa.; Hahnemann
Medical College and Hospital of Philadelphia, 1901; aged 66 ;
died, September 12, in the Lancaster (Pa.) General Hospital.

Henry O’Keefe, Grand Forks, N. D. ; McGill University
Faculty of Medicine, Montreal, Que., Canada, 1SS2; aged 81;
died, September 2, in St. Paul, Minn., of bronchopneumonia.

Clinton B. Staley, Enfield, 111. ; Barnes Medical College,
St. Louis, 189S; served during the World War; aged 68 ; died,
September 22, as the result of a fall from his front porch.

James Harvey Craft ® Brannvcll, W. Va. ; University
College of Medicine, Richmond, Va., 1905; aged 65; died,
September 24, of cardiovascular renal disease and uremia.

Blanche Leonora Heiss Sanborn, San Francisco; Hahne-
mann Hospital College of San Francisco, 1S99; aged 70; died,
September 27, of cardiorenal disease and arteriosclerosis.

John Ray Beatty, Butte, Neb.; University of Nebraska
College of Medicine, Omaha, 2S99; aged 64; died, September 3D,
in a hospital at Lincoln of coronary embolism.

Mathias C. Scbenecker, Webster, S. D.; Bennett College
of Eclectic Medicine and Surgery, Chicago, 1894; aged SO;
died. September 4, of carcinoma of the liver.

Milton Augustus Hardin, Norpjdct, Ark.; St. Louis Col-
lege of Physicians and Surgeons, 1907 ; member of the Arkansas
Medical Society; aged 61; died, September 4.

Edward Napoleon Bywater, Grants Pass, Ore.,- State
University of Iowa College of Homeopathic Medicine, Iowa
City. 1903; aged 62; died, September 11.

D. C. Walker, Decatur, Ala. ; Birmingham Medical College,
1905: member of (be Mcdic.il Association of the State of
Alabama ; aged 62; died, September S.

Joi-c, A. )I V
Nov. 2:, It;:

William Franklin Holmes, Brockton, Mass.; Univctsi-.r
of Michigan Homeopathic Medical School, Ami Arbor, lfi- •
aged 66 ; died, September 22.

John Gunnell Talbot, Btirkesviiie, Ky.; Hospital Colkt
of Medicine, Louisville, 1897; served during the World War;
aged 67 ; died, September 30.

Frank Hughes, Boston; Tufts College Medical Schcd.
Boston, 1910; aged 66 ; died, September 13, at his sumrr-.r
home in Nortli Weymouth.

Erwin Walter Markham, Great Barrington, Mass.; Di-
versity of Vermont College of Medicine, Burlington, 1S99; jrv!
64; died, September 10.

Hugh Buck Nunn, Ripley, Tcnii. ; Kentucky School d
Medicine, Louisville, 1893; for many years postmaster; aj«!
67; died, September 6 .

William J. Kavanaugh, Brooklyn; Baltimore Universal-
School of Medicine, 1901; served during the World 'War; aged
59 ; died, August 22.

Franklin M. Skaggs, Ardmore, Olda. (licensed in Okla-
homa under the Act of 1908); Confederate veteran; aged?:;
died, September 19.

Albert C. Lusby ® Brush, Colo.; Hospital College ct
Medicine. Louisville. 1898; aged 63; died, September IP, ft
coronary thrombosis.

John Craton Gambill, Ashland, Ky. ; Hospital College tj
Medicine, Louisville, 1905; aged 54; died, September -■), ct
coronary sclerosis.

Benjamin A. Pyatt, Georgetown, S. C. ; Medical College ft
South Carolina, Charleston, 1886; aged 77; died, September
of lobar pneumonia.

Arba Sherman Green, Lorain, Ohio ; Cleveland Hwufr
pathic Medical College, 1898; aged 69; died, September tr,
coronary thrombosis. , ,

Robert W. McGehee, Yoakum, Texas; Tulanc Univcw?
of Louisiana School of Medicine, New Orleans, 1889; ag 1
died, August 10. _ ■

Edward Grigsby Moench, Belle Center, Ohio;
Medical College, Cincinnati, 1926; aged 38; died, Sep
of heart disease. .. I

George Nicholas Waldeck, Huntington, W. ' r ®’' jj'ii
College of Ohio, Cincinnati, 1895; aged 67; died, Sept
of myocarditis. _ , .

Max Bresler, New York; Columbia University 0 5^,
Physicians and Surgeons, New York, 1899; ag d
September 15. . -,,^1

Elmore Oscar Smith, Kansas City, Mo.; R“ s * y Vbrorie
College, Chicago, 1881 ; aged 88 ; died, September ,
myocarditis. T pin-

Charles Billington, Madison, Wis.; Boston B

School of Medicine, 1903; aged 68 ; died, Sep
myocarditis. _ . Timer

Ignatius George Moleski, Philadelphia? died,

sity School of Medicine, Philadelphia, 1919; aged
August 31. . _ ... . ro .| ffi c tf

Charles Robert Magee, San Diego, Califi,

Physicians and Surgeons, Keokuk, Iowa, 188 ,

August 20. TT , -,j( T ti

James Hansford Davis, Temple, "’'- 5 , Ji-.J,

Nashville (Teiin.) Medical Department, ISA, ag
August 23. . .. 0 f Cal'*

Edward James Rice, San Francisco; Umve y ^ ^
fornia Medical Department, San Francisco, •*>

August 7. T . . .... 0 ; Ir.vi

Henry E. Steen, New York; State c cf !tr-

College of Medicine, Iowa City, 1884; aged 8 -,
ber 15. , ou ;. J

Lashley M. Gray, California, Mo.; . iosc kred-
College, 1882; aged 81; died, September 6 oi ^ 0 «-.r

John William Barnhill, Owensboro, Ky ; * cffl y r jj.
of Medicine, Louisville, 1882; aged // ; died, P Q":'-,
ighar, Iowa;

Chicago, 1890; aged 82; died, September 1, oi- • ; ; f.

Ella Camp, Primghar, Iowa; Womans
hicago, 1890; aged 82; died, September 1, o,

Claude Clegg, Clarksdalc, Ariss,_ (licensed in (

1911); aged 50; died, September 2r °t heart a

Rowe R. Bunner, Fort Neal. \\. 4 .

College, Baltimore, 1909; aged a0; died, Severn - .

Amy L. Silvieus, Cleveland I; Cleveland Ln^r.

cine and Surgery, 189/; aged 63; died, - ^

Volume 113
Number 22

CORRESPONDENCE

1981

Correspondence

HYPERSENSITIVITY TO PITUITARY

To the Editor:— A clinical note in The Journal October 14
by Dr. Walter McMann reports a case of hypersensitivity to
solution of posterior pituitary. I would like to add a case of
my own to the few that have been reported.

An octigravida aged 36 was seen by me in August 1934 for
antepartum care. She made only this one antepartum call, at
which time it was found that all previous labors had been
normal and that all children were living and well. The present
pregnancy had progressed without incident, and the estimated
date of confinement was about September 7. On September 4
she was delivered of a normal male infant at 4 : 50 a. m. Fol-
lowing the second stage of labor she was given 1 cc. of solu-
tion of posterior pituitary intramuscularly* which is my routine
practice. On completion of the third stage she complained of
generalized itching and moderate dyspnea. This became pro-
gressively worse, and she was given epinephrine for no other
reason than that the picture appeared to be one of anaphylactic
shock; I had no idea as to the etiology. The symptoms grad-
ually cleared up and by noon she was quite well.

She became pregnant again in 1935 and on July 8, 1936, was
delivered of a normal female infant. In view of her previous
experience I gave her only 4 minims (0.25 cc.) of solution of
posterior pituitary' following completion of the second stage of
labor. Her previous symptoms recurred, but in a mild form,
and subsided promptly on administration of epinephrine.

Her tenth pregnancy began in 1939 and she was delivered of
a normal female infant on October 14. She was given no solu-
tion of posterior pituitary at any time during or after labor,
reliance being placed on Adair’s ergonovine orally following
completion of the third stage.

It might be noted, incidentally, that different brands of solu-
tion of posterior pituitary were used on the two occasions.
The only physical disorders in this woman’s history are obesity
in 1936, at which time she weighed 248 pounds (112.5 Kg.)
and at present cholecystitis with stones. The latter was proved
by x-ray examination.

Wayne C. Rydbuhg, M.D., Brooten, Minn.

OXYGEN THERAPY

To the Editor : — The clinical lecture on oxygen therapy by
Dr. if. A. Blankenhorn in the October 7 issue of The Journal
is inadvertently and unfortunately misleading.

“Cyanosis is the main and only important indication for oxygen
therapy in pneumonia.” This opening sentence in the lecture
does not take into account the fact that a grayish color to the
face is generally indicative of the more severe types of anox-
emia. Furthermore, in peripheral circulatory failure the capil-
laries of the skin are collapsed and a cyanotic hue may not be
discerned in the presence of the most profound anoxia. In
anemia there may be insufficient hemoglobin to provide a bluish
color to the skin, although a marked decrease in oxygen satura-
tion of the arterial blood may exist. Cyanosis may be consid-
ered a reliable indication for oxygen therapy in pneumonia only
when it is present. There are other important indications for
oxygen therapy, such as a pulse which is elevated out of pro-
portion to the fever, dyspnea, restlessness and irrationality,
abdominal distention, rapid shallow respiration ; namely, the
symptoms of anoxemia which are indicative of oxygen want
and which Dr. Blankenhorn himself referred to as resembling
the toxic effects of infection.

"Oxygen treatment may not be successful in relieving anox-
emia for a number of reasons other than reasons of technic.
It cannot succeed if too much lung is consolidated or obstructed
by exudate. It cannot succeed if the circulation is failing or
if there is toxic depression of the respiratory center by infec-
tion or drugs.” These remarks do not take account of the
fact that oxygen in physical solution in the blood is increased
in proportion to the pressure or concentration of oxygen in
the air breathed. Thus, at 50 to 60 per cent of oxygen con-
centration in the inspired air there is an increase of two and
one-half to three times the normal physically dissolved oxygen.
Furthermore, the hemoglobin even of a normal individual can
be additionally saturated by 5 per cent. The summation of
these two influences (not reckoning the additional oxygen which
penetrates partially obstructed areas of the lung, which may
be considerable) will increase the oxygen content in 100 cc.
of blood by almost 2 cc. Since from 4 to 6 cc. of oxygen is
consumed in 100 cc. of blood as it passes from artery to vein, an
increase of 2 cc. has considerable physiologic significance.
Reference to the oxygen dissociation curve indicates that a sub-
stantial elevation in oxygen tension takes place under these
circumstances.

Oxygen treatment in the conditions referred to is frequently
of great importance. Studies during the past decade have
shown that a failing circulation, whether due to congestive
disease, coronary thrombosis or peripheral circulatory failure,
is especially aided by inhalation of oxygen enriched atmos-
pheres (Barach, A. L., and Richards, D. W. : Effects of Treat-
ment with Oxygen in Cardiac Failure, Arch. Iut. Med. 48:
325 [Aug.] 1931. Levy, R. L., and Barach, A. L. : Therapeutic
Use of Oxygen in Coronary Thrombosis, The Journal, May
3, 1930, p. 1363. Freeman, N. E. ; Show, L. J„ and' Snyder,
J. C. : The Peripheral Blood Flow in Surgical Shock, /. Clin.
Investigation 15:651 [Nov.] 1936).

In toxic depression of the respiratory center by drugs oxygen
treatment is also of value to prevent asphyxia, in some instances
employed with carbon dioxide. The histotoxic anoxias, for
example, produced by ingestion of alcohol, have been shown
to be ameliorated by inhalation of oxygen (van Wulfften,
Palthe, P. M. : Deutsch. Ztschr. }. Nervcnh. 92:79, 1926.
Barach, A. L. : The Action of Oxygen in Counteracting Alco-
holic Intoxication, Am. J. Physiol. 107:610 [March] 1934.
McFarland, R. A., and Barach, A. L. ; The Relationship
Between Alcoholic Intoxication and Oxygen Want, Am. J.
M. Sc. 192:186 [Aug.] 1936).

It is my belief that oxygen tents should generally have 50
per cent oxygen rather than from 35 to 40 per cent, since these
concentrations do not always raise the arterial oxygen satura-
tion as near to the normal range as higher concentrations, and
since the administration of very high concentrations of oxygen
has been found valuable under certain conditions (Barach,
A. L. : Methods and Results of Oxygen Treatment in Pneu-
monia, Arch. Int. Med. 37:186-211 [Feb.] 1926. Evans, J. H„
and Durshordwe, C. J. : Ancsth. Sr Analgesia 11:193 [Sept.-
Oct.] 1932. Boothby, W. M. ; Mayo, C. W., and Lovelace,
W. R. : One Hundred per Cent Oxygen: Indications for Its
Use and Methods of Its Administration, The Journal, August
5, p. 477. Fine, J. ; Hermanson, D., and Frehling, S. : Further
Clinical Experiences with Ninety-Five per Cent Oxygen for
the Absorption of Air from the Body Tissues, Ann. Surg.
107:1-13 [Jan.] 1938). Oxygen may also be administered in
conjunction with positive pressure, vaporized solutions of neo-
synepbrin and epinephrine as well as with helium, but it is not
my purpose to discuss the importance of oxygen therapy in
pneumonia but rather to point out certain differences in
emphasis or opinion in my views to those expressed in Dr,
Blankcnhom’s lecture.

At- van L. Barach, M.D., New York.

1982

CORRESPONDENCE

jovt. a. yi }
Nov. 25, ijji

POSTPARTAL CARE OF THE
URINARY BLADDER

owners who employ many peons, and they state that they hi;
never heard of the disease.

To the Editor:— At the annual session of the American Medi-
cal Association in 1939 TeLinde read a paper on the routine
instillation of an ounce of a 1 per cent solution of mercuro-
chrome into the bladder of gynecologic patients before they left
the operating table. In this way he was able to reduce materi-
ally the incidence of postoperative catheterization. Since many
patients have to be catheterized after delivery conducted under
anesthesia, I determined to try TeLinde ’s plan in obstetrics. On
my return from St. Louis I saw two patients being catheterized,
one of whom developed a cystitis. I lost no time in putting
the plan into operation. One hundred and fourteen obstetric
patients, all delivered under an anesthetic, have been treated in
this manner, and only two have been catheterized. One of
these, I might say, had been in labor three days and had been
dribbling urine for twenty-four hours before she was sent into
the hospital. Her bladder was greatly distended. She com-
plained more of the bladder pain than she did of the labor pains,
and her physician had been giving her morphine to make it
bearable. Had I been trying for a favorable record for the
plan I should have omitted the instillation of mercurochrome
into the bladder after delivering this patient. Nevertheless, it
seems to be a simple and worthwhile addition to the delivery
technic. M P IE rce Rccker> m D _ Richmond, Va.

VERRUGA PERUANA

To the Editor : — In view of the editorial in The Journal
July IS, page 235, in which reference is made to Dr. Trigo Arce
having reported clinical cases of verruga peruana in the Yungas
in 1935, it might be in order for one who has now spent nearly
two years of continuous practice in the Yungas of Bolivia to
give a little report on the possible presence here of this disease.
I have not had an opportunity to communicate with Dr. Trigo
Arce before making this report.

“Septique” or “tzerktiti" is one of those snceze-cough-and-
spit Aymara Indian words, and I would suggest that any one
with false teeth trying to pronounce it for the first time do
so in private. “Septique” or “tzerktiti" is used commonly by
the Indians as the name for yaws or frambesia. Of course
they do not always make exact diagnoses and at times may
apply the term to cutaneous leishmaniasis or fungous cutaneous
infections. This "tzerktiti” responds rapidly to neoarsphen-
amine, gives a positive Kahn reaction, does not usually produce
a striking anemia unless associated with other disease, is not
highly fatal and, if not treated, tends to run a chronic course
of several years. The word “siete" I have heard less often and
usually spoken of as “siete anos” (seven years) and is applied
to chronic sores that run a course of several years.

As I have stated before, I have practiced here almost two
years now and I have not seen a case that I woutd suspect as
being verruga peruana. My attention has been called to the
disease, as several of our missionaries have contracted it in
Peru and some have died. The Sanatorio y Hospital de Sud
Yungas, of which I am at present medical director, has been
in operation in Chulumani, the capital of the province of South
Yungas, for about ten years. It draws its patients from both
North and South Yungas as well as from the more outlying
districts. Although I have gone over the records of the hos-
pital for these ten years I have not found any cases even tenta-
tively diagnosed as verruga peruana or Oroya fever. Our
present head nurse, an American who has been here since 1934,
states that she has not known of any cases here. The Peruvian
pharmacist in town. Jose Keiffer, who has seen cases oi the
disease in the hospitals in Lima, Peru, and who has resided
here since 1932, states that he has seen no cases here, nor has
he heard of any. I have also asked several large property

Our climate, elevation and housing conditions compare faver-
ably with other regions of the world where the disease is
reported. We also have a large population of Peruvian Infcj,
but they come for the most part from the region about hak
Titicaca, where the disease is not generally known. In tint
of these facts it is possible that this illness might present itself
here at some future date, but for the time being I believe it is
one of the few diseases we have been fortunate in escaping here.

Waldo W. Stiles, M.D., D.O.,
Chulumani, South Yungas, Bolivia,

VULVOVAGINITIS IN PREGNANCY

To the Editor : — We submit a few comments subsequent to
those of Dr. H. Close Hesseltiue with respect to our artide
“The Significance of Vulvovaginitis in Pregnancy” published
in The Journal July 1, 1939, page 30.

All patients with symptoms and/or vaginal discharge bad
both the direct Sabouraud and the culture-transfer technic
employed. The latter seemed to give a higher incidence oi
positive results and the incidence we reported was as w
found it. Observations by one of us (E. G. \Y.) on L®
private patients shows a much lower clinical incidence.

The words "type of" should have preceded "lochia! doiv
in ascribing the postpartum disappearance oi Monilia to fe
alteration in vaginal function. In our comment it is suggested
that hyperestrinism with sequential vagina! changes in preg-
nancy may account for the appearance of Monilia in certain
pregnant women. Inversely the rapid fall in estrogen result'
in glycogen-poor vaginal secretion during the time of loclm
flow. Dr. Hesseltine is quite correct in criticizing the existence
of any “loehial flow influence.”

We are not of the opinion that oral thrush is necessarily a
result of intrapartum infection from a mycotic vagina. 1
have encountered too many exceptions in this and other studies
to believe it to be the rule.

The data reported are as they occurred in our study. T^t
is no more, finality in them than in other published data on I -

subject. Edward G. Waters, M.D.

Eakle W. Cartwright, M.&

Jersey City, h- >•

A SURGICAL PROCEDURE FOR
ANGINA PECTORIS

To the Editor :— The report by Dr. Rupert B. Raney ( <
Journal, October 2S, p. 1019) of a successful surgical proc
to relieve angina pectoris by cutting the efferent s)
fibers to the heart exclusive of the afferent fibers of j w ^
is confirmatory evidence of the experimental work v, ttc
IC Jochim and I have recently reported (Am. J- >
126:395 [June] 1939) in which we demonstrated that u ^
coronary vasoconstrictor fibers present in the dog arc a
in character, tonically active and bundled m the s , jn ’ ^
nerves. In our studies we did not find any cholinergic i;I _
vasoconstrictors in the vagi but only cholinergic
It would appear, therefore, from the report of Dr. (J

the innervation of the coronary arteries in man are si (j
that reported by us in the dog. Hence, it is not ncc ^ ^
assume, as the author did, that the sympathetic ac ) pat
coronary vessels is reversed in angina, pectoris bu ^
this is the innervation actually present in man. t grJl j

that, when angina pectoris results, the sympat ic ic
vasoconstriction may be exaggerated or, without «■ - ^

that its effect is added to other constricting racciiam.-im,
it easier for severe coronary narrowing to occur. ^

Lons X. Katz, M-D-, Clr.ca, ■

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QUERIES AND MINOR NOTES

Jovs. A. SI. A
Sot. 25, 1SJJ

back to the heart and tiierefore the amount of work accom-
plished by the heart. It should be understood, however, that
these figures are rough and that it would be impossible to cal-
culate with great accuracy the amount of work done by the
human heart.

MANDIBULAR NERVE AND REFLEX PAIN

To the Editor : — A man aged 29 has had a constant pain over the mastoid
region for nearly two years. No precipitating cause can be elicited in
the history or physicaf examination. He has had alcohol Injections else-
where followed by excision of second and third cervical nerve branches.
I believe that the area is supplied by the great auricular and mastoid
branch of the second small occipital nerves, and their excision should
give relief. The patient complains of a reflex pain in the upper half
of the entire face on that side. Any suggestions to throw light on
the subject will be appreciated. M .D., California.

Answer. — It is a popular misconception that the excision of
the superficial sensory nerves in such a disorder will afford
relief. There is, of course, some precipitating cause and it
should be discovered. An old chronic sclerosing mastoid dis-
ease must be thought of and ruled out by x-ray and aural
examinations. Arthritis of the temporomandibular joint must
be thought of, for it could conceivably cause such a pain. Like-
wise, arthritic change around the foramina of exit of the second
and third cervical nerves must be looked for. The mandibular
nerve is notorious for the reflex pain which it may produce
about the ear or in other parts of the area of supply of the
trigeminal nerve; such pain may arise from a carious tooth,
intra-oral chronic lesions or old low grade inflammatory foci
some place in the trigeminal area, Fontaine and Leriche have
suggested a role assumed by the upper cervical sympathetic
nerves in just this type of pain, and their discussion should be
referred to with the thought that treatment of the superior
cervical sympathetic ganglion and the sympathetic nerves on
the carotid artery with procaine hydrochloride might afford
relief (Leriche, Rene : The Surgery of Pain, translated by
Archibald Young, Baltimore, Williams & Wilkins Company,
1939).

CRACKING JOINTS

To f he Editor: — A patient complains of a peculiar cracking noise in the
different joints on motion. There is no evidence of arthritis, the history
is clear, and laboratory data are negative. The only thing that might have
a bearing on the symptoms is the fact that several years ago she had
large infected tonsils; this condition was followed by cholera. No cardiac
symptoms are present, nor is there evidence of joint involvement other
than as stated. D. F. Russell, M.D., Van Wert, Ohio.

Answer. — The condition of cracking or snapping joints is
occasionally a source of much worry to sensitive persons. When
this symptom is present alone, without pain, swelling or other
evidence of arthritis, it is of no clinical significance. The crack-
ing has been explained on several bases. Its pathogenesis is
similar to that of the cracking that is made by children and
occasionally by adults when the distal phalanx of a finger is
suddenly pulled distally. The surfaces of interphalangeal joints
which are suddenly pulled apart will cause a popping sound
similar to, and perhaps produced in the same way as, the noise
made by abruptly pulling the tongue away from the roof of the
mouth. Just why this should occur more at certain times than
at others in the same person or should be present to a high
degree in some persons is not definitely known.

A roentgenogram, of course, should be taken to rule out the
presence of loose bodies and a careful examination made to
exclude other pathologic conditions. In the absence of these,
however, the patient should simply be reassured that she has
nothing to fear from this harmless symptom.

UNTOWARD EFFECTS FROM GONADOTROPIC
SUBSTANCE

To the Editor : — Have there been any proved cases of premature epiphysial
closure when gonadotropic substance is given to the preadolescent child?
Hove any other permanent harmful effects been reported?

M.D., Nebraska.

Answer. — There is no published record of proved premature
epiphysial closure following the use of gonadotropic ^substance.
Inquiry from several physicians who have made intensive studies
in this field fails to reveal any knowledge of such premature
osseous development. The possibility is recognized and has
been the basis for caution in the use of large doses of gonado-
tropic substance before adult stature is achieved.

Other possible harmful aspects from the use of this factor
would include the precocious production of adult size and activity
of the male genitalia (Thompson, W. A., and Heckcl. M. J. :
Precocious Sex Development from an Anterior Pituitary-like
Principle, The Journal, May 23, 1938, p. 1813).

TRICHOMONAS VAGINITIS IN YOUNG GIRL

To the Editor : — Please advise as to treatment of Trichomonos wairfa •
vaginitis in a girl 7 years of age.

T. M. Watson, M.D., Greenville, N. C.

Answer. — If the child has no disturbing symptoms and only
a slight discharge, ail that is necessary is to keep the externa!
genitalia clean by frequent washing with soap and wafer, li,
however, there is true vaginitis, not only should soap am! water
be used liberally on the external genitalia but treatment must
also be applied to the vagina. Since the vagina is small and
the hymenal orifice tiny, no attempt should be made to cleans:
the vagina except in refractory cases. A form of therapy which
is simple and which can be carried out at home by the child's
mother is the use of acidulated dextrose-lactose tablets as advo-
cated by Karnaky, 0.3 Gm. (S grains) each of boric acid,
dextrose and lactose being sufficient material to make thirty
tablets.

One of these tablets should be inserted into the child's vagina
two or three times a day. This treatment is directed toward
producing and maintaining an acid medium in the vagina, a
medium in which Trichomonas vaginalis cannot survive. The
tablets have a pn of about 3.

PALPATION OF ARTERY AND THROMBOSIS

To the Editor :■ — In palpating the brachiol artery to determine its degree
sclerosis and tortuosity, one usually presses the wails of Ike
together. It has often occurred to me that some degree of ^ trauma
might be inflicted on the vessel by this maneuver, especially iMI s
superficial. Are there any reports of experimental or ciinicoi studies to
show whether intimal damage or even thrombosis con occur in this monrw*

M.D., Tennessee.

Answer. — Trauma may cause a sclerotic plaque to project
into the intima of an artery and thus cause thrombosis. Ikw*
ever, as far as is known there is no report in which thromoods
has been produced by palpation of the brachial artery. Theo-
retically, thrombosis could follow such palpation in instances o
atherosclerosis but actually the trauma is almost certainly to®
slight.

LEAD LINE IN BONES OF INFANTS FROM BISMUTH

To the Editor : — If a growing child with congenital syphilis is r T 0 *' 11 v *; lt
bismuth compounds such as bismorsen, will the bones show a dense
line in x-ray films similar to a lead line at the growing en
bones? Will treatment with mercury produce such a line?

M.D., Massachusetts-

Answer. — The bones of infants treated with JjJjJ

immediately neonatal period will show a bismuth im
to that seen in the bones of the newborn of moU ■ ;s

received treatment with bismuth during pregnancy, i
not seen in older children. The age at which it ceases tow
is not definitely known but probably is less than 1 } car. t
causes no such effect.

SEAL RING CELLS AND FOURNIER'S SYNDROME

ro the Editor:— In a case of scleroderma the presenter spoke „

seal ring cells in the biopsy section Will you
meant by a seal ring cell? Also what is meant by ^

I asked two syphilologists and got two diometncolly ditlcrcn

Albert S. Tenney, M.D., East Orongr, t- ^

Answer.— -The term “seal _ ring cell’’ has been K jj 5

■'red YVeidman, of Philadelphia, to denote the . P sCC n j,i
vhich have assumed signet ring or seal ring shapes, ; w
icleroderma. In all probability Fourniers s\ . p a ; n !:‘S
he combination of interstitial keratitis and ;,j late

welling of the knee joints which sometimes occui.
irenatal syphilis. It

nr! Prrnnta] Svnllilis

nee joints wnicn

It has been mentioned by Cole : l A)),
T tip Ioitrval. Atrcr. 21, J* v

tad

TETANUS AND INSECT BITES

he Editor:— In The Journal, September 2, page 964, |, r''

id answer on tetanus ond insect bites or stings. J 0 , ,j. c PT-

cose of tetanus observed when I was a hous ^coth 0* J S 'J,T
usotts Generol Hospital. A mon who wos on Hr f-

thc winter of 1931 had been bitten on the feet by so «

tie attention to those bites but when he was ^ch tr »

iston his jaws begon to tighten end he wot J M)nf c -i ( -
spital wards. I looked long ond hard for the P > 4 r- .

scovered on area about the toe nail which , c , D r.us
,s excised by the surgeon, ond cultures yielded tetonu T K: « <

ussive doses of ontitetomc scrum the patient rceo

ly cose of its kind that I hove hoard about or - - ■ j..,:-.

Eoilc M. Chapman, l-M*

LUME 113
JXOER 22

EXAMINATION AND LICENSURE

1985

Medical Examinations and Licensure

COMING EXAMINATIONS

NATIONAL BOARD OF MEDICAL EXAMINERS
SPECIAL BOARDS

Examinations of the National Board of Medical Examiners and Special
ards were published in The Journal, Nov. IS, page 1904.

STATE AND TERRITORIAL BOARDS

Alabama: Montgomery, June 18-20. Sec., Dr. J. N. Baker, 519
ixter Ave., Montgomery.

Alaska: Juneau, March 5. Sec., Dr. W. W. Council, Box 561, Juneau.
Arizona: Basic Science, Tucson, Dec. 19. Sec., Dr. Robert L.
igent, University of Arizona, Tucson. Medical. Phoenix, Jan. 2. Sec.,

J, H. Patterson, 826 Security Building, Phoenix.

California: Oral examination (required when reciprocity application
based on a state certificate or license issued ten or more years before
ing application in California), Dos Angeles, Jan. 17. Sec., Dr. Charles
Pinkham, 420 State Office Bldg., Sacramento.

Colorado: Basic Science . Denver, Dec. 13-14. Sec., Dr. Esther B.
arks, 1459 Ogden St., Denver. Medical Endorsement . Denver, Jan. 2.
edical Examination. Denver, Jan. 3-5. Sec., Dr. Harvey W» Snyder,

1 Republic Bldg., Denver.

Connecticut: Endorsement (Regular). Hartford, Nov. 28. Sec.,
r. Thomas P. Murdock, 147 W. Main St., Meriden.

Delaware: Examination. Dover, July 9-11. Reciprocity. Dover, July
i, Sec., Medical Couw. 1 of Delaware, Dr. Joseph S. McDaniel, 229 S.
:ate St., Dover.

District of Columbia: Basic Science . Washington, April 22-23.
:c., Dr. George C. Ruhland, 203 District Bldg., Washington.

Georgia: Atlanta, June. Joint-Sec., Mr. R. C. Coleman, 111 State
ipitol, Atlanta.

Illinois; Chicago. Jan. 23-25. Acting Superintendent of Registration
id Education, Mr. Lucien A. File, Springfield.

Indiana: Indianapolis, June 18-20. Sec., Board of Medical Registra-
on and Examination, Dr. J. W. Bowers. 301 State House, Indianapolis.
Iowa: Basic Science. Des Moines, Jan. 9. Medical. Des Moines,
ec. 4-6. Dir., Division of Licensure and Registration, Mr. H. W. Grefe,
tate Department of Health, Capitol Bldg., Des Moines.

Kansas: Topeka, Dec. 12-13. See., Board of Medical Registration
ad Examination, Dr. J. F. Hassig, 905 N. 7th St., Kansas City.
Kentucky: Louisville, Dec. 5-7. Sec., State Board of Health, Dr.

.. T. McCormack, 620 S. Third St., Louisville.

Marylanp: Regular. Baltimore, Dec. 12-15. Sec., Dr. John T.
•'Mara, 1215 Cathedral St., Baltimore. Homeopathic. Baltimore, Dec.
2-13. Sec., Dr. John A. Evans, 612 W. 40th St., Baltimore.

Michigan: Ann Arbor and Detroit, June 12-14. Sec., Dr. J. Earl
Iclntyre, 202-4 Hollister Bldg., Lansing.

Minnesota: Basic Science. Minneapolis, Jan. 2-3. Sec., Dr. J. C,
IcKinley, 126 Millard Hall, University of Minnesota, Minneapolis..

1 edical. Minneapolis, Jan. 16-18. Sec., Dr. Julian F. Du Bois, 350
t. Peter St., St. Paul,

Mississippi: Reciprocity. Jackson, December. Asst. Sec., State
loard of Health, Dr. R. N. Whitfield, Jackson.

Montana: Reciprocity. Helena, April 1. Examination. Helena,
Lpril 2-3. Sec., Dr. S. A. Cooney, 216 Power Block, Helena.

Nebraska: Basic Science . Omaha, Jan. 9-10. Dir., Bureau of Exam*
tiing Boards, Mrs. Clark Perkins, 1009 State Capitol Bldg., Lincoln.

Nevada: Reciprocity with oral examination. Carson City, Feb. 5.
»ec., Dr, Frederick M. Anderson, 215 N. Carson St., Carson City.

, New Hampshire: Concord, March 14-15. Sec., Dr. T. P. Burroughs,
state House, Concord.

New Jersey: Trenton, June 18-19. Sec., Dr. Earl S. Hallinger,
•8 \V. State St., Trenton.

New Mexico: Santa Fc, April 8-9. Sec., Dr. Le Grand Ward, 135
Sena Plaza, Santa Fe.

New York: Albany, Buffalo, New York and Syracuse, Jan. 29-Feb. 1.
-hief, Bureau of Professional Examinations, Mr. Herbert J. Hamilton,
>15 Education Bldg., Albany.

„ North Carolina: Reciprocity and Endorsement. Raleigh, Dec. II.
>ec,. Dr. \V. D. James, Hamlet.

North Dakota; Grand Forks, Jan. 2-5. Sec., Dr. G. M. Williamson,
l 1 /] S. Third St., Gran 5 Forks.

Ohio: Columbus, Dec. 5-7. Sec., Dr. H. M. Platter, 21 W. Broad
5t>, Columus.

Oklahoma: Oklahoma City, Dec. 13. Sec., Dr. James D. Osborn, Jr.,
Frederick.

Oregon: Basic Science. Portland, Feb. 24. Sec., State Board of
Higher Education, Mr. Charles D. Byrne, University of Oregon, Eugene.

Pennsylvania: Philadelphia, January. Dir., Bureau of Professional
Licensing, Dr. James A. Newpher, Department of Public Instruction,
358 Education Bldg., Harrisburg.

Puerto Rico: Santurce, March 5. Sec., Dr. O. Costa Mandry, Box
3354, Santurce.

Rhode Island: Providence. Jan. 4-5. Sec., Dr. Robert M. Lord, 366
State Office Bldg., Providence.

South Dakota; Pierre, Jan. 16-17. Dir., Medical Licensure, Dr.
G, J. Van Hettvelen, State Board of Health, Pierre.

Tennessee: Memphis, Dec. 20-21. Sec., Dr. H. W. Qualls, 130
Madison Ave., Memphis.

Vermont: Burlington, Feb. 15-15. Sec., Board of Medical Registra-
tion, Dr. W. Scott Nay, Underhill.

\irginia: Richmond, Dec. 13. Sec., Dr. J. W. Preston, 30 Es
tranUm Road, Roanoke.

\\isconsin: Boric Science. Milwaukee. Dec. 2. Sec., Professor
Robert K. Bauer, 3414 W. Wisconsin Ave., Milwaukee. Medical. Madi-
son, Jan. 9*11. See., Dr. E. C. Murphy, 314 E. Grand Ave., Eau Claire.

Vv yomjnc: Cheyenne, Feb, 5. See., Dr. M. C. Keith, Capitol Bldg.,
t ' eyenne.

Texas June Report

Dr. T. J. Crowe, secretary, Texas State Board of Medical
Examiners, reports the written examination held at Austin,
June 19-21. The examination covered twelve subjects and
included 120 questions. An average of 75 per cent was required
to pass. Two hundred and six candidates were examined, 194
of whom passed and twelve failed. The following schools were
represented :

Year Per

School PASSED Grad. Cent '

Chicago Medical School (1937) 75, 75, 79, 0938) 75

Rush Medical College OM8) S3

University of Illinois College of Medicine.. ( 75.5, 7o

State University of Iowa College of Medicine... (1937) //.l,

(1938) 81.4, 83.3 . . ,

University of Louisville School of Medicine...... 0 9331 84. l

Tulane University of Louisiana School of Medicine. .. (1939) 81.7, S4
University of Maryland School of Medicine and College

of Physicians and Surgeons (1937) SI. 9

St. Louis University School of Medicine (1939) 80

Washington University School of Medicine.(I933) 86.2, (1935) 78.6, 82.6

Duke University School of Medicine (1939) 76.2

University of Tennessee College of Medicine. (1939) 78

Baylor University College of Medicine... (1939) 75,

76.6, 76.8, 77.6, 78, 78, 78.2. 78.2, 78.2, 78.3, 78.9,

79, 79, 80, 80, SO, 80, 80, 80.2, 80.3, 80.3, 80.3, 80.5,

80.7, 81.1, 81.2, 81.4, 81.5, 81.5, 81.6, 81.7, 81.8, 81.9,

81.9, 82, 82, 82, 82.1, S2.2, 82.4, 82.4, 82.5, 82.7,

83, 83, 83, 83, S3.2, 83.3, 83.3, 83.4, 83.5, S4, 84.1,

84.1, 84.6, 84.7, 84.8, 85, 85.5, 85.6, 86, 86, 86.7, 87,

87, 88.3, 88.6

University of Texas School of Medicine (1937) 7/,

(1938) 84.4, (1939) 75.6, 77.3, 77.6, 77.6, 77.7, 78.2,

78.7, 79, 79, 79.8, 80.3, 80.5, 80.7, 80.8, 80.9, 80.9,

81, 81.1, 81.2, 81.3, 81.4, 81.5, 81.6, 82. 82, 82.1, 82.1,

82.2, 82.3, 82.4, 82.4, 82.5. 82.6, 82.6, 82.6, 82.6, 82.6,

82.6, 82.7, 82.7, 82.9. 83, 83, 83, 83.1, 83.1, 83.2, :

83.2, 83.3, 83.3, 83.3, 83.4, 83.5, 83.5, 83.6. 83.6,

83.7, 83.8, 83.8, 84, 84, 84.3, 84.6, 84.8, 85, 85, 85,

85, 85.6, 85.8, S5.9, 86, 86, 86, 86.4. 86.4, 86.5, 86.5,

86.5, 86. 5, 87.1, 87.3, 87.6. 87.7, 88.7, 89.6, 90

Universitat Basel Medizinische Fakultat ,(1934) 75

Universitat Bern Medizinische Fakultat (1937) 77

Osteopaths- 77.6, 77.7, 77.7, 78, 78.2, 78.3, 78.3, 79.8, 80.3, 82,3, 82.4,

83.5, 84, 85.4, 85.6

Year Number

School failed Grad. Failed

Mcharry Medical College (1937) 1

Baylor University College of Medicine (1939) 1

Christian-Albrechts-Universitat Medizinische Fakultat,

Kiel (1924) 1

Friedrich-Wilhelms-Universitat Medizinische Fakultat,

Berlin (1926) 1

Hnmburgische Universitat Medizinische Fakultat, Ham-
burg (1937) 1

Escuela Medico Militar, Mexico .(1922) 1

Osteopaths* 6

Fifty-five applicants were licensed by reciprocity and one
applicant was licensed by endorsement on July 31. The follow-
ing schools were represented:

School licensed bv kecimocitv £ear Rec^proc.ty

University of Arkansas School of Medicine ...(1936) Arkansas

Denver and Gross College of Medicine (1905) Washington

University of Colorado School of Medicine. (1937) Colorado

Virginia
Mississippi
• S. Dakota
Illinois

, " Indiana

jveoKuk Medical College, College of Physicians and

Surgeons (1903) Illinois

State University of Iowa College of Medicine. .(1924, (1929) Iowa

University of Kansas School of Medicine (1936), (193S) Kansas

Louisiana State University Medical Center (1938) Louisiana

Louisiana State University School of Medicine (1939, 2) Louisiana

University of Louisiana School of Medicine (1931),

(1934), (1937), (1938, 4) Louisiana

Baltimore Medical College (1905) Penna.

University of Michigan Medical School (1936) Michigan

University of Minnesota Medical School (1933), (1935) Minnesota

Creighton University School of Medicine (1927), (1933) Nebraska

University of Nebraska College of Medicine (1934) Kansas

University and Bellevue Hospital Medical College (1909) New York

University ~ ~ Ohio

'j cs,cr T , ' Ohio

Um\. of Oklahoma

Jefferson _ W. Virginia

Meharry , Tennessee

Unyvcrsit , Tennessee

Umversvt

(1937, s), (1938) Tennessee

Vanderbilt University School c e ' r * , '*‘ , Tennessee

Ba^or ym^y College of Louisiana

University of Virginia Denartn ■ Vireimi

University of Western Ontaric * New York

Umversite de Geneve Facolte de Medicine (1935) New York

Med.zin.sche Fafcvltat ......... .(1935) New York

us.eopaths | Colorado, 2, Michigan, Ohio. Oklahoma

School LICEXSED BY ex dor seme xt X*“ Endorsement

, . Urad. of

Northwestern University Medical School (2939) U. S. Army

2 ^\ xa niined in medicine and surgery,
i Licensed to practice medicine and "surgery.

1986

BOOK NOTICES

Book Notices

Operative Orthopedics. By Willis C. Campbell, M.D. Cloth. Price,
$12-50. Pp. 1,154, with S45 illustrations. St. Louis: C. V. Mosby Com-
pany, 1939.

At last we have a book that lives up to its title. The volume
is intended for the orthopedic specialist, the industrial surgeon
and the general surgeon. It is written out of the experience
of a small group who have had tremendous experience and
excellent guidance by an administrator and capable technician.
The book should be well received by orthopedic surgeons,
industrial surgeons and general surgeons. The author has
correlated the mechanical and surgical principles of orthopedic
practice and has emphasized the practical physiologic prin-
ciples. The choice of material is fine and the presentation,
composition and organization of the book are excellent. The
author has drawn freely from the literature, and his choice is
most acceptable. Operations are described and grouped accord-
ing to the diseases for which they are most applicable. The
chapter on surgical technic includes preparation before and
after treatment ; there are also chapters on apparatus and sur-
gical approaches.

Some of the features of the book deserving special mention
are the sections on arthroplasty, stabilization, joints and the
treatment of malunited and ununited fractures. There is an
interesting diagrammatic presentation of calcium metabolism;
also a handy table of blood and urine changes in bone dis-
eases, including serum calcium and phosphorus and serum
phosphatase. A long chapter covers apparatus, plaster casts,
splints and skeletal traction. Another long chapter concerns
low grade disorders of joints, including arthritis, -backache,
sciatica, facetectomy, section on the piriformis muscle and sec-
tion on the iliotibial band. One of the especially good sections
is that on arthroplasty, toward which the author has con-
tributed so much classic work. He is one of the pioneers
and one of the international authorities on this subject.

Traumatic lesions of the joints are discussed, including
internal derangements of the knee, disturbances and injuries
to ligaments around the knee and osteochondritis dissecans.
Dislocations are described in detail. The section on fractures
is excellent. The chapter on malunited fractures is probably
one of the features of the book. To those who know the
literature the wonderful contributions of the author on mal-
united fractures are excellent. The section on delayed union
and nonunion ol fractures is good, also the section on acute and
low grade disorders of the bones, including osteomyelitis. Note-
worthy too is the material on tumors of bones, joints and soft
tissue, which cover well these aspects.

Favorable comment is due the composition, format and beau-
tiful character of the majority of the illustrations. Special
mention should go to Dr. Hugh Smith for his collaboration.
Tlie publishers may be congratulated for beautiful work with
the marvelous material with which they dealt.

A Visual Motor Gestalt Test and Its Clinical Use. By Lauretta Bender,
M.A., M.D., Senior Psychiatrist, Psychiatric Division, Bellevue Hospital,
New York. Besearcli Monographs No. 3, American Orthopsychiatric
Association. Lawson G. Lowrey, M.D., editor. Cloth. Price, S3.50. Pp.
176, with 75 illustrations. New York: American Orthopsychiatric Asso-
ciation, 293S.

This monograph brings together and expands Dr. Bender’s
previous publications on visual motor gestalt function. The
author assumes a familiarity with the classic teachings of gestalt
psychology, which are not reviewed in the book. She defines
the gestalt function as “that function of the integrated organism
whereby it responds to a given constellation of stimuli as a
whole; the response itself being a constellation, or pattern, or
gestalt.” The material offered is based on studies of psychiatric
patients, of normal adults and children by use of a series of pat-
terns first devised by Max Wertheimer. Bender has selected
nine of Wertheimer’s original patterns and has studied the vari-
ations in capacity to copy these patterns dependent on differing
levels of maturation or growth in the visual gestalt function and
in organically or functionally determined pathologic states.

The first part of the book' is devoted to theoretical consider-
ations. In the second chapter the author observes the stages

Joi-t. A. y .i
■Nor. 2i, ;r:

of maturation the child passes through in achieving visual trer:
experiences enabling him to read and write and to percent a
does the adult. The responses of small children to the Wire-
heimer patterns and the spontaneous sidewalk drawings t:
children are here studied. In the child of 2 at first scribbling h
a motor activity which may acquire some significance after Re-
duction. By motor experiment patterns eventually are fi;-
duced that may resemble the desired one. An enclosed loop ‘i
the basis of all perceived form.” The child tends to persevere i
reproduction of any one learned pattern and initially to reprefa
this whatever figure is offered as a stimulus. Between the ape
of 4 and 7 there is rapid differentiation of form. The author
traces the increasing accuracy in reproducing size and form ad
in motor control with advancing age. Movement and pint;-
tion cannot be separated and “form in the perception of chikkn
. . . is the outgrowth of motion.”

The author comments that the child’s earliest play activity
and spontaneous drawings constitute experiments in form and i’.
spatial and temporal relationships. She concludes that the cHi
gets satisfaction out of his new experiences which is complete
enough for the given age of maturation ; that there is a continecs
reaching out for new experiments in which the child freely par-
ticipates, so that a continuously expanding "gestaltung" is In-
experienced by and produced by the child. 1 ,

The responses of low grade mentally defective persons to t" 1
visual patterns are utilized for the further study of development
of visual motor patterns. The most primitive patterns si [
analyzed in detail. It is emphasized that some tendencies b
reproduce the patterns are present at the three year level
that perceptual motor capacities which appear only at big -
intellectual levels are functionally associated with some of t-
gestalt principles. Tendencies to revert to the more prmi:»-

patterns are always present. _ ,

A study of maturation in the primitive child is based on in
ings obtained from native African children. Her dra"in?s •
designs from the army performance tests were utilized an
analyzed in accordance with the gestalt principles user 5 •

author. Details of seven levels of accomplishment arc d«cti

The author concludes that the unschooled native children
previous experience with paper and pencil copy the forms ^
as do average American born and educated children. P
orientation must then be thought of in terms of the or ® 8IM .-jj
of the perceptual motor patterns, and the different n» u
levels are alike in the “primitive” and the civilized chili - ^

Movement and temporal factors are studied in the 1
chapters of the theoretical part of the book. The ‘ ac0 . ( ;
determine the gestalt are the stimulating pattern, uic m
the visual field which determines spatial relationships,
poral factor, the motor reaction pattern of the m >'■ ^
his attitudes toward the experience. These factors 3 {C :

separable but constitute “a total process which is t ic res
the whole organism to the total situation.” s

The second section of the book consists .of eig ' c ’,-^^rr.
which the visual motor gestalt function is stu K _ . ^ vii
Eight cases of organic brain disease in which sensory
conspicuous are reported. The studies show tha £ ( ;

principles are never fixed but are the Integra ne^ ^
the personality-as-a-whole in any given situation.
dency to revert to more primitive patterns with nr nc( .',uA
the orderly course of recovery of function in acc . , c( j. I»
the laws of developmental maturation are demons ■
turbances in the visual motor gestalt function (£J !f :
paralytica, alcoholic psychosis and acute confusi , nC jo
reported; a chapter is devoted to schizophrenia *
depressive psychosis. In the schizophrenics t!ofl in i'

disturbance of splitting” is expressed by a ‘ B ; r art‘.

gestalt figures. Fragmentation and perseve .
micropsia, dissociation by spatial separation and r , 3 tior,‘.i . e '
were noted in the schizophrenic. Manic depre. . f

the other hand, evidence much less disturbance
function, their productions reflecting inhibitioi 5 , Jle j.
meticulousness, at times florid embellishments r ; r :

Of particular interest is Dr. Benders standar a rt
gestalt function in a performance test for chiiorc ■
of 800 nursery school and school children to * - ,.y -

figures have been used for the standardizatw- • '■

regards the test as of value as a test of maturi } • *

Volume 113
Number 22

BOOK NOTICES

198 7

in visual motor gestalt function between the ages of 4 and 11
years. A summarizing chart is presented, useful in determining
the maturation level of individuals whose mental age is not above
11 years.

Analysis of the performances of mentally defective persons
leads to the conclusion that the multiple causes of mental defec-
tiveness may be classified as simple retardation in maturation,
specific disabilities in the field of language, “dissociative phenom-
ena which distort the whole personality,” impulse disturbance,
perceptual disturbances and confusional disturbances. The
author concludes with reports on the use of the test in the study
of malingering, in the Ganser syndrome and in the study of
psychoneurotic individuals.

This book will be useful to physicians who are interested in
problems of development and growth. The test devised by Dr.
Bender will doubtless prove of clinical value as a performance
test yielding specific information relative to perceptual function-
ing otherwise not ready available. It should prove to be par-
ticularly useful in diagnostic studies of retarded children and
those suspected of being retarded. Where disturbances are
primarily in the field of emotional development, the test will be
of limited usefulness.

Dfe Hamaturle und ihre Behandlung. Von Priratdozent Dr. Rudolf
Chwalla. Die Urologle In Elnzeldarstellungen. Herausgegeben von
Professor Dr. H. Boemlngliaus. Boards. Price, 4.20 marks. Pp. 04.
Leipzig: Georg Thieme, 1939.

In this monograph the author considers hematuria thoroughly.
He stresses the importance of hematuria as a symptom of some
underlying pathologic condition and states that the presence of
blood in the urine always calls for a cystoscopic examination;
that hematuria may be due to general disease processes outside
the genito-urinary tract, as well as due to disease in the genito-
urinary tract. He emphasizes the importance of following a
definite routine in each case, which should include (1) demon-
stration of the presence of blood in the urine, (2) localization of
the origin of the blood, (3) the diagnosis of the pathologic
condition that makes the hematuria, and (4) the treatment. As
a rule the experienced physician can recognize gross hematuria
with the naked eye; he may be able to recognize even the
presence of small amounts of blood in the urine. When doubt
exists, one must resort to the use of the microscope and chemical
tests. Changes in the color of the urine may be mistaken by the
patient for the presence of blood, and some of the factors respon-
sible are discussed.

The author stresses the importance of obtaining a compre-
hensive history and discusses its value, and he also calls atten-
tion to some of the important facts that may be obtained from a
careful history. This is illustrated with statements showing
some of the general causes of hematuria. Next in order is a
careful urologic history, and special emphasis is given to the
value and the information obtained from such a history. During
the physical examination of the patient with hematuria, especial
attention should be paid to the nutritional state of the patient,
the appearance of the mucous membrane, heart and lungs, and
so on. The various bits of information obtained by a careful
physical examination are mentioned and discussed from the
possibility of how much information can be obtained that will
aid in making a presumptive diagnosis before resorting to the
various special methods of examination.

The special methods of examination are discussed in detail.
Anterior and posterior urethroscopy, cystoscopy, chromocystos-
copy, ureteral catheterization, x-ray examination and retrograde
and intravenous pyelograms are presented. Much discussion is
presented regarding the technic of these various procedures.
Attention is called to the fact that a kidney which shows dis-
turbance in function may not necessarily be the cause of the
bleeding and that the bleeding may have its origin in latent and
unrecognized disease in the opposite kidney.

The cause of the hematuria is presented under three headings :
1. Hematuria due to general disease processes. Among these he
mentions hemorrhagic diathesis, the various forms of nephritis,
acute infectious diseases and chemical intoxications. Although
lesions of the renal vessels are rare, they may be the cause of
profuse bleeding and one must consider them in the differential
diagnosis ; they include embolism and thrombosis of the renal
artery, aneurysm, thrombosis and thrombophlebitis of the renal
vein. 2. Hematuria due to primary lesions of the genito-urinary

system. The author stresses the frequency of malignant tumor
as a cause of hematuria. As one would expect in a monograph
of this kind, lesions of the urinary tract that make hematuria
are given careful detailed discussion and are given a good deal
of space. 3. Hematuria in infancy and childhood. Owing to the
rarity of the condition, this phase of the subject receives short
but detailed discussion.

The author discusses the treatment of hematuria under the
following headings : general measures that are directed toward
controlling or stopping the bleeding, various forms of local instru-
mental measures, and the appropriate measures to relieve the
underlying pathologic condition which is causing the bleeding.

One is impressed by the long list of drugs recommended (many
proprietary).

Getting Ready to be a Father. By Hazel Corbin, General Director,
Maternity Center Association, Hew York, N. Y. Cloth. Brice, $1.25.
Pp. 48, with illustrations. New York: Macmillan Company, 1939.

This book, by the general director of the Maternity Center
Association in New York, is dedicated to the men who attended
the first class for expectant fathers at the Maternity Center
Association. It is written in narrative form, describing what
happens to the fetus from month to month, the processes of
labor and the attitude of the husband toward these processes.
It describes the choice of a doctor and of a hospital and also
tells what to do about grandmothers and grandfathers and
diapers. It tells how to build a crib at home and how to fix
up a nursery. There is even complete information to help
the father in nursing the baby in every way except by supply
of breast milk. There are also pictures which might as well
have been omitted for all that they teach. Intelligent men do
not need books of this kind except for a few hints which can
be included in 300 words of text. The kind of men who need
this book will never buy it. There is much to be said, how-
ever, for the holding of classes for expectant fathers where
the right kind of teachers and lecturers are available.

Alcohol and Human Life Being Partly a Revision of "Alcohol and the
Human Body,” by the late Sir Victor Horsley and the late Dr. Mary
Sturge and Others. By Courtenay C. Weeks, M.R.C.S., L.lt.C.P. With
foreword by Sir Thomas Barlow, F.B.C.P., M.D., F.K.S. Second edition.
Cloth. Price, 6s. Fp. 455, with 20 illustrations. London: H. K. Lewis
& Co., Ltd., 1938.

The first edition of this book was published during 1928.
The present edition is revised and enlarged. All profits from
the book are to be devoted to educational work. The author
says that alcoholic indulgence is still the greatest enemy Britain
has to fear. His book is, of course, an argument for tem-
perance and prohibition, preferably the latter. It provides
massive data regarding the effects of alcohol on life, always
with a tendency toward the worst that it does and with little
to say about its values. A chapter called “Alcohol and the
Duration of Life” is devoted to an analysis and dissection of
the writings of Raymond Pearl on the same subject and comes
to the conclusion that Pearl is wrong and has not established
his case. The book is unfortunately not quite up to date, even
in making the best possible use of material distinctly favorable
to its point of view. In other words, it is an attempt at the
use of . scientific data lor propaganda, which must inevitably
result in something that is not quite scientific.

Hypertension and Nephritis. By Arthur M. Fish berg, M.D., Associate
in Medicine, Mount Sinai Hospital, New Y'ork City. Fourth edition.
Ciotli. Brice, $7.59. Bp. "79, with 41 Illustrations. Philadelphia : Lea
& Febiger, 1939.

In its latest edition, this popular and authoritative textbook
has been thoroughly revised. In previous editions the author
managed to include all current information on the subject which
was reliable, and this edition is no exception. Many important
contributions have been made in the five years since the previous
edition was published and the author has included most of them.
The additions are fundamental contributions to the subjects and
justify a new edition. The following are some of the important
subjects which have been added: perirenal azotemia and the
fundamental role of decreased blood flow in the pathogenesis ;
the mechanism and the pathogenesis of hypertension and its
important complications ; Goldblatt's important contribution ;
recent additions to our knowledge of kidney function tests, and
the role of acacia and concentrated blood serum in the treatment

book notices

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VoLVUE H3
Number 22

BUREAU OF LEGAL MEDICINE AND LEGISLATION

198

many hours of research. She gives the story of early medical
practitioners among women in the United States and even the
stories of those two famous charlatans Mrs. Mapp and Jane
Stevens. Through an excellent index the book enables any
one interested in any aspect of the work of women in the field
of medicine to find here the data that he will require. The
author writes in a forthright manner without much embroidery,
so that the book is not easy to read, but it is unquestionably
the most complete and authentic work of its kind available.
Obviously, it has been impossible for the author to tell the
history of women in medicine without repeating much of the
history of medicine itself. Thus the reader is enabled to trace
the record of discovery and the manner in which women par-
ticipated in the advancement of medical science.

The Evolution of Chronic Rheumatism with Treatment to Correspond:
The Preventive Clinic as a First Lino of Defence. By It. Fortescuc Fox,
M.P., F.It.C.P. Founded on a Lecture Delivered at Margate, at the Con-
gress of The Royal Institute of Public Health and The Institute of
Hygiene, May, 1937. Paper. Pp. 2G, with 5 illustrations. London :
H. Iv. Lewis & Co., Ltd., 1938.

Here the etiology of rheumatism is discussed. The treat-
ment advocated includes particularly the use of sulfur waters
and the use of baths, but little is said about pathology.

Bureau of Legal Medicine
and Legislation

MEDICOLEGAL ABSTRACTS

Malpractice: Amputation of Leg Attributed to Neg-
ligent Treatment of Fracture; Effect of Covenant Not
to Sue. — The plaintiff fractured his left leg and was sent to
the Seaside Hospital in Long Beach, Calif. The treatment
there administered was unsuccessful and the leg was later
amputated. Thereafter the plaintiff sued the two physicians
who attended him, the hospital and the superintendent of nurses
of the hospital, contending that the physicians were negligent
in using too tight a cast and that the other defendants were
negligent in not promptly advising the physicians of the dis-
covery of this fact.

During the course of the trial, a claim superintendent for
the insurance company representing the hospital and the nurse
reached an agreement with the counsel for the plaintiff whereby
for a consideration of $6,000 tbe plaintiff executed a covenant
not to sue the defendants represented by the insurance com-
pany. Thereafter the trial proceeded against the two physi-
cians until on their motion the trial court directed a verdict
for them. From the resulting judgment, the plaintiff appealed
to the district court of appeals, second district, division 2,
California, which affirmed the judgment of the trial court.
The plaintiff then appealed to the Supreme Court of California.

There was competent evidence, said the Supreme Court, to
necessitate a submission of the case to the jury. The fracture
was reduced and tbe cast applied about 10 a. m. Sunday,
August 9. One of the defendant physicians visited tbe plain-
tiff at 11:30 that same morning. He did not see him again
nor communicate with him in any way until 8 p. m. When
the physician left the plaintiff on Sunday morning he gave
instructions to the nurses as to what they should do in an
emergency resulting from a tight cast. Meanwhile, in the
afternoon, the patient felt such severe pain that narcotics were
administered, and his toes appeared swollen and a dark blue.
The physician partially split the cast Sunday night, but the
plaintiff continued to suffer great pain, and the swelling and
discoloration continued. The condition of the plaintiff’s leg
became increasingly worse and required continual treatment
until the amputation became necessary. A properly qualified
medical witness for the plaintiff testified in response to a hypo-
thetic question that the care of the plaintiff following the
original treatment was not up to the standard of care and
skill in the locality. He specifically criticized the failure to
have constant after-care and observation of the leg when the

rigid cast was applied and testified that provision should ha’
been made to notify the physician of the changes in conditio
which would have made it possible to open the cast mui
earlier. This expert testimony, the court commented, w:
enough to make a prima facie case, and the cross examinatii
and conflicting views of the witnesses for the defendants raisi
only questions of credibility for the jury.

Two other medical witnesses called by the plaintiff co
roborated the expert testimony previously given that the cau
of the injury was a cast that was too tight. These physicia:
were asked hypothetic questions as to whether the conduct
the defendant physicians constituted due care, and an offer
proof was made to the effect that they would testify that
did not. The trial court, however, sustained objections to t
questions on the ground that the witnesses were current
practicing in Los Angeles and could not testify as to t
standard of care in Long Beach, in which community t
present case arose. The Supreme Court, however, could s
no justification for such a narrow view. The cities of Loi
Beach and Los Angeles, the court pointed out, are in the sar
county; they are contiguous communities, both metropolit;
in character, and their business centers are only about
miles apart. There is reason in the general requirement th
the medical expert must be familiar with the standard of ca
in the particular locality in order that the standards of wide
separate localities with different practices may be exclude
But to make the exclusion rest arbitrarily on a geograpl
line separating two cities of the same county with almost ide
tical kinds of medical service would, in the opinion of t
court, be a misuse of the rules of evidence and an unjustifial
emphasis on empty technicalities. Common knowledge, as w
as the testimony of the physicians on both sides, convinc
the court that the method used in treating the particular ki
of fracture involved in this case was one in use throughc
the world. And there was testimony to the effect that lo
prior practice in Los Angeles County, including Long Bea<
showed that there was no difference in the treatment in t
two communities. Both on principle and under the authorit:
the court was satisfied that the exclusion of the proffer
testimony was error.

An expert witness for the defendants testified that t
patient’s kg was suspended in a “Bohler fracture frame” a
that the witness had studied under Dr. Bolder and used 1
textbook and that his, the witness's, opinion was in part has
on the book. The plaintiff’s counsel then sought to crc
examine the witness by use of Dr. Bohler’s book, and t
trial court sustained objection to the impeaching questio
This was improper, the Supreme Court said, for the ri
against admission of such works as direct evidence is subji
to the qualification that textbooks relied on by an expi
witness may be used as a foundation for impeaching cr<
examination.

The defendant physicians contended that the original fi
defendants were sued as joint tort-feasors, or wrong-doers, a
that the agreement resulting in the dismissal of the c;
against the hospital and nurse destroyed the plaintiff’s cat
of action against the other two defendants. They undertc
to uphold the trial court's decision on the theory that 1
agreement constituted a release. But, said the Supreme Coe
the agreement was entitled “Covenant Not to Sue and Coi
nant Not to Sue Further." It recited that the named deft
dants desired “an agreement and covenant not to sue and
covenant not to sue them or either of them further” or pro;
cute “any suit or suits now pending against them.” It stal
that the plaintiff “promises and agrees that he will not :
and/or sue further” the said defendants and that he covenanl
and agreed to hold them harmless from any liability arisi
out of the accident or treatment. It concluded with the sta
ment that the plaintiff did not waive any claims against 1
other defendants. This instrument, the court said, was unra
takably intended to constitute a covenant not to sue. Unii
a release, a covenant not to sue one joint tort-feasor does i
relieve the others.

The judgment of the trial court directing a verdict for 1
defendants was therefore reversed.— Cm* v. Johnson (Cali]
SO P. (2d) 90; S6 P. (2d) 99.

1990

SOCIETY PROCEEDINGS

Jour. A. M. A.
Nov. 25, 1939

Accident Insurance: Death of Donor During Blood
Transfusion as Accidental Death. — The beneficiary obtained
a judgment in the United States district court for the Eastern
District of Virginia on a life insurance policy which provided
double indemnity benefits if the insured died by reason of bodily
injuries effected exclusively and wholly by external, violent and
accidental means. The insurer appealed to the United States
circuit court of appeals, fourth circuit.

A child of the insured was a patient in a hospital and was in
need of a blood transfusion. The insured, then 34 years of
age, finding that his blood was suitable, submitted himself for
the purpose. He went to the hospital and walked up three
flights of stairs to the operating room. The physician took his
blood pressure, examined his heart and found him to be normal.
The physician washed the insured’s arm with antiseptic, applied
a tourniquet and injected a needle into a vein, whereupon, before
a tablespoon of blood had been withdrawn, the insured died.
The undisputed evidence was that the insured was in good
health at the time, that the operation was performed according
to the customary and approved routine, that every act of the
physician and of the insured was voluntary and intentional and
that nothing unforeseen, unusual or accidental occurred in the
manner in which the operation was performed. In short,
although the death was a totally unexpected result, the acts
which preceded it were done with due care and with specific
intent. The physician who undertook to perform the transfusion
operation, according to the appellate court, was of the opinion
that “the death was caused by shock although he was not certain
that it was not caused by heart failure.”

The law of Virginia as declared by its legislature or by its
highest court is decisive in this case, said the federal court. In
Ocean Accident & Guarantee Corp. v. Glover, 165 Va. 283, 182
S. E. 221, the insured died from septicemia caused by an infec-
tion carried into the blood stream when he picked a pimple or
boil inside his no.ie with a knife or needle. The Supreme Court
of Appeals of Virginia in that case held that the death of the
insured was effected by accidental means within the coverage
clause of the policy involved. The decision was based on the
idea that the word “accidental” in the policy was used in the
ordinary and popular sense as meaning “happening by chance
or not according to the usual course of things” ; and since
septicemia was not the probable consequence of the insured’s
act, recovery under the policy was justified. In the present
case, the insurer contended that the only unexpected and
unlooked for circumstance was the result, that is, the sudden
death of the insured, whereas in the Glover case the means
whereby the injury and death of the insured was produced may
be fairly regarded as accidental because death followed the
totally unintended and unexpected introduction of a germ into
the body of the insured. To the circuit court of appeals, how-
ever, the distinction was not a valid one, because the insured in
the Glover case voluntarily exposed himself to the risk of infec-
tion involved in picking the boil with a sharp instrument.

The circuit court of appeals, therefore, on the strength of the
Glover case, agreed with the district court that the insured’s
death in this case was caused by bodily injuries effected exclu-
sively and wholly by external, violent and accidental means
within the meaning of the insurance policy, and the judgment
for the beneficiary was affirmed . — American Nat. Ins. Co. of
Galveston, Tex., v. Belch, 100 F. (2d) 48.

Malpractice: Negligence in Diagnosis of Hip Frac-
ture. — The appellee injured his right hip and the appellant
physician, after making a roentgen examination, diagnosed the
injury as an impacted complete fracture of the surgical neck of
the femur and treated it as such. The patient, however, con-
tinued for several years to have trouble with the hip and finally
consulted another physician, who discovered that the shaft had
slipped past the head of the femur for a distance of about
2 inches, resulting in only a fibrous union. The patient then
brought suit and obtained a judgment in the United States dis-
trict court, District of Idaho, eastern division, against the
physician who had first treated him, the appellant in this case,
the judgment being based principally on the finding that the
physician diagnosed and treated the injury as an impacted
fracture when the fracture was unimpacted. This judgment was
reversed by the United States circuit court of appeals, ninth

circuit, because in the opinion of the court there was not suf-
ficient evidence to warrant a submission to the jury of the
question of whether or not the physician was negligent in mak-
ing the diagnosis of impacted fracture . — Moore v. Trcmclling,
78 F. (2d) 821; abstr. J. A. M. A. 106 : 16S5 (May 9) 1936,

The case was tried a second time, the patient again obtained
a judgment and the physician again appealed to the United
States circuit court of appeals, ninth circuit.

The evidence was conflicting, said the court of appeals, as to
whether or not there was negligence in the diagnosis and treat-
ment of the fracture, but there was ample evidence on which to
submit that question to the jury. There was testimony by the
patient, his son and son-in-law, who were present at the time
of the examination of the patient by the physician, and testi-
mony by the patient’s daughter that his right foot everted, or
rolled over. On the other hand, the physician testified that the
foot did not evert or roll over but agreed with all the other
experts that if the foot did in fact evert the diagnosis should
have been that the fracture was unimpacted. There was testi-
mony that according to the standard of medical practice at
Paris, Idaho, several roentgenograms should have been taken
at once at different angles to determine the nature of the frac-
ture and that other roentgenograms should have been taken
later, one when the plaster cast was applied and another when
it was removed. The physician took only one roentgenogram
at the time of his diagnosis and none later. Expert evidence
was given that the amount of pain, of mobility and of crepitus,
if any, should have indicated to a practitioner of ordinary skill
whether or not the fracture was impacted. Another expert
witness testified that from his examination of the roentgeno-
gram taken by the appellant if the foot was rolled over or
everted the fracture was an unimpacted one. A roentgenologist
testified that in his opinion from an examination of the roent-
genogram taken by the appellant the fracture was unimpacted.
A physician who practiced in a locality similar to Paris, Idaho,
testified that from examination of a roentgenogram taken under
his supervision some two years after the injury the fracture
appeared to have been unimpacted. He testified that the recog-
nized practice in diagnosing an unimpacted fracture was to take
several roentgenograms, sometimes as many as three or four
views, and that it was necessary to use a great deal of care in
the manipulation of any injured hip, “until you have had your
pictures and know just what has happened.” With reference
to evidence tending to show that the result would have been
better had there been no negligence in treatment or diagnosis,
the court said there was definite testimony by expert witnesses
which justified the submission of the question to the jury.

After reviewing the entire record, the court of appeals could
find i*o prejudicial error in it and the judgment in favor of the
pati-int was affirmed . — Moore v. Trcmclling, 100 F. (2d) 39.

Society Proceedings

COMING MEETINGS

American Association for the Study of Neoplastic Diseases, Baltintorc,
Dec. 28-30. Dr. Eugene R. Whitmore, 2139 Wyoming Avenue
Washington, D. C., Secretary.

Imerican Society of Anesthetists, Los Angeles, Dec. 34. Dr. Paul at.

Wood, 745 Fifth Ave., New York, Secretary. .

tnnual Congress on Industrial Health. Chicago, Jan. 1 5-1 C. Dr. C. .

Peterson, 535 North Dearborn St., Chicago, Secretary,
eastern Section, American Laryngological, Rhinological and Utolo^ie. i
Society, Pittsburgh, Jan. 5. Dr. John R. Simpson, Medical Arts ismg-.
Pittsburgh. Chairman. ... . n,

diddle Section, American Laryngological, Rhinological and . Utolo^ca
Society, Kansas City, Mo., Jan. 19. Dr. Sam E. Roberts, Professional
Bldg., Kansas City, Mo., Chairman. _

tadiologic.nl Society of North America. Atlanta, G a., Jeft
Donald S. Childs, 607 Medical Arts Bldg., Syracuse, N. k-. , TT?'

society for the Study of Asthma and Allied Conditions, TMateW*.

Dec. 9. Dr. W. C. Spain, 116 East 53d St., New kork, Secretary,
iociety of American Bacteriologists New. Haven, Conn.. Dec. 28 -Ju. i
I. L. Baldwin, Agricultural Hall, Lmversity of \\ isconsin,

e Shia m i: iC c" M 0Si £: “ rir^P^o"

Bldg., Columbia, S. C., Chairman. - rjr F Alton

Southern Surgical Association, ^Augusta, Ga^ Dec. S-/.

Ochsner, 1430 Tulane Aye., JSew Orleans, Secretarj. ^ jj.

Yes tern Surgical Association, Los Angeles, Dec. la*lo. Dr.
Montgomery, 122 South Michigan B!vd. v Chicago, Secrc.arj.

Volume 113
Number 22

CURRENT MEDICAL LITERATURE

1991

Current Medical Literature

AMERICAN

The Association library lends periodicals to members of the Association
and to individual subscribers in continental United States and Canada
for a period of three days. Three journals may be borrowed at a time.
Periodicals are available from 1929 to date. Requests for issues of
earlier date cannot be filled. Requests should be accompanied by
stamps to cover postage (6 cents if one and 18 cents if three periodicals
are requested). Periodicals published by the American Medical Asso-
ciation are not available for lending but may be supplied on purchase
order. Reprints as a rule are the property of authors and can be
obtained for permanent possession only from them.

Titles marked with an asterisk (*) are abstracted below.

Annals of Internal Medicine, Lancaster, Pa.

13: 385-562 (Sept.) 1 939

Significance of Postprandial Glycosuria in Treatment of Diabetes Mel-
litus with Protamine Zinc Insulin. I. M. Rabinowitch, Montreal. —
p. 385.

Tamil)' Outbreak of Type V Pneumococcus Infections: Clinical, Bacteri-
ologic and Immunologic Studies. J. \V. Brown and M. Finland,
Boston. — p. 394.

Electrocardiographic Observations in Cardiac Surgery. H. Feil and P. L.
Rossman, Cleveland. — p. 402.

•Vitamin C Requirement in Rheumatoid Arthritis. M. G. Hall, R. C.

Darling and F. H. L. Taylor, Boston.— -p. 415.

Postoperative Progressive Exophthalmos with Low Basal Metabolic Rate.
S, Ginsburg, New York. — p. 424.

Occurrence and Clinical Significance of Hemoconcentration. V. H.
Moon, Philadelphia.— p. 451.

Bacteriology of Endocarditis: Report of Two Unusual Cases. M. S.
Shiling, Baltimore. — p. 476.

•Observations on Experimental and Clinical Use of Sulfapvridine: II.
Treatment of Pneumococcic Pneumonia with Sulfapyridine. P. H.
Long and W. B. Wood Jr., Baltimore. — p. 487.

Clinical Manifestations of Various Types of Right Sided Heart Failure
(Cor Pulmonale). I. C. Brill, Portlandi Ore. — p. 513.

Some Professional and Social Trends in American Medicine. I. Abell,
Louisville, Ky. — p. 523.

Ascorbic Acid Requirement in Rheumatoid Arthritis. —
Hall and his associates determined the ascorbic acid content of
the blood of fifty-six patients with rheumatoid arthritis as com-
pared with twelve normal individuals on a similar dietary regi-
men. Of the fifty-six patients fourteen showed an ascorbic acid
level in the plasma of 0.8 mg. or higher per hundred cubic
centimeters, which is within the accepted normal range. Nine
had values between 0.5 and 0.8, whereas thirty-three had levels
below 0.5 mg. Five of the patients who had plasma levels above
0.8 mg. had supplemented the hospital diet at the time of the
survey with sufficient citrus fruits or orange juice to account
for an additional daily intake of 80 mg. of ascorbic acid. Ten
of the twelve normal subjects had levels of ascorbic acid in
the blood plasma ranging between 0.9 and 2 mg. per hundred
cubic centimeters and two had values of 0.6 and 0.25 mg.
respectively. The patient with the lowest level of ascorbic acid
stated that he rarely ate fruits or uncooked vegetables included
in the diet. Studies on the requirements of an arthritic indi-
vidual for ascorbic acid showed that this was between 100 and
200 mg. daily or between two and four times that required by
a normal person. None of the arthritic patients showed symp-
toms associated with scurvy itself in spite of the fact that many
had ascorbic acid levels below that usually present in scurvy.
After eight months, during which time the patients were given
ascorbic acid daily and their blood was known to be saturated
with the vitamin, no clinical improvement which could be
attributed to the ingestion of the acid was observed. Some
patients improved during this period but others continued
unchanged or became worse as judged by the condition of their
joints, hemoglobin or failure to gain weight and slowing of the
erythrocyte sedimentation rate. No increase in the erythrocyte
count was found in any of the patients, although occasionally
sporadic but slight increases in the reticulocytes were observed.
The study indicates that the ordinary hospital diet was inade-
quate in its ascorbic acid content to supply the increased demands
of the rheumatoid arthritic patient and may lead to a general
revision of diets in institutions devoted to the care of this
disease.

Sulfapyridine for Pneumococcic Pneumonia. — From
July 1, 1938, until June 20, 1939, Long and Wood state that
139 adult patients were treated in the Johns Hopkins Hospital
tor presumptive pneumococcic pneumonia. Pneumococci, identi-

fied by specific antiserums, were obtained from the sputums of
124 of these patients and pneumococci were identified in the
sputum of five, but it was not possible to type the organisms
and from ten patients pneumococci were not isolated at any
time during the course of their illness. The fatality rate in the
139 cases was 7.2 per cent. This low death rate is attributed
by the authors to the use of antipneumococcus serum, sulfa-
pyridine and serum and sulfapyridine. Sulfapyridine is irregu-
larly absorbed from the gastrointestinal tract of human beings.
A relatively large fraction of the sulfapyridine absorbed may
be conjugated to acetylsulfapyridine. The soluble sodium salt
of sulfapyridine which may be given by the intravenous route
is a valuable adjunct in the treatment of severe pneumococcic
infections. If relapses of pneumonia are to be avoided, sulfa-
pyridine must be continued until convalescence is established.
Renal calculi, composed of acetylsulfapyridine, may form in the
urinary tracts of patients who are receiving sulfapyridine. The
abandonment of type specific serum in the treatment of pneu-
monia is not indicated in the light of the authors’ experience.

Annals of Otol., Rhinol. and Laryngology, St. Louis

48: 577-864 (Sept.) 1939

Care of Mastoid Wounds Following Complete Mastoid Operation, Sirius
Thrombosis and Operations on Petrous Pyramid. M. F. Jones, New
York. — p. 579.

Care of Mastoid Wounds Following Radical and Modified Radical Mastoid
Operations. J. M. Smith, New York. — p. S85.

Care of Mastoid Wounds Following Operations on Abscess of the Brain.
H. G. Tobey, Boston. — p. 590.

Note on Greater Disability for Hearing High Tones in Cases of Conduc-
tion Deafness. A. G. Pohlman, Los Angeles. — p. 596.

Nasal Obstruction Caused by Collapse of Nasal Alas. H. I. Lillie and
K. M. Simonton, Rochester, Minn. — p. 600.

Eighth Nerve High Tone Deafness from Nutritional Standpoint: Further
Contribution. G. Selfridge, San Francisco. — p. 608.

Method of Closing Antro-Alveolar Fistulas. Rea E. Ashley, San Fran-
cisco. — p. 632.

Management of Cicatricial Stenosis of Larynx. J. H. Foster, Houston,
Texas. — p. 643.

Benign Cysts of Antrum. G. Hardy, St. Louis. — p. 649.

•Hearing Acuity and Stammering. M. Arline Harms and J. Y. Malone,
Milwaukee. — p. 658.

Latent Period of Crossed Stapedius Reflex in Man. H. E. Perlman and
T. J. Case, Chicago. — p. 663.

Syphilis of Ear: Histopathologic Study. V. Goodhill, Los Angeles. —
p. 676.

Some Phases of Tuberculosis of Larynx. M. C. Myerson, New York. —
p. 707.

Pyogenic Mediastinal Infections: Their Significance of Otorhinolaryn-
gologist. A. Ochsner and M. DeBakey, New Orleans. — p. 747.
Sinusitis: Present Rationale of Treatment. C. T. Porter, Boston. —
p. 769.

Hearing Acuity and Stammering. — Harms and Malone
point out that speech defects in pupils of elementary grades
have been estimated by different investigators to be from 4 to
18 per cent, which percentage would mean that at least a
million children have defective speech. Thus they outnumber
the crippled, blind and deaf combined. It is estimated that
10 per cent of those with defective speech are stammerers. Speech
is a social habit developed through imitation. This involves not
only the mental motor mechanism but also the proper receiving
mechanism. Therefore defective hearing is a legitimate cause
for defective speech, especially if this defective bearing occurs
during the ages when speech habits are being formed. As
stammering is a type of speech defect, whatever principles apply
to speech correction apply to stammering correction. In addi-
tion, the stammerer has some individual problems. The literature
reveals no investigations to relate hearing acuity to stammering,
although there is frequent reference made to the relation of the
hearing acuity and certain types of speech defects. The greatest
toll in hearing loss is taken by childhood diseases which occur
during the first seven to eight .rears of life. The greatest good
can be accomplished during these years. It is the authors’
opinion that the hearing acuity of all school children should be
tested by the end of their first year at school and that these
tests are just as important as visual acuity tests. This testing
should be done with audiometers, as investigators have found
that examinations carried out by parents, school teachers and
nurses miss the majority of these hard-of-hearing children. A
national survey of all the schools for the deaf and hard of
hearing have shown the authors that stammering is rare in those
with a total loss of hearing. It becomes more frequent in those

1992

CURRENT MEDICAL LITERATURE

Jour. A. M. A.
Nov. 25, 1939

with approximately 50 per cent loss of hearing. In sixty-two
consecutive cases of stammerers who were unaware of any
hearing loss there was a loss of from 10 to 22 per cent, which
strongly suggests a relation between hearing loss and the
development of stammering. Cases are cited of former normal
hearing and speech in which subsequent disease resulted in poor
hearing and was followed by stammering. Also a case is pre-
sented showing stammering on words falling within the island
defect of hearing acuity. Hearing aids should be used for
speech correction in these cases if the hearing cannot be
improved to a useful level.

Archives of Neurology and Psychiatry, Chicago

42: 595-788 (Oct.) 1939

Pathologic Laughing and Crying. C. Davison and H. Kelman, New
York. — p. 595.

Treatment of Schizophrenia with Glandular Extracts. S. Fischer, San
Francisco. — p. 044.

^Capillary Structure in Patients with Schizophrenia. D. M. Olkon,
Chicago. — p. 652.

Lesions of Fundus Associated with Brain Hemorrhage. L. L. Tureen,
St. Louis, — p. 664.

Cerebral Changes in Fatal Cases Following Treatment with Barbital,
Soluble Barbital U. S. P., Insulin and Metrazol. G. B. Hassin,
Chicago. — p. 679.

Histopathologic Changes in Brain Following Experimental Injections of
Metrazol. E. Liebert and A. Weil, Chicago. — p. 690.

*Mode of Action of Brilliant Vital Red in Epilepsy. R. B. Aird, San
Francisco. — p. 700.

Skin and Body Temperatures of Schizophrenic and Normal Subjects
Under Varying Environmental Conditions. H. Freeman, Worcester,
Mass. — p. 724.

Central Visual System: Evidence Against Bilateral Representation
Through Splenium of Corpus Callosum. O. R. Hyndman, Iowa City.
— p. 735.

Capillary Structure in Schizophrenia. — The character of
the cutaneous capillary structure of 1,100 schizophrenic persons
was studied by Olkon and compared with that of normal per-
sons. In cases of schizophrenia the cutaneous capillaries showed
striking deviations, consisting of reduction in number, few comma
shapes, a paler color, lack of uniformity in size and a variety
of bizarre shapes — spiral, crescent, hairpin-like and stellate forms
and dilated, ameboid forms with pseudopodia. Moreover, the
flow through the capillaries was seldom uniform ; at times it
was more rapid and at times slower than normal ; at other times
the contractions and dilatations were remarkably irregular.
Another striking feature was the frequent occurrence of capillary
hemorrhage among excited schizophrenic patients. In cases of
hebephrenia of long standing, sparseness of capillaries was the
most marked feature aside from the bizarre shapes already men-
tioned. Schizophrenic patients showed these changes, whereas
normal persons of similar age did not. From the observations
it is clear that in organic and vegetative derangements there are
definite disturbances in the capillaries which may be corrobora-
tive evidence for the increasingly accepted theory that schizo-
phrenia is a vegetative and metabolic disorder.

Brilliant Vital Red in Epilepsy. — Aird states that of six
patients suffering from severe and varied forms of epilepsy,
chosen because they had failed to respond to any accepted type
of treatment, five, after intravenous injection of brilliant vital
red, showed from slight to marked improvement in the fre-
quency of the attacks, and the attacks of all six were reduced
in duration and severity. The improvement lasted from four
to seven months. Thus, as in the experimental work, the
observations of Cobb and his co-workers were confirmed, an
abstract of whose article appears in Thc Journal, Feb. 4,
1939, page 472. The author’s conclusions are that the endo-
thelium concerned with the formation of cerebrospinal fluid
forms an effective protective barrier to the central nervous sys-
tem. In animals with experimental epilepsy, brilliant vital red
renders this “barrier” relatively impermeable to the passage
of cocaine hydrochloride. The same effect presumably holds for
the other convulsive agents (picrotoxin, strychnine, camphor and
triphenylphosphite) tested in connection with brilliant vital red.
As brilliant vital red affords protection in cases of human
epilepsy, this fact affords strong evidence in support of the
hypothesis that “convulsive toxins” and the endothelium of the
hemato-enccphalic barrier are factors of etiologic importance in
human epilepsy and that the relation between them is analogous
to that demonstrated in experimental epilepsy.

Archives of Ophthalmology, Chicago

22: 533-726 (Oct.) 1939

T he Problem of Etiology of Trachoma: I. Rickettsia. A. de Rotth
Chicago. — p. 533.

Meningioma Producing Unilateral Exophthalmos: Syndrome of Tumor
r ,f, ter 2 on . aI P,ac l ue Arising from Outer Third of Sphenoid RitW.
J. W. Smith, New York. — p. 540.

Susruta and His Ophthalmic Operations. N. K. Bidyadhar, Sonnur
State, Sonpur Raj, India. — p. 550.

Adrenal Neuroblastoma, with Particular Reference to Metastasis to Orbit-
Report of Case and Notes on Two Other Cases. \V. C. Clark, Ann
Arbor, Mich. — p. 575.

* Experience with Sulfanilamide in Treatment of Gonorrheal Ophthalmia.
F. A. Barbour and H. A. Towsley, Ann Arbor, Mich.— p. 581.
Ocular Ichthyosis: Report of Case. F. C. Cordes and M. J. Hogan,
San Francisco. — p. 590.

*Dark Adaptation, Night Blindness and Glaucoma. J. B. Feldman, Phila-
delphia. — p. 595.

Clinical Study of Transillumination of Eyelids. E. H. Wood, Auburn,
N. Y. — p. 608.

Induced Size Effect: III. Study of Phenomenon as Influenced by
Horizontal Disparity of Fusion Contours. K. N. Ogle, Hanover,
N. H. — p. 613.

Attachment to the Ferree-Rand Perimeter for Determining Light and
Color Minimums. C. E. Ferree and G. Rand, Baltimore. — p. 636.
Study of Transillumination of the Eye. E. H. Wood, Auburn, N. Y.
— p. 653.

Sulfanilamide for Gonorrheal Ophthalmia. — Barbour and
Towsley compare the results obtained in fifteen cases of gonor-
rheal ophthalmia treated with sulfanilamide with those obtained
among fifteen similar patients treated before the drug was used
at the University Hospital. In only one of the fifteen cases in
which sulfanilamide was used did corneal ulcers develop after
treatment with it was started. These remained superficial and
healed rapidly with only tiny residual nebulas. Since of the
fifty-five cases summarized from the literature there were none
in which significant visual loss occurred after the administration
of sulfanilamide was started, this makes a total of seventy cases
in which serious corneal complications did not occur. Corneal
ulcers developed in five of the fifteen cases in the control group
after treatment was started. In two of these control cases
(both in infants) useful vision was lost in both eyes. Since
each corneal ulcer indicates a potentially blind eye, the decreased
incidence of this complication with sulfanilamide therapy is an
important economic and sociologic factor. The clinical improve-
ment noted after the administration of sulfanilamide was started
was frequently dramatic in its rapidity. No recurrence of dis-
charge was noted in the group of cases in which sulfanilamide
was used. Of the fifty-five cases reviewed, inconsequential recur-
rence of discharge occurred in only one of those in which treat-
ment was adequate. In two cases the drug was temporarily
discontinued in one because of toxicity, causing a hemolytic
anemia (Willis) ; in both there was a moderately severe recur-
rence of discharge. The hemolytic anemia readily responded to
transfusion, and the drug was again given with satisfactory
results. Smears once negative remained negative in the authors
series and in those which they review from the literature. I 11
no case in either group was there a persistent positive smear
after the discharge had ceased. In one of the control cases
positive smears were obtained fifteen days after the discharge
had ceased. Mayou pointed out that virulent gonococci have
been found twenty-eight days after all discharge had stopped.
This point is significant from the standpoint of cross infection
and reinfection. The average duration of the disease in the con-
trol group after treatment was begun was almost four times as
long as in the group in which sulfanilamide was used. It took
approximately four times as long for the discharge to become
minimal in the control group. This means a substantial saving
in the cost of hospitalization.

Dark Adaptation, Night Blindness and Glaucoma —
Feldman attempted to determine the causes, if any, of idiopathic
night blindness, i. e. night blindness without any known account-
able constitutional disease, and what relation, if any, there > s
between pathologic dark adaptation and night blindness. As
glaucoma in the majority of case's is associated with pathologic
dark adaptation, an attempt was made to correlate thc frequenc)
of night blindness in this condition. The study calls attention
to the presence, but the none too frequent association, of mg 1
blindness in patients suffering with renal calculi and glandu M
and hepatic diseases. Night blindness is, however, frequent )
encountered in association with dietary indiscretions in wine '
there js a definite lack of vitamin A in thc food. In these ca.-t’
the cure is effected in a reasonable period. However, crcn m

Volume 113
Number 22

CURRENT MEDICAL LITERATURE

1993

these cases the treatment may sometimes have to be prolonged
before night blindness is overcome. Night blindness does not
bear any relation to the intensity of pathologic dark adaptation.
Thus, for example, many patients with hepatic disease whose
dark adaptation curve almost approaches that of persons, with
pigmented retinitis do not necessarily have night blindness. It
is important to determine whether the supposed night blindness
from which a person suffers is not presbyopia instead. A high
cholesterol content of the blood was observed in eight of the
fourteen cases of glaucoma studied. Only with the examina-
tion of a large number of persons with beginning uncomplicated
glaucoma who have not been operated on can it be determined
whether or not defective sterol metabolism plays any part in
the cause or the effect of the disease. It is possible that patho-
logic dark adaptation may be found of value as an indication in
evaluating a phase of faulty metabolism of the liver.

Illinois Medical Journal, Chicago

70: 201-300 (Sept.) 1939

Acute Appendicitis with Perforative Peritonitis. K. A. Meyer, P. A.

Rosi, A. Lueck and M. Todd, Chicago. — p. 221.

Tuberculous Enterocolitis: Diagnostic Data. L. L. Hardt, M. Weiss-
man, C. E. Cook and C. L. Martin, Chicago. — p. 229.

Plastic and Reconstructive Surgery About the Face and Head — Then
and Now. J. C. Beck, Chicago. — p. 237.

Traumatic Psychoses. H. H. Goldstein, Chicago. — p. 242.

Psychotic Reaction Following Trauma. D. L. Steinberg, Elgin. — p. 246.
# Schizophrenic-Iike Psychosis Following Head Injuries. E. B. Shapiro,
Elgin. — p. 250.

Acute Suppurative Otitis Media and Mastoiditis. M. A. Glatt,
Chicago. — p. 254.

Clinical Roentgcnographic Aspects of Petrositis. S. M. Morwitz,
Chicago — p. 258.

Interdependence of a Public Child Health Program to the Practice of
Obstetrics and Pediatrics Elizabeth B. Ball, Springfield. — p. 265.
Pregnancy in Double Uterus. M. P. Rogers and B. H. Blocksom, Jr.,
Rockford. — p. 270.

Psychoses in Children. E. I. Falstein, Chicago. — p. 271.

Carcinoma of Rectosigmoid in Patient 26 Years of Age; Six Year
Cure Following Abdominal Resection. G. V. Pontius and E. L.
Strohl, Chicago. — -p. 281.

Effects of Smoking. J. R. Head, Chicago. — p. 283.

Sonic Effects of Injection of Pitressin in Dementia Praecox. I.

Finkelman, Chicago, and A. Simon, Elgin. — -p. 287.

Endemic Typhus Fever. S. J. Lang and P. K. Boyer, Evanston. —

p. 288.

Practical Significance of Gross Rectal Bleeding. M. Diamond, Chicago.
— p. 290.

Schizophrenoid Psychosis Following Head Injuries. —
Shapiro found that of 2,000 cases of dementia praecox twenty-
one showed a relationship between trauma and the onset of
psychotic symptoms. In ten cases there was no evidence of
brain injury, but the mental symptoms developed in such a close
time relationship to a severe head trauma that the sequence of
events cannot be disregarded. The patients were all of intro-
, verted personalities and had marked hereditary tainting, so that
, the possibility of schizophrenic-like reaction was present. As a
result of the injury, this latent tendency became overt and the
' P lychosis which followed the trauma was that of a so-called
schizophrenia. The author concludes that in this group the
, trauma acted simply as a precipitating factor. In the other
eleven cases evidence of brain damage was present. Confusion,
dizziness, defects in memory and orientation, as well as persis-
tent headaches with irritability do not belong commonly in a
schizophrenic-like picture. Furthermore, in seven of these cases
' the prepsychotic personality was well integrated and hereditary
' tainting was present in only two. The neurologic changes, the
mixture of organic-like mental symptoms ar.d the absence of
any predisposing factors in the history suggest that in these
cases the trauma did more than precipitate a psychotic reaction.
■ In producing pathologic changes in the brain, the injury would
' seem to have contributed to the formation of the clinical picture.
' Although postmortem studies are as yet not available in this
- group, the development of a parkinsonian-like syndrome in one
case and evidence of hemiplegia and convulsions in another
' suggests localized cerebral damage. In evaluating the part that
: trauma plays in the schizophrenic-like picture, the personality
•as a whole should be considered. In all cases of so-called
schizophrenia one should consider whether the psychosis is not
•attributable to some definite etiologic factor, such as trauma,
•infection or tumor. The need is in the exact evaluation of all
'mental symptoms, so that these patients (trauma) may be dif-
ferentiated from tlie so-called schizophrenia in which no traceable
'etiologic factor occurs.

Journal of Allergy, St. Louis

10: 513-642 (Sept.) 1939

Electrophoretic Separation of Antibody from Human Allergic Serum.
J. M. Newell, A. Sterling, M. F. Oxman, S. S. Burden and Laura E.
Krejci, Philadelphia. — p. 513.

Assay of Ragweed Pollen Extracts. C. E. Arbesman, Baltimore, and
H, Eagle, Washington, D. C. — p. 521.

Immunologic Relationship of Giant, Western, Common Ragweed and
Marsh Elder (Iva Ciliata). H. E. Prince and P. G. Secrest Jr.,
Houston, Texas. — p. 537.

Highly Concentrated Pollen Extracts and Their Deterioration in Various
Mediums. C. J. Sullivan, St. Louis, and W. T. Vaughan, Richmond,
Va. — p. 551.

•Further Observations on Nature of House Dust Antigen. M. B. Cohen,
S. Cohen and K. Hawver, Cleveland. — p. 561.

Local Hemorrhagic-Necrotic Skin Reactions in Man (Shwartzman
Phenomenon). J. Harkavy and A. Romanoff, Ne\v York. — p. 566.

Oral Ragweed Pollen Therapy. M. Zeller, Chicago. — p. 579. -

Epinephrine in Oil: Its Effect in Symptomatic Treatment of Hay
Fever. E. L. Keeney, Baltimore. — p. 590.

Prophylaxis and Treatment of Poison Ivy Dermatitis with an Extract
of Rhus Toxicodendron. L. Zisserman and L. Birch, Philadelphia.—
p. 596.

House Dust Antigen. — The Cohens and Hawver find that
a dialyzed extract from a suitable sample of linters will give
nonspecific reactions in normal and in allergic individuals when
judged by the results of passive transfer experiments as well
as by direct endermal tests. However, a one plus or larger
endermal reaction with a 1 : 50 dilution of such an extract will
be present in more than 90 per cent of individuals clinically
sensitive to dust, and consistently negative controls are obtained
in normal persons and in allergic persons not sensitive to dust.
Guinea pigs can be sensitized and shocked with this linters
extract. The active principle in this extract cannot be cotton-
seed or any of the contaminants ordinarily present in house
dust extracts prepared from dust obtained from vacuum cleaners.

Journal of Aviation Medicine, St. Paul

10:113-158 (Sept) 1939

An Instrument for Testing Pilot Fitness. C. E. Ferree and G. Rand,
Baltimore. — p. 114.

Personality Reactions in a Group of Military Airplane Pilots, with Spe-
cial Reference to Behavior to Alcohol. P. G. Hamlin, Cambridge, Md
— p. 129.

Journal of Experimental Medicine, New York

70: 333-442 (Oct.) 1939. Partial Index

Reticulo-Endothelial System and Hormone Refractoriness, A. S. Gordon,
W. Kleinberg and H. A. Charippcr, New York: — p. 333.'

Virulence of Group C Hemolytic Streptococci of Animal Origin* C. V.
Seastone, Princeton, N. J. — p. 361.

Estimation of Purity of Preparations of Elementary Bodies’ of Vaccinia.
J. E. S mad el, T. M. Rivers and E. G. Pickels, New York. — p. 379,

. Specificity of Keratin Derivatives. L. Pillemer, E. E. Ecker and E. W.
Martiensen, Cleveland. — p. 387.

Experiments on Histamine as Chemical Mediator for Cutaneous Pain.
S. R. Rosenthal and D. Minard, Chicago. — p. 415.

Journal Industrial Hygiene & Toxicology, Baltimore

31: 231-320 (Sept.) 1939

Dupuytren's Contraction as Occupational Disease. L. Tcleky, Vienna,
Germany. — p. 233.

Acute and Subacute Toxicity of Morpholine. T. E. Shea Jr., Phila-
delphia. — p. 236.

Coding of Occupations for Machine Tabulating Purposes with Reference
Principally to Studies on Occupational Morbidity. H. E. Seifert,
Washington, D. C.— p, 246,

Vapor Pressure Method for Estimation of Volatile Solvents. C. E.
Couchman and W. H. Schulze, Baltimore. — p. 256.

Vapor Pressure Method for Determination of Concentration of Some
Organic Solvents in Air. K. Kay, G. M. Reece and P. Drinker,
Boston. — p. 264.

New Vapor Pressure Instrument for Determining Organic Solvents in
Air. L. Silverman, G. M. Reece and P. Drinker, Boston. — p. 270.
•Survey in Seventeen Cement Plants of Atmospheric Dusts and Their
Effects on Lungs of 2,200 Employees. L. U. Gardner, T. M. Durkan,
D. M. Brumfiel and H. L. Sampson, Saranac Lake, N. Y. — p. 279.

Effects on Lungs of Cement Dusts.— Gardner and his
associates made an engineering survey of environmental con-
ditions in a representative group of cement plants in various
sections of the United States. The purpose of the survey was
to determine the quantity and nature of the dust in the air and
its effect on the lungs of the employees. Technical obstacles
•prevented exact determination of the proportion of atmospheric
silica present in the air in the earlier phases of manufacturing;
nevertheless much of the silica was too -coarse to create danger.
Modern preventive measures as -well as intermittent.cxposures

1994

CURRENT MEDICAL LITERATURE

in some of the departments likewise decreased exposure. Fin-
ished cement dust was found present in relatively high con-
centrations in the finishing mills and packing departments but
this dust was practically devoid of free silica. Complete physi-
cal and x-ray examinations were made on 2,278 employees of
eleven plants, 1,979 of whom worked in departments where
they were exposed to dust of various kinds. The majority
were white American men of slightly greater age distribution
than in most industries. More than 55 per cent of the exposed

employees had worked in the cement industry for more than

ten years and 32 per cent for more than fifteen. Eighteen

employees had worked for more than forty-five years. Since

so many of them worked in several departments, an exact cor-
relation between exposure to the dusts of different compositions
and the pulmonary conditions was not possible. Analysis dis-
closed that prolonged inhalation of finished cement dust produced
such slight anatomic reactions that practically no abnormality
was seen in the roentgenograms. The mixed dusts of the raw
mills were probably responsible for a limited number of well
marked linear exaggerations, nondisabling in character. Only
eight of the examined employees showed evidence of nodular
fibrosis attributable to dust. In six of these cases exposure to
silica dust in previous employment was probably responsible,
while the other two were exposed to sandstone dust in special
operations not typical of raw mill atmosphere. The occurrence
of tuberculosis and chronic infections of the lungs was found to
be less frequent than among the general population. The mani-
festations of tuberculosis occurred in typical form and at the
same age periods as in persons not exposed to dust by occupa-
tion. It was concluded therefore that prolonged inhalation of
cement dust has no unfavorable influence on susceptibility to
tuberculous infection or its subsequent evolution.

Journal-Lancet, Minneapolis

59: 367-4X8 (Sept.) 1939

Report of Committee on Organization and Administration, American
Student Health Association. Helen B. Pryor, Palo Alto, Calif.—
P. 377.

Hyperimmune Human Serum in Prophylaxis and Treatment of Pertussis.

P. F. Dwan and E. S. Platou, Minneapolis. — p. 379.

Further Observations on Allergy to Smuts. F. \V. Wittich, Minne-
apolis. — p. 382.

Infectious Equine Encephalomyelitis. C. E. Cotton, St. Paul. — p. 388.
•Comparative Energy Expenditures and Time Required for Digestion of
Homogenized or Pureed Vegetables in Human Stomach, J. A. Killian
and C. Oclassen, New York. — p. 395.

Adsorptive Power of Animal Charcoal for Toxic Principle of Tuber-
culin: Preliminary Report. II. P. Snyder, Baltimore. — p. 400.
Influence of Prolonged Administration of High Dosages of Vitamin D
on Serum Calcium of Adults. R. T. Farley, Chicago. — p. 401.

Digestion Time of Homogenized or Pureed Vegetables.
— Killian and Oclassen determined the advantages and limita-
tions of homogenized fruit and vegetables as supplements to
the smooth or bland diet for the treatment of patients with
functional disturbances of the gastrointestinal tract. The com-
parative energy expenditures and the times required for diges-
tion of homogenized and of pureed vegetables in the stomachs
of average normal adults and of ambulatory patients with
chronic peptic ulcers were studied. According to McLester,
these patients require adequate nutrition but at the same time
rest, both motor and secretory, for the stomach. Observations
are reported on three average normal adults and eight adults
with histories of chronic peptic ulcers, confirmed by x-ray
examinations before the rates of the digestion of vegetables were
determined. In four comparative tests made on the three normal
subjects, the average emptying time of the stomach after meals
of homogenized vegetables was 43 per cent less than the average
emptying time of the stomach after meals of strained vegetables.
The average energy expense for gastric digestion of homogenized
vegetables, determined in four experiments, was 10 per cent of
the fuel value of the vegetables and for digestion of the strained
vegetables it was 30 per cent of their fuel values. Gastric
evacuation times for homogenized vegetables were less than those
for strained or pureed vegetables in six of the eight cases of
chronic peptic ulcer. The greatest differences in gastric empty-
ing times for the two forms of vegetables were observed in
cases showing pyloric stenosis or retarded gastric motility. The
average gastric evacuation time for 300 Gm. of homogenized
vegetables was three and a half hours and for 300 Gm. of
pureed vegetables it was more than five hours.

Jour. A. M. A.
Nov. 25, 1939

Journal of Nutrition, Philadelphia

16:217-318 (Sept.) 1939. Partial Index
Calcium Content of White Bread. IV. W. Prouty and W. H. Cathcart
Chicago. — p. 217.

Oxalic Acid in Foods and Its Behavior and Fate in the Diet. E F
Kohman, Camden, N. J. — p. 233.

Distribution of Chick Antidermatitis Factor (Pantothenic Acid) in
Meats and Meat Products. H. A. Waisman, O. Mickelscn and C. A.
Elvehjem, Madison, Wis. — p. 247.

Approximation of Calculated to Determined Calcium Content of Human
• Dietaries. A. B. Gutman and Margaret Low, New York. — p. 257.
Rat Growth Factors of Filtrate Fraction of Liver Extracts. G. II.
Hitchings and Y. Subbarow, Boston. — p. 265.

•Effect of Phosphorus on Biologic Estimation of Vitamin D Activity.

B. O’Brien and K. Morgareiage, Rochester, N. Y. — p. 277.

Food of Present Day Navajo Indians of New Mexico and Arizona.
T. M. Carpenter and M. Steggerda. — p. 297.

Phosphorus and Vitamin D Activity.— O’Brien and Mor-
gareidge observed, under conditions commonly employed for
the biologic estimations of vitamin D, that phosphorus added
to the vitamin supplement greatly enhances its apparent potency.
The equivalent healing is found to be proportional to the
product of the vitamin by the phosphorus fed to the rat. For
example, 4 mg. of phosphorus daily for eight days (as sodium
glycerophosphate) enhances the potency of crystalline vitamin
D- by 3.4 times. Phosphorus containing compounds do not
all possess the same enhancement factor. The significance of
this relationship in the estimation of the antirachitic potency
of phosphorus containing foods (such as milk) is pointed out.

Medicine, Baltimore

IS: 221-430 (Sept.) 1939

^Pyelonephritis: Its Relation to Vascular Lesions and to Arterial Hyper-
tension. S. Weiss and F. Parker Jr., Boston. — p. 221.

Diffuse Arteriolar Disease with Hypertension and Associated Retinal
Lesions. H. P. Wagener and N. M. Keith, Rochester, Minn. — p. 317.

Pyelonephritis. — Weiss and Parker summarize the clinical
and morphologic features of 100 cases of pyelonephritis in
various stages of the disease and report on certain heretofore
not well recognized aspects of the disease. Focal pyelonephritis
of no clinical significance was not studied. Pyelitis practically
never exists unaccompanied by pyelonephritis. Clinically a dis-
tinct classification of pyelonephritis as acute, chronic (active),
healed or healed and recurrent is often difficult. The structural
characteristics of pyelonephritis are essentially the same regard-
less of the type of infection. In all types (hematogenous, uroge-
nous or lymphatic) marked changes occur in the renal lymphatic
system as well as in the nephrons. In chronic and healed pyelo-
nephritis the main morphologic characteristics consist of inflam-
matory reaction of the interstitial tissues ; colloid casts in the
tubules, which are lined with atrophic epithelium; periglomer-
ular fibrosis, and evidence of infection or inflammation within
the tubules. Pyelonephritis, particularly in the chronic and the
healed stages, is often associated with arterial hypertension.
The hypertension of pyelonephritis is often severe and is fre-
quently accompanied by nervous symptoms, cerebral encepha-
lopathy, neuroretinitis and high cerebrospinal pressure, and
toxemia in pregnancy. The syndrome of left ventricular failure
with attacks of cardiac asthma was observed frequently. The
hypertension of pyelonephritis can be independent of the activity
of renal infection. It often advances when the disease is in the
healed stage. Vascular changes occur frequently in pyelo-
nephritis, particularly during the chronic and the healed stages.

A relation was found between the severity and diffusencss of
the vascular lesions and arterial hypertension. Cases of severe
hypertension showed advanced hyperplastic arteriolosclcrosis, a
certain type of productive endarteritis and necrotizing artcrio-
litis. The correlation between vascular changes and hyperten-
sion was close. Vascular changes and hypertension did not
occur in the group of cases of renal tuberculosis and hydro-
nephrosis uncomplicated by pyelonephritis. It appears that t ic
inflammatory renal process and the intravascular pressure arc
responsible for the arterial lesions. In unilateral pyelonephritis,
particularly without severe hypertension, the vascular lesions
are confined to the affected side. Unilateral pyelonephritis with
advanced vascular changes may or may not he associated with
hypertension. It is estimated that pyelonephritis is responsible
for at least 15 to 20 per cent of malignant hypertension. 1 he
vascular lesions in chronic pyelonephritis are restricted mainly

Vou ntE 113
Number 22

CURRENT MEDICAL LITERATURE

199 5

to tile kidneys, in contrast to those in “primary” malignant
hypertension, which arc generalized. Polycystic kidneys, hydro-
nephrosis and renal tuberculosis were often complicated by
pyelonephritis. Glomerulonephritis and pyelonephritis seldom
coexisted. Alterative glomcrulitis was found in cases with ter-
minal uremia. Pyelonephritis in the chronic and the healed
stages should be considered as one type of Bright’s disease. The
vascular and the renal functional damage are related to the
same cause but they may be independent of each other. Chronic
and healed pyelonephritis occurs more frequently than chronic
glomerulonephritis. Pyelonephritis is one renal disease which
can be treated effectively in its incipient stage.

New England Journal of Medicine, Boston

321 i 445-480 (Sept. 21) 1939

# Early Recurrence of Sul fa pyridine -Treated Type I Pneumococcus Pneu-
monia. M. Hamburger Jr. and J. M. Rttegsegger, Cincinnati. — p. 445.
Role of Personality in Certain Hypertensive States. T. A. C. Rennie,

Baltimore. — p. 44S.

Need for Cooperation Between Gcnito-Urinary and Orthopedic Surgeons.

C. J. E. Kickham, Boston. — p. 456.

Pharmacology. G. P. Grabficld, Boston. — p. 464.

Recurrence of Sulfapyridine-Treated Type I Pneu-
monia. — Hamburger and Ruegsegger report the recurrence of
type I pneumonia two weeks after apparent recovery following
treatment with sulfapyridine. The authors point out that this
recurrence is the more unusual as it is the only one to have
occurred in the Cincinnati General Hospital in the last three
years. During that time more than 1,200 cases of typed pneumo-
coccic pneumonia have been observed. In the case presented
the strain of pneumococcus was manifestly sensitive to the action
of sulfapyridine, but the defensive forces of the body were pre-
sumably not able to bring about the death of all the pneumococci
present. The authors have no data that would help to decide
whether the organisms remained in the lung, the throat or else-
where, nor can a new extrinsic infection be absolutely ruled out.
However, convalescence took place in a ward in which there
had been no other type I patients and in which the patient
himself bad not been present during his first attack. Data also
are lacking concerning the mechanism of recovery from the first
attack of pneumonia, but no agglutinins could be demonstrated
in the patient’s serum after recovery from the second attack.
Empyema followed recovery from the second attack, but sulfa-
pyridine was unable to sterilize the pleural cavity even when
the exudate was relatively thin. X-ray and physical examina-
tions indicate that little if any of the same pulmonary tissue was
involved in both attacks. Further data on sulfapyridine-treated
patients is necessary to determine whether the incidence of recur-
rences of pneumonia by the homologous type pneumococcus is
greater in these than in serum-treated patients or in those who
recover spontaneously.

221:481-514 (Sept. 2S) 1939

-Indications for Surgical Ligation of Patent Ductus Arteriosus. J. P.

Hubbard, P, W. Emerson and H. Green, Boston. — p. 481.

Surgical Aspects of Obstructive Jaundice. R. Zollinger and A. Y.

Kevorkian, Boston. — p. 486.

Treatment of Alcoholism. M. Moore, Boston. — p. 4S9.

Treatment of Fractures. G. IV, Van G order, Boston, — p. 494.

Indications for Ligation of Patent Ductus Arteriosus.
— Hubbard and his associates show that in evaluating the indi-
cations for the surgical treatment of ductus arteriosus many
questions arise concerning the prognosis and the complications
of this cardiac malformation. The two complications of greatest
importance are subacute bacterial endarteritis and congestive
failure. The authors conclude that any patient with a diagnosis
of patent ductus arteriosus should be carefully studied to deter-
mine whether or not there is an arteriovenous shunt large enough
to impair the normal cardiac function and the peripheral cir-
culation. The evidence to be looked for is a delay in the growth
and development of the child, symptoms of cardiac insufficiency
and, more specifically, the signs of free aortic regurgitation,
congestion or pulsation of the pulmonary vessels at the hilus
of the lung as seen by x-ray examination. Once these symptoms
have been established, surgical intervention should be considered
in the hope of abolishing the excessive load on the heart, restor-
ing normal circulation, allowing normal growth and eliminating
the danger of heart failure. With regard to the possibility of
preventing subacute bacterial endarteritis, the situation is uncer-

tain. It will be necessary to observe the successfully treated
cases for years before it can be said with conviction that this
danger has been removed. If a ligated ductus does remain free
of vegetations and if the surgical risk remains as low as now
seems possible, it would then, and only then, appear permissible
to operate with the expectation of preventing this fatal com-
plication. The optimal age would seem to be in childhood before
the second decade, when the incidence of subacute bacterial
endarteritis increases, and after the period of infancy. In infancy
there is little or no chance of developing this complication and,
furthermore, the diagnosis is usually difficult. Two of the
cardinal signs of a patent ductus arteriosus, the thrill and
characteristic loud continuous murmur, are apt not to be found.
In any event a great deal will depend on the surgeon’s ability
to maintain a low operative risk. The authors think that, until
more is known of the operative mortality and the future of the
cases already treated, surgical intervention should not be recom-
mended for all patients with a patent ductus arteriosus but should
be limited to those showing evidence of circulatory embarrass-
ment.

Public Health Reports, Washington, D. C.

54: 1709-1746 (Sept. 22) 1939

Procedure for Putting Health Department Reports to Work. M. Derry-
berry and J. O. Dean. — p. 1709.

Experimental Transmission of Poliomyelitis to Eastern Cotton Rat,
Sigmodon Hispidus Hispidus. C. Armstrong. — p. 1719.

Relapsing Fever: Guinea Pig as Experimental Animal in Study of
Ornithodoros Turicata, Parkeri and Hermsi Strains of Spirochetes.
G. E. Davis. — p. 1721.

Efficiency of Condensation Method of Sampling Certain Vapors. F. H.
Goldman and J. M. DallaValle. — p. 1728.

54: 1747-1806 (Sept. 29) 1939

•Treatment of Lymphopathia Venereum with Sodium' Sulfanilyl Sulfanilate
and Sodium Sulfanilate. A. Hebb, S. G. Sullivan and L. D. Felton.
— p. 1750.

Protection of Mice Against Haemophilus Influenzae (Non-Type Specific)
with Sulfapyridine. Margaret Pittman. — p. 1769.

Possible Relation of Calcium Deficiency to Utilization of Vitamin Bi:
Preliminary Report. L. F. Badger and E. Masunaga. — p. 1775.

Sulfanilate for Venereal Lymphogranuloma. — Of four-
teen patients with venereal lymphogranuloma in the tertiary
stage (diagnosed by a positive Frei test) Hebb and his asso-
ciates treated eight with sodium sulfanilyl sulfanilate; for two
this compound was followed by sodium sulfanilate, and for four
with sodium sulfanilate alone. In addition, sodium sulfanilyl
sulfanilate was given in four cases of chronic ulcerative colitis.
These patients were so treated because of the possibility of this
disease being caused by a virus and also as all four failed to
respond to usual medication. In the eight cases of venereal
lymphogranuloma in which sodium sulfanilyl sulfanilate was
administered the average duration of treatment varied from six
to thirty-five weeks. Despite this prolonged medication the
blood picture was, if anything, improved, particularly in hemo-
globin content. The leukocyte count varied somewhat, but there
was no indication of bone marrow destruction. Successive treat-
ment of the two cases, first with sodium sulfanilyl sulfanilate
and then with sodium sulfanilate because of lack of tolerance
of the former drug, resulted in an alteration in the blood picture
in one case: the leukocytes were reduced from 5,500 to a low
count of 3,650, 56 per cent of which were polymorphonuclcars.
There is no indication of abnormal cells at present. Two of
the four patients given sodium sulfanilate were cured, treatment
being continued for twelve and fourteen weeks, respectively.
Treatment in all the fourteen cases was followed by general
improvement in health, increased appetite, increase in weight
and the absorption of strictural tissue. The mechanism of cure
and general improvement in health is purely speculative and yet
it may be assumed that both drugs cause destruction of the
virus and that absorption of strictural tissue with return to
normal intestinal function follows the destruction of the infective
agent. The four cases of ulcerative colitis apparently responded
to sodium sulfanilyl sulfanilate, suggesting the possibility that
this disease may be caused by a virus. A larger series of
patients so treated must be studied before its general use can
be advocated. The intravenous route of injection has been used
throughout in these reported cases. However, three .other
patients have been given sodium sulfanilate orally; 12 Gm. a
day was given in four divided doses every four hours. Results

1996

CURRENT MEDICAL LITERATURE

Jour. A: M. A.
Nov. 25, 1939

in these cases would indicate that oral administration would be
at least as effective as intravenous injection, and perhaps the
method of choice. The reactions obtained from intravenous or
oral administration were similar to those with sulfanilamide but
not as severe. Whatever the route of medication, blood studies
should be made at frequent intervals and, if signs of cell degen-
eration occur, the dose should be reduced or the drug discon-
tinued until the blood picture becomes normal. Cure or great
improvement appeared in all. This was indicated by cessation
of the bloody purulent discharge, the disappearance of the fistulas
or lympheroids and absorption of the rectal stricture. Four of
the cases, in which colostomy had previously been performed
with no improvement, responded to treatment with closure and
healing of the colostomy and the restoration of normal intestinal
function.

Southern Surgeon, Atlanta, Ga.

8: 359-444 (Oct.) 1939

Cancer of Stomach: Conclusions from Study of 200 Cases. E. L. Rippy,
Nashville, Tenn. — p. 359.

Emotional Disturbances with Pelvic Symptoms. W. O. Johnson, Louis-
ville, Ky, — p. 373.

management of Hyperthyroid Patient. L. Noland and W. N. Payne,
Birmingham, Ala.— p. 384.

Spinal Cord Tumors: Report of Two Cases. E. Walker, Atlanta, Ga. —
p. 388.

Urologic Surgery in Infants. M. F. Campbell, New York. — p. 394.
Mortality of Appendicitis: A National Disgrace. M. R. Reid, Cincin-
nati. — p. 404.

Treatment of Adynamic Ileus by Gastrointestinal Intubation. G. C.

Penberthy, C. G. Johnson and R. J. Noe r, Detroit. — p. 416.
Transsection of Deep Association Fibers of Prefrontal Lobes in Certain
Mental Disorders. J. G. Lyerly, Jacksonville, Fla. — p. 426.

Surgery, Gynecology and Obstetrics, Chicago

69: 417-576 (Oct.) 1939

Malignant Lesions of Thyroid Gland: Review of 774 Cases. J. dej.
Pemberton, Rochester, Minn. — p. 417.

* Acute Cholecystitis. F. Glenn, New York. — p. 431.

Cold Pressor Test in Pregnancy. L. C. Chesley and Elizabeth R.
Chesley, Jersey City, N. J. — p. 436.

*Use of Silk in Thyroid Surgery. J. E. Dunphy and T. W. Botsford,
Boston. — p. 441.

*Intraspinal Causes of Low Back and Sciatic Pain: Results in Sixty
Consecutive Low Lumbar Laminectomies. F. K. Bradford and R. G.
Spurling, Louisville, Ky. — p. 446.

Traumatic Enophthalmos. C. W. Rand and D. L. Reeves, Los Angeles.
— p. 460.

Blood Supply of Mammary Gland. B. J. Anson and R. R. Wright,
Chicago; surgical considerations by J. A. Wolfer, Chicago, — p. 468.
Acute Diverticulitis of Colon. A. M. Shipley and W. II. Gerwig Jr.,
Baltimore. — p. 474.

Evaluation of Neck Dissection in Carcinoma of Lip. G. W. Taylor and
I. T. Nathanson, Boston. — p. 484.

Acute Cholecystitis. — Glenn reviews the histories of the
219 patients with acute cholecystitis who have been treated at
the New York Hospital in the last six years. Early operation
is not difficult, it was not attended by a greater incidence of
complications nor was the mortality higher than that ordinarily
reported for operative diseases of the gallbladder. The outcome
of an inflammatory process in the gallbladder is unpredictable.
Therefore delay in operating may lead to serious complications,
which greatly increase the difficulty of operation and the atten-
dant mortality. The younger the patient when subjected to
operation, the better the chance of an uneventful recovery and
good end result. On the basis of his observations the author
recommends that disease of the biliary tract be treated surgically
as soon as the diagnosis is made unless the general condition
of the patient makes such treatment dangerous without pre-
operative therapy. If this policy is pursued, he believes that
the mortality rate in surgery of acute cholecystitis will be
diminished and, perhaps, the progress of certain systemic dis-
eases, such as cardiovascular and hypertensive disease, may be
retarded.

Use of Silk in Thyroid Surgery— Dunphy and Botsford
state that a study of the factors involved in the healing of more
than 600 thyroidectomy wounds reveals that, when fine silk was
used instead of catgut, the incidence of nonsuppurative wound
complication was reduced from 40 to less than 15 per cent and
the incidence of suppurative complications from 3.2 to 0.3S per
cent. Suppurative complications were more frequent in the
cases in which drainage of the wound was employed. There
were no infections following thyroidectomy when fine silk was
used and the wound closed primarily. No other factor produced
so favorable an influence on wound healing as the use of fine

silk. Comparable results were not obtained with catgut even
when a careful technic was followed. Postoperative discomfort
(tenderness, swelling and induration of the wound) is minimized
and consequently the period of morbidity is shortened when silk
is used and also the hospital stay is about three days less.
Patients are generally discharged from the hospital without a
wound dressing when silk is used, and probings after discharge
are seldom necessary.

Intraspinal Causes of Low Back and Sciatic Pain. — In
sixty consecutive lumbar laminectomies performed for the relief
of low back and sciatic pain, Bradford and Spurling found
that the gross and microscopic observations fall into four'
groups: thirty-five cases of herniated nucleus pulposus, thirteen
of hypertrophy of the ligamentum flavum, three of true neo-
plasms and nine negative surgical explorations. Disability was
more apparent in the cases of herniated nucleus pulposus and
hypertrophied ligamentum flavum than in the negative group.
Pain throughout the distribution of the sciatic nerve, although
at times secondary in severity to back pain, was present in 88
per cent of the cases of herniated nucleus pulposus and hyper-
trophied ligamentum flavum, while it was present in only 33
per cent of the negative explorations. Therefore it seems that
low back pain indicates an intraspinal lesion only when accom- ’
panied by sciatic pain. In 60 per cent of the cases of herniated
nucleus pulposus there was hypesthesia or anesthesia limited ■
to the lateral aspect of the leg or foot or both. In contrast,
the cases of hypertrophied ligamentum flavum and the negative
group showed areas of hypesthesia elsewhere, but in only 15
per cent and 11 per cent, respectively, was hypesthesia limited
to these areas. The immediate as well as the final result in
twenty-six of the thirty-five cases of herniated nucleus pul-
posus was excellent. Improvement was slow in seven cases
but with definite relief of the more severe pain which had
occurred before operation. One patient died too soon after
operation to judge whether or not there was any relief, and
one patient, who was relieved completely of his pain, died on
the twelfth postoperative day. The longest postoperative period
through which a patient has been followed is eighteen months,
the shortest six months. Therefore the eventual results may
not be the same as they appear at present. In the hyper-
trophied ligamentum flavum group one patient died from menin-
gitis following operation. Of the surviving twelve patients,
eight recovered completely and four have slight residual pain
but are much improved over their preoperative state. The
longest postoperative period in this group is two and on.e-half
years, the shortest six months. Two of the three patients with
neoplasms recovered completely and have remained well. The
third continues to have mild discomfort in the region of the
sacrum, presumably owing to incomplete removal of the der-
moid tumor. Four of the nine patients in whom the explora-
tions were negative were relieved almost immediately by the
operation and four more have improved slowly. Six of the
nine patients are at present free from symptoms, two are mod-
erately improved and in one case there has been no modifica-
tion in the patient’s severe back pain. The diagnosis of her-
niated nucleus pulposus or hypertrophied ligamentum flavum
must be made clinically as well as roentgenologically to assure
successful selection of cases for operation. The use of 2 cc.
of iodized oil intraspinally is a safe procedure and the amount
is adequate for diagnosis.

West Virginia Medical Journal, Charleston

35: 447-494 (Oct.) 1939

European or American Medicine. N. B. Van Etten, New Vorl.'.—-J>. 44/.
Failure of Peripheral Circulation. D. C. Ashton, Beckley.- — p. 45j.
Endocrine Treatment of Menopausal Symptoms. J. A. Ilepp, Pittsburgh.
— p. 457.

Intestinal Obstruction. H. H. Ilaynes, A. J. Weaver and J. F. l.eni-
bright, Clarksburg. — p. 459. ...

Postoperative Vomiting and Pbenobarbital. J. D. Roraino, Fairmont.

p. 461.

doniliasis of External Ear Canal. R. F. Simms, Richmond, \ a.— p.
rreatment of Artificial Menopause. R. Kessel, Charleston.— p. 46 j.
>igns. Symptoms and Treatment of Neuronitis: Report of Cases. I. J*
Spear, Baltimore. — p. 469.

'yclopropane Anesthesia. M. Baptista Garvey, Charleston.— p. 4//.
lanagement of Congestive Heart Failure. A. S. Brady Jr., Charles. • •

~e<ting System for Approving Syphilis Serology Laboratories. A. F.
McCluc, Charleston.— p. 482.

Volume 113
Number 22

CURRENT MEDICAL LITERATURE

1997 -

FOREIGN

An asterisk (*) before a title indicates that the article is abstracted
below. Single ease reports and trials of new drugs are usually omitted.

Journal of Mental Science, London

SG: 859-1140 (Sept.) 1939. Partial Index

Value of Mental Hospital Participation in Early Treatment. \V. J. T.
Kimber. — p. 871.

Some Practical Considerations in Relation to Inpatient and Outpatient
Treatment in Psychoncuroscs. J. Flind. — p. 886.

Mechanisms of Convulsive Phenomena, with Reference to Effects of Vaso-
dilator Drugs. D. J. Watterson. — p. 904.

Short Review on Histology of Epilepsy. A. Meyer. — p. 927.

Electro-Encephalography in Study of Epilepsy. W. G. Walter. — p. 932.

Epileptics in the Community. J. T. Fox. — p. 940.

The Problem of the Epileptic in Industry. G. E. G. Pierce. — p. 953.

*L’se of Sodium Diphenyl Hydantoinate. W. McCartan and J. Carson. —
p. 965.

Report on Five Years’ Use of Prominal as Routine Treatment for
Epileptics. C. G. Millman. — p. 971.

Sodium Diphenyl Hydantoinate in Treatment of Epilepsy; Preliminary
Observations in Severe Cases. I. Frost. — p. 976.

Sodium Diphenyl Hydantoinate (Dilantin) and Its Combination with
Phenobarbital in Treatment of Epilepsy; Review and Preliminary
Report. C. II. Pratt. — p. 986.

Schizophrenic Thinking in a Problem-Solving Situation. N. Cameron. —
p. 1012.

Sodium Diphenyl Hydantoinate for Epilepsy. — McCar-
tan and Carson report the use of sodium diphenyl hydantoinate
for nineteen adults with the grand mal type of epilepsy and
for one child with petit mal attacks. All but two of the nine-
teen showed considerable intellectual deterioration or were
mentally defective. In fifteen cases of the major type a com-
plete cessation of fits occurred; there was a decrease in the
number of fits in two cases and a slight decrease in the other
two. In the case of petit mal (confirmed by electro-encephalog-
raphy) the fits were slight and lasted only a few seconds, con-
sisting of conjugate deviation of the eyes and loss of touch
with tlie surroundings. The patient was given 0.1 Gm. of the
drug twice a day for one month, and there appeared to be some
slight improvement; but he then complained of dizziness, and
the treatment was stopped and a tonic given. His condition
improved immediately, and, apart from his feeling mucti better
now than for some time past, the fits have been much less
frequent. These results are better than those given by Putnam
and Merritt and may not be borne out over a longer period.
The improvement ill behavior is striking. Irritability and vio-
lent episodes are diminished in frequency and severity. The
patients are bright and alert, and there is a subjective feeling
of well-being. Even the more deteriorated patients have com-
mented spontaneously on the change and have expressed their
gratitude for the treatment. Indeed this is so definite that the
drug possibly tends to elate slightly. The undeteriorated patients
comment on their increased efficiency and particularly on the
absence of drowsiness, which they experienced on bromide and
phenobarbital treatment. Toxic symptoms occurred in eight
patients and were similar to those described by Putnam and
Merritt. In addition to the blood examination carried out before

treatment was commenced, a comprehensive blood count ha;
been done at about fortnightly intervals in every case. Then
is a slight progressive diminution in the erythrocyte count
accompanied by a proportionate fall in the packed cell volume
so that the mean corpuscular volume is unchanged and then
is no tendency to macrocytosis. There is no significant chatigf
in the hemoglobin content. On the whole there is a sligh
tendency to lowering of the leukocyte count, and this is due tc
a fall in the granulocytes. No alteration in the blood pictun
followed the development of toxic symptoms, apart from at
eosinophil increase. It appears that the drug has a sligh
depressant effect on the hematopoietic marrow; further invest!
gation is necessary to show whether this is progressive, but s<
far aplastic anemia has not been diagnosed. These blood change:
are not sufficiently serious to discourage the use of the drug
but they emphasize the advisability of carrying out frequen
blood counts on those under treatment. A curious phenomenot
observed in a number of cases was a progressive and market
fall in the blood sedimentation rate. This was not constan
throughout the series but did occur in the majority of cases
I he authors can offer no explanation for this phenomenon.

Journal of Physiology, London

96:367-396 (Sept.) 1939

Comparative Study of Effect of Interaction of Ions, Drugs and Electrical
Stimulation as Indicated by Contraction of Unstriated Muscle,. - I.
Singh. — p. 367.

Properties of Substance Liberated by Adrenergic Nerves in Rabbit's Ear.

J. H. Gaddum and H. Kwiatkowski. — p. 385.

Effect of Monosaccharides on Water Absorption from Subarachnoid
Space. T. H. B. Bedford. — p. 392.

Medical Journal of Australia, Sydney

2: 383-420 (Sept. 9) 1939

Uterine Inertia and Contraction Ring Dystocia. G. S. Adam. — -p. 383.
•Nutritive Value of Powdered Whole Milk. R. C. Hutchinson. — p. 392.

Use of Helium. G. M. Clough. — p. 400.

Hyperthyroidism Improved by Radiation Over Thymic Area: Pre-
liminary Communication. F. S. Hansman. — p. 402.

Nutritive Value of Powdered Whole Milk. — Hutchinson
determined the nutritive value of a popular brand of powdered
whole milk which is prepared in Australia from fresh Australian
milk. In many parts of Australia it is no more expensive than
fresh milk, and its keeping qualities are excellent. It was on
samples of this product, bought in the open market, that the
study was performed. The milk powder was reconstituted by
the addition of the amount of water recommended in the direc-
tions. Compared with fresh milk, the reconstituted milk had
a somewhat bleached appearance and a flat, slightly cooked
taste. The flat taste was partly due to the absence of dissolved
gases, for when the milk was shaken for at least thirty minutes
in a glass jar and the lid was removed several times during
the process, so that more fresh air was allowed to come into
contact with the milk, the flavor was improved. The charac-
teristic milky odor was a little more pronounced than in fresh
milk. It was found that its nutritive value, compared both
chemically and biologically with that of fresh whole milk,
although not replacing the latter was an excellent substitute
and in some of its properties was even superior.

Chinese Medical Journal, Peiping

5G: 99-196 (Aug.) 1939. Partial Index

Peking Diets: II. During Minor Illness. R. A. Guy and K. S. Yeh.
— p. 99.

Observations on Chronic Effect of Sulfanilamide in Dogs and Monkeys,
with Particular Reference to Blood. S. Y. P’an. — p. 111.

Management of Cut Throat: Review of Thirty-Eight Cases. J. Hua Liu
and Y. H. Hsu.— p. 131.

Agglutinin Response Following Prophylactic Inoculation of Typhoid-
Cholera Vaccine. S. B. Wang. — p. 145.

Sulfanilamide Therapy of Lung Abscess: Report of Case. Florence A.
Hui.— p. 153.

Pneumococcic Empyema Treated by Local Irrigation with Sulfonamide.
T. L. Kuo. — p. 155.

Occurrence of Blackwater Fever in New Territories of Kowloon
Peninsula (Hongkong): Report of Case. P. P. Chiu. — p. 157.

Japanese Journal of Obstetrics & Gynecology, Kyoto

22: 131-216 (May) 1939

Short Wave Therapy of Endocrine Diseases and of Carcinoma. J.
Samuels. — p. 132.

•Menarche and Sterility. T. Mukuda and K. Hone. — p. 190.

Significance of Mikulicz Drainage, Especially the Significance for Pre-
vention of Postoperative Infection. T. Mukuda. — p. 195.

Menarche and Gterility. — After reviewing earlier reports
on the relationship between the menarche and sterility, Mukuda
and Horie, in order to obtain information about this problem,
conducted inquiries among the outpatients of the obstetric and
gynecologic institute of the University of Kyoto. Their material
consisted of several thousand cases. They found that in the
sterile women the average age of the menarche was 14 years
and 11)4 months. This is only slightly later than the general
average for Japanese women. At first glance this appears to
contradict the view that sterility is especially frequent in women
with a late menarche. However, detailed inquiry revealed that
this is due to the fact that there are comparatively few women
whose menarche is delayed. In grouping the women according
to their age of menarche and then determining the incidence of
sterility in each group, the authors found that the rate of sterility
is relatively low in the women in whom the menarche was early
but that it increases as the menarche is delayed. The incidence
of sterility is especially high in the women in whom the menarche
is delayed beyond the age of 17 years.

1998

CURRENT MEDICAL LITERATURE

Jouk. A. M. A.
Nov. 25, 1939

Revue Frangaise de Puericulture, Paris

6: 49-96 (No. 2) 1939. Partial Index
•Hypoglycemia by Hyperinsulinism in the Newborn. P. Rambert. — p. 49.
Pulmonary Steatosis and Lipoid Pneumonia in Nurslings. F. Lautmann.
— p. 63.

Varicose Dilatation of Epicranial Veins of a Nursling: Deductions on
Hvptiopathogenesis. J. Wertheimer. — p. 69.

Intra-Uterine Fetal Respiration. M. D. Fenning. — p. 87.

Hypoglycemia by Hyperinsulinism in the Newborn. —
Rambert thinks that the hypoglycemic accidents of the newborn
which are brought on by excessive functioning of the islands of
Langerhans are not given sufficient attention. These hypo-
glycemic accidents occur mostly in the newborn infants of
diabetic mothers. These infants present a syndrome of hyper-
insulinism comparable to the syndrome of langerhansian adenoma
in adults. The hyperinsulinism is a defense reaction of the fetus
to the maternal hyperglycemia. Its symptoms may be readily
misconstrued and as a result the proper treatment may be with-
held with possibly fatal results for the infant. The symptoma-
tology is not characteristic, but the symptoms noted most
frequently are cyanosis and convulsions. Cyanosis is usually the
first to appear; it increases rapidly and is accompanied by
respiratory disturbances. However, in some cases the colora-
tion remains normal. Agitation is frequently observed and it
is accompanied by hypotonia, flaccidity, nystagmus, trembling
of the extremities and especially convulsive attacks. There are
no cardiac disturbances, but in some cases the clinical aspects
are those of collapse with pallor, sweats and a comatose state.
Since the symptomatology is not typical, the diagnosis would
be extremely difficult were it not for three factors: (1) the
hyperinsulinism usually occurs in the infants of mothers with
severe diabetes, (2) hypoglycemia can be observed in the infants
during the postnatal hours and (3) the administration of dex-
trose generally arrests the symptoms, especially the cyanosis
and the convulsions. The evolution of the hypoglycemia in the
newborn depends to a large extent on the promptness of the
treatment. However, the ultimate prognosis depends on whether
hyperplasic lesions exist in the pancreas or whether the dis-
order is merely functional. The simple administration of dex-
trose solution makes possible a definite and complete cure in
a great number of cases, at least in those in which the disorder
is only functional. The injection of dextrose may have to be
repeated in cases in which the hypoglycemic attacks recur.
Epinephrine and maternal blood have been employed as adjuvants
and, in case of cyanosis, inhalation of an oxygen-carbon dioxide
mixture has been found helpful.

Cardiologia, Basel

0: 233-300 (No. 4) 1939

Intermittent Sinu-Auricular Bloc 1 *: Solitary and Temporary Electro-
cardiographic Anomaly in Course of Acute Polyarticular Rheumatism.
M.-P. Marcel. — p. 233.

Aspects of Sinu-Auricular and Interauricular Conduction Disturbances.
O. Spuhler. — p. 244.

Systematic Examination of Thoracic Leads in Normal Type of Electro-
cardiogram. J. Freundlich and E. Lepeschkin. — p. 269.

•Changes of Electrocardiogram Brought About by Fear. F. Mainzer and
M. Krause. — p. 286.

Fear as Cause of Electrocardiographic Changes. —
Mainzer and Krause say that aside from the influence of fear
on the cardiac rate, which is known from everyday experience,
strong fear may induce considerable changes in the electro-
cardiogram. They observed such fear-induced electrocardio-
graphic changes in the course of studies on the effect of
anesthetics on the electrocardiogram. They took electrocardio-
graphic records on the day before the operation, immediately
before anesthesia was induced, once or several times during
narcosis and again one or several days subsequent to operation.
The patients on whom the observations were made were chosen
at random from the surgical and gynecologic departments. The
three classic leads were taken and the instrument used for this
was an amplifier electrocardiograph. The electrocardiograms
taken after the patients had been placed on the operating table,
when compared with those taken the day before, showed in some
of the patients insignificant deviations. These minor deviations
are disregarded by the authors. In five patients without cardiac
disturbances, the electrocardiographic records taken on the
operating table showed considerable changes in comparison with
those taken the day before. The authors regard these curves
as pathologic and think that the changes were due to fear, for

the fear of the impending operation was quite evident in these
patients. The authors differentiate two groups of changes. The
characteristic features of the first group were that the ST
descended below the iso-electric level and that the T deflection
was reversed, which makes these electrocardiograms similar to
those found in coronary insufficiency. The characteristic changes
of the second group of electrocardiograms were increased ampli-
tude of P and T and a more pointed -outline of these two
deflections. . These electrocardiographic records resembled those
of thyrotoxic conditions. As mentioned before, all these patients
were highly irritable and overanxious regarding the impending
operation. Other possible influences on the configuration of the
electrocardiogram, as the effect of drugs, physical exertion and
changes of posture, could be excluded. It is noteworthy that
the mere elimination of consciousness through anesthesia repeat-
edly caused the curve to become similar to the original one.
It can therefore be regarded as proved that fear, even in per-
sons without cardiac disturbances, may pro'duce considerable
changes of the electrocardiogram. As far as it is permitted to
draw a conclusion from the form of the electrocardiogram it
seems probable that it is either the influence of the nervous
excitement on the contraction of the heart muscle (by way of
the sympathetic nerve) that predominates (group 2) or the
(vagal) effect on the coronary circulation (group 1). The
authors observed fear-induced electrocardiographic changes also
in two patients with cardiac disturbances and found that in
these they were especially severe. They conclude that a knowl-
edge of such fear-induced electrocardiographic changes is impor-
tant in order to avoid incorrect diagnosis of organic heart disease.

Schweizerische medizinische Wochenschrift, Basel

69 : 825-848 (Sept. 16) 1939. Partial Index
Enervation of the Kidney. E. Wildbolz. — p. 825.

•Hiatus Hernias. E. Biro. — p. 830.

•Early Diagnosis of Uterocervical Carcinomas by Means of Menstruation
Calendars and Blood Curves. T. Marti. — p. 832.

Bromine Content in Blood of Human Body. J. Karp and Gerda Wolf-
sohn. — p. 834.

Hiatus Hernia. — Biro gives a clinical description of five
cases of hiatus hernia (age of patients between SI and 63 years;
sex not differentiated). These cases were selected from a large
number not because of their exceptional character but because
they illustrated, according to the author, the diagnostic diffi-
culties of hernia detection in the initial stages, which usually
elude the observation of the general practitioner. Roentgeno-
graphic discovery of hiatus is best effected with the patient in
the recumbent position, head downward, stomach full and dur-
ing inspiration. Much experience is needed and a trained eve
to note suspicious conditions. One of the greatest difficulties
is the presence of tonus fluctuations of the cardia in the same
individual within a short period, in consequence of which tem-
porary protrusion does not occur. According to the author,
hiatus hernia does not constitute a disease entity but is secon-
dary to other morbid conditions. It is of frequent occurrence.

Individual Menstruation Calendars. — Marti reports the
use of menstruation calendars and blood curves as employed in
the gynecologic division of the university clinics in Geneva.
These calendars, simplified adaptations of Kaltenbach s and
De Seigneux’s blood curve ideas, are regarded as diagnostical!)
valuable for the detection of initial uterocervical carcinomas,
since they enable prompt evaluation of atypical and irregular
hemorrhages and the early recourse to colposcopy and Schillers
test. The cards, measuring 15 by 11 cm. (about 6 by 4 inches)
are issued for one year’s use and reissued at the end of t ic
year. The principal side contains the name, age, address, con
suitation hours of the clinics and sundry information on ie
significance of menstrual irregularities, the avoidance of sc
medication, the need of seeking medical counsel at an early da .
even though no pain is experienced, and so on. The reverse s
bears the calendar for the year. The bearer of this calcm*
card merely crosses the days when her period occurred as
as those on which she observed the slightest atypical disc S •
She brings the card with her when consulting the dim _•
which time her menstrual notations are transferred to tn
curve records kept by the clinics. The author thinks that
cause of individual and public health would be served by issum c
of menstruation cards to adolescent girls in connection

Volume 113 •
Number 22

CURRENT MEDICAL LITERATURE

1999

hygiene instruction in the schools and by their adoption by the
medical profession, the more so as women are notoriously care-
less in noting hemorrhagic abnormalities and too prone to resort
to self medication on dubious advice.

Annali Italian! di Chirurgia, Bologna

18: 559*669 (July) 1939. Partial Index
Cystic Adenoma of Kidney of Complicated Structure: Case. A. Scalfi.
— n, S59.

•Main Principles of Surgical Treatment of Suppuration of Lung, S.
Bigi. — p. 623.

Surgical Treatment in Suppuration of Lung.— -According
to Bigi, all forms of suppuration of the lung which are not
controlled by administration of medical treatment within the
first eight or twelve weeks of evolution call for surgical inter-
vention. The author reports nine cases of suppuration of the
lung, of various forms. He found that suppuration of the lung
with multiple separate abscess is grave and has a tendency to
chronicity. Chronic suppuration of the lung involves large
territories of the parenchyma in a process of diffuse pyosclerosis
and is complicated by secondary bronchiectasia with abscesses.
Simple pulmonary abscesses which follow bronchial or pul-
monary infections may be either solitary or multiple. Simple
abscesses frequently evolute to solitary or multiple putrid
abscesses which are clinically different from gangrenous abscess
of the lung. The treatment of well circumscribed abscesses is
as follows: pneumonectomy with detersion of the cavity of the
abscess in simple solitary and simple multiple abscesses, and
pneumonectomy with more or less ample resection of necrotic
tissues followed by drainage with medicated gauze in simple
putrid and multiple putrid abscesses. The operation is performed
once in cases of solitary abscesses and it is repeated in cases of *
multiple abscesses. In cases of central, parahilar and deeply
located abscesses the operation consists of paraffin plugging,
which is followed in twelve days by pneumonectomy. Cortical
abscesses call for an early pneumonectomy because of the fact
that they are a menace and may either invade the pleura or
rupture into it. In either case the treatment consists of pleu-
rotomy followed by ample drainage. The surgical treatment of
gangrenous abscesses gives satisfactory results only when it
is resorted to early in the development of the abscess. It consists
of repeated pneumonectomy and resection. The author con-
cludes by calling attention to the importance of early x-ray
diagnosis and early surgical treatment.

Deutsche Zeitschrift fur Chirurgie, Berlin

2 5 3 : 24 1-448 (Aug. 9) 1939. Partial Index
Function of Thymus and the Adrenals. H. Adler.— p. 241.

Microscopic Studies of Effect of Local Application of Certain Medica-
ments in Third Degree Burns. N. Anagnostidis.— p. 248.
Exophthalmic Goiter-Thymus Problem. P. Sunder-Plassmann.— p. 257.
Treatment of Chronic Bursitis with Pulmonary Extract from Swine.
L. Stumpfegger.— p. 275.

"Further Experiments on Distribution of Tetanus Toxin in Animal Body.
H. Bromeis. — p. 285.

•Influence of Pregnancy and Lactation on Mammary Cancer and Its
Management, H, Bromeis. — p. 294.

Distribution of Tetanus Toxin in Animal Body. —
Bromeis attempted to determine in experiments on guinea pigs
and mice the proportion of tetanus toxin carried to the central
nervous system directly by the regional motor nerve and that
part which is first transported by the lymph and blood to the
rest of the motor nerves and is then carried by them to the
central nervous system. This was accomplished by injecting
massive doses of the toxin, estimating the amount found in the
regional motor nerve ; by extirpating the depots of toxin and
determining the amount contained in them by injections into
mice ; by estimating the amount found in the motor nerves away
from the seat of tiie injections, and lastly by subtracting the
toxin that lias not been taken up by the nerves. It was found
that the regional motor nerve takes up about two thirds of the
injected toxin, while the remaining third is first carried by
lymph and blood to other motor nerves to be transported by
them to the central nervous system. The absorption of the
toxin by the regional nerve takes place within the first hour
after the injection and travels along the nerve toward the central
nervous system at about the rate of 1 cm. an hour. The greater
part of the incubation period (from one half to two thirds) is
consumed by the process of combining the toxin molecule with
the nerve cells of the spina! cord. The time occupied by the

transport of the toxin to the central nervous system constitutes
a small fraction of the incubation period. The time required
for the manifestation of symptoms after the bacillary infection
amounts to from one day to one third of the entire incubation
period, depending on the virulence of the bacillus and the local
conditions. The prophylactic dose of antitoxin may therefore
still be effective if given in larger doses on the second or third
day of the trauma. His experiments, the author feels, not only
do not negate the value of antitoxin but indicate the rationale
of administering it at the earliest moment and in maximum
doses. This is best accomplished by intravenous injections and
local injection into the tissues between the wound and the
regional motor nerve.

Influence of Pregnancy and Lactation on Mammary
Cancer. — On the basis of 2,000 cases of mammary carcinoma
and of 1,500 cases of carcinoma of other parts in female patients
observed in the Tubingen clinic between 1911 and 1935, as well
as on the observations of other authors and on his own experi-
mental studies, Bromeis attempts to determine the influence of
pregnancy and lactation on mammary cancer. It appears from
his study that pregnancy and lactation exert the very opposite
effect on carcinoma and that the incidence and the degree of
malignancy of the cancer find themselves in the same relation-
ship. Nulliparas and, even more so, women who do not nurse
are more liable to the development of mammary carcinoma than
others even though the carcinoma in their instance is somewhat
less malignant. A large number of childbirths is likely, how-
ever, to increase the incidence and the malignancy of a later
cancer because of the greater possibility of lactation alterations
within the breast. Cancer of the breast develops exceptionally
only in the course of a pregnancy but is then unusually malig-
nant, the last months of pregnancy having a particularly unfavor-
able influence on the neoplasm. The exceptionally high-grade
malignant condition here is not explainable on the basis of the
patient’s youth. An intervening pregnancy likewise exerts an
unfavorable influence on the neoplasm. The latter, however,
is not nearly as malignant as that which develops in the course
of a pregnancy. Mammary cancers arising after childbirth are
much more frequent but are less malignant, especially if
lactation is practiced. Lactation appears to have a beneficial
influence on the existing mammary cancer. Malignant trans-
formation of a benign mammary tumor is particularly frequent
in the lactation period. Bromeis was able to demonstrate in
experiments on mice that pregnancy stimulates the growth of
a carcinoma and that lactation retards it. The incidence of
recurrences in animal experiments is lessened when pregnancy
takes place shortly after operation. The recurrences arise not
during the pregnancy but toward the end of the lactation period.
In contrast to this, tumors removed in the course of a preg-
nancy recur with great rapidity. The author injected nucleinic
acid into tumor mice and obtained the same alterations in their
breasts as those observed in pregnancy and lactation. These
alterations exerted an influence on the growth of the tumor
which paralleled that of pregnancy and of lactation. The former
stimulated the growth of the tumor and the latter retarded it.
He had also made the observation that more than one fourth
of the women with mammary carcinoma were of the type
presenting marked developmental weakness of the connective
tissue. The hormonal influence of pregnancy and lactation was
not clear.' In his opinion a radical operation for mammary
cancer without interruption of pregnancy is permissible within
the first two or three months, provided that an early operation
is possible and that the biopsy reveals a tumor of average
malignancy. In all other instances a radical operation and inter-
ruption of pregnancy arc indicated up to the third month. Preg-
nancy should be interrupted during the fourth and fifth months
only when the existing mammary carcinoma is easily operated
on and the life of the child is not of any particular importance.
From the sixth month on, the interruption of pregnancy presents
no advantage except that in the interest of prolonging the
mother's life induction of labor during the seventh month is
indicated. Pregnancy is to be interrupted in all advanced
inoperable cases of mammary carcinoma. The termination
should precede the radical operation by from two to four weeks.
Benign mammary tumors are to be removed in the early stage
of pregnancy. They are to be removed at once when observed
for the first time during lactation. Castration in pregnant

2000

CURRENT MEDICAL LITERATURE

Jour. A. M. A.
Nov. 25, 1959

women with mammary cancer is indicated only in the older
patients close to the menopause; in younger women it is suf-
ficient to prevent conception for the next three to five years.
Castration is not indicated in cases in which the carcinoma was
first recognized during the lactation period. The author like-
wise feels that sterilization is not to be recommended after a
radical operation for mammary carcinoma in a woman during
the child bearing period. It is sufficient here to prevent con-
ception for several years and to keep the other breast under
observation during, and especially after, a later pregnancy.

Geburtshilfe und Frauenheilkunde, Leipzig

1: 523-592 (Aug.) 1939. Partial Index
Anemias of Pregnancy and Their Treatment. R. Hansen. — p. 523.
Clinical Evaluation of Leukoplakia of Vaginal Portion of Cervix
Uteri. W. Bickenbach, — p. 553.

Clinical Investigations on Arrest of Lactation After Delivery of Dead
Fetuses. B. Manstein. — p. 55 9.

Results of Treatment in Third Degree Perineal Tears. F. Movers.
— p. 565.

•Length of Twins at Birth as Sign of Maturity. W. Wolf. — p. 570.

Length of Twins as Sign of Maturity. — Wolf reports
that in the course of a lawsuit on the paternity of twins the
question arose whether twins who measured 47.5 and 46.5 cm.,
respectively, could be born 305 days post cohabitationem. The
question was answered in the affirmative with the suggestion
that twins are normally always shorter than azygous infants
and that they could be born without signs of hypermaturity
even after a gestation lasting that long. In view of the foren-
sic importance of this problem, the author investigated the
records of 400 twins born during the period from 1908 to
1938. After excluding those cases in which the mother’s last
menstruation was not definitely stated or the length of her
menstrual cycle was irregular, as well as those in which dead
or macerated fetuses were born, there remained 160 cases which
seemed suitable for this investigation. They were classified
in seven groups, depending on the length of gestation. The
first group included those born after 231 to 240 days of gesta-
tion; the second group those born after 241 to 250 days and
so on, the seventh group including those born after 291 to
300 days. The author agrees with Litdi that for the estima-
tion of the degree of maturity it is best to consider only the
length of the longest of the twins. He found that after a
gestation of from 270 to 280 days the length of the longest
twin varies between 46 and. 52 cm., the mean being 49 cm.,
that is, a length which does not greatly differ from that of
azygous infants. The author regards it as extremely rare that
twins are carried for longer than 300 days after the last .men-
struation. However, if they are carried past the normal term
they seem to have at least the signs of complete maturity.
According to the figures that are available so far, twins that
are born before the eighth month of gestation seem to be longer
rather than shorter than azygous fetuses that have been car-
ried for the same length of time. This observation contradicts
all expectations; however, in view of the small numbers, of
the fact that sex of the twins has been disregarded and of
other factors, this statement must be evaluated with extreme
caution. The author reaches the conclusion that the statement
(often made in paternity lawsuits) that twins need not show
the signs of maturity after a normal length of pregnancy or
may lack the signs of hypermaturity even if carried far beyond
the term normally is not justified. Actually the length mea-
surements established as a criterion for the maturity of azy-
gous fetuses apply with slight deviations also to twins.

Munchener medizinische Wochenschrift, Munich

SG: 1261-1296 (Aug. 18) 1939. Partial Index
•Hyperinsulinism. R. Thomae. — p. 1261.

Experiences with Bulffarian Treatment. H. Hechler.—p. 1~64.

Vitamin A and Detoxin in Removal of Bacilli from Diphtheria Bacillus
Carriers and Eliminators. Anneliese Klinzing. — p. 126/.

Blood Transfusion, Blood Transfusion Apparatus and Fluids to Substi-
tute for Blood. F. Schorcher. — p. 1268. . . _

Prevention of Distant Thromboses with Elastic Adhesive Compression
Bandages. W. Leun.—p. 1271.

Water Exchange and Weather. Alter. — p. 12/9.

Hyperinsulinism. — Thomae directs attention to a disease
entity which is characterized by hypoglycemic manifestations.
Hvp'og'vccmia is observed (1) during adrenal insufficiency (Addi-
son's disease), (2) during hvpafunction of the thyroid, that is,
during mvxedema, (3) during insufficiency of the posterior lobe

of the hypophysis, namely, occasionally during diabetes insipidus
and adiposogenital dystrophy, (4) during hypofunction of the
anterior lobe of the hypophysis, sucli as in hypophysial cachexia
and (5) during hyperfunction of the insular apparatus (liypcr-
insulinism) which is due to adenoma or carcinoma of the island
cells or to insular hyperplasia. In order to arrive at the diag-
nosis of spontaneous hypoglycemia it is necessary to exclude
disorders of the adrenals, the thyroid and the hypophysis. All
earlier studies, especially those of Harris, who first described
hyperinsulinism in 1924, brought clarification so far as they
differentiated between functional hyperinsulinism, in which no
changes are found in the pancreas, and hyperinsulinism, in’ which
there exist changes in the island cells. To be sure, there still
remains the problem whether the h)'pophysis is perhaps respon-
sible for the so-called functional hyperinsulinism. The author
describes in detail the history of a patient observed and treated
by him. Discussing this case and the multiform symptomatology
of glycopenia, he directs attention to Josef Wilder’s suggested
classification of “small,” “moderate” and “great” glycopenic
attack. The small attack has only few symptoms that are
characteristic for hypoglycemia; there are sensations of hunger,
sudden sweats and visual disturbances (swimming of objects
before the eyes) ; irritability and quarrelsomeness are occasion-
ally observed ; heart action and blood pressure may be decreased
or increased; fatigue, somnolence and excessive yawning are
quite frequent. The only constant sign is that all these symp-
toms are counteracted by intake of sugar. The author believes
that “small” attacks of hypoglycemia are not always recognized.
He thinks that physicians should give more attention to the
aforementioned complaints and that medication with sugar might
perhaps lead to a correct diagnosis of such symptoms. In
“moderate” glycopenic attacks the symptoms are about the same
as in the “small attacks” but they are more severe. The “great"
attacks are accompanied by threatening collapse and fainting,
by temporary paralysis and blindness. Pallor and cold sweats
are characteristic for beginning glycopenic coma, and lethargic
and stuporous conditions have been observed. In remarks about
the therapy of sugar deficiency, the author takes up diet, surgical
treatment and treatment with insulin. For the dietetic treat-
ment he recommends numerous small meals with a high carbo-
hydrate content. Surgical treatment is necessary in case of
neoplasm of the pancreas. The apparently paradoxical insulin
treatment of hyperinsulinism was suggested by H. J. John, who
reasoned that the exogenic administration of insulin would
induce hypofunction of the insular cells. John recommends a
diet with a high fat content and the injection of insulin after
every meal. The author says that encouraging results have been
obtained with this treatment and points out that Harris likewise
attempted to reduce insulin production by diets with a high fat
content. In the conclusion he expresses the opinion that glyco-
penic attacks are more frequent than they are diagnosed. He
thinks that the sugar metabolism should be investigated of
patients with repeated attacks of fainting as well as of persons,
particularly children, who are easily fatigued.

Nervenarzt, Berlin

12: 385-440 (Aug. 15) 1939

Encephalitidcs with Choked Disk. A. Leischner. — p. 385.

Question of Paranoid Involutional Psychoses. H. J. Weithrecht.-— JL
Diagnostic Observations on Tumors of Corpus Callosum. K. kss
— p. 405.

•Treatment of Delirium Tremens. G. Saker. — p. 410.

Treatment of Delirium Tremens. — Saker directs attention
to the fact that chronic alcoholism and delirium tremens arc
accompanied by impairment of the liver and that this hepatic
disturbance can be influenced by treatment with insulin an
dextrose provided anatomic changes do not prevent it. He sa> 5 _
that Krai and his collaborators observed a favorable effect o
this insulin therapy in chronic alcoholism. Moreover, hie)
found that it has a sedative and an abridging effect on 1
delirium. The author, however, by giving twice from i 5 to
units of insulin and dextrose, did not observe these effects
tiic delirium but did observe a favorable effect on prcdclino >>
pseudoneurasthenic conditions and noted an accelerate ’’
appearance of the psychosomatic symptoms that remained a
the delirium. In two cases of delirium tremens he attemp
to obtain results with preliminary shocks induced by means ,
insulin. In the first case a threatening circulatory collapse " 11

Volume 113
Number 22

CURRENT MEDICAL LITERATURE

2001

did not yield to cardiac and circulatory remedies could be
counteracted by preliminary insulin shock. In the second case
a severe delirium could be counteracted by preliminary insulin
shock without resort to cardiac remedies or narcotics. Both
of these patients presented a relative insensibility to insulin in
that comparatively high doses were necessary to induce insulin
shock. It is noteworthy that the gradual transition from pre-
liminary shock to true shock was lacking and that only the
deep shock interrupted the delirium. It is also interesting that
the hallucinations and other signs of delirium disappeared only
at the threshold of deep shock and that they reappeared when
the shock was interrupted by means of dextrose. The improve-
ment in the circulation, however, was effected before the shock.
The author docs not recommend this treatment for general use
in delirium tremens because the delirium is not noticeably short-
ened by it and it is not without danger, but he thinks that it
could be tried as a last resort in especially severe cases. He
further discusses the use of vitamin Bi in chronic alcoholism
and its complications and expresses the hope that the further
development of the insulin, dextrose and vitamin. Bi therapies
will lead to a causal therapy of alcoholism and especially of
delirium tremens.

Zeitschrift fur Urologie, Leipzig

33 : 481-552 (No. 8) 1939. Partial Index
Extraction of Ureteral Calculi with Sling Catheter, H. A. Degc. —

p. *186.

'Trichomoniasis of Urinary Tract in Women. M. Rodecurt.— p. 487.
Clinical Treatment of Stricture of Urethra. C. E. Aiken and E.

Zumach. — p. 498.

Retropcristalsis of Urinary Passages in Hyperplastic Kidneys. K.

Hutter. — p. 511.

Renal Injuries by Dull Force and Their Sequels. H. Domrich. — p.

521.

Urinary Trichomoniasis in Women. — According to Rode-
curt, in cystitis, ureteritis and pyelitis the possibility of infes-
tation with Trichomonas is rarely considered. The female
urethra harbors Trichomonas more frequently than is generally
assumed. The majority of women with urinary trichomoniasis
have simultaneously a vaginal or cervical leukorrhea, frequently
combined with vulvitis, colpitis or erosions of the cervix, or
they previously have had a nongonorrheal discharge. Primary
trichomoniasis of the urethra is rare; more rarely still does
trichomoniasis remain restricted to this organ or the urinary
tract. The presence of Trichomonas does not necessarily cause
symptoms. The infection may remain latent for a long period
until symptoms are elicited by such factors as colds or cathe-
terization. The subjective symptoms of urinary trichomoniasis
are not characteristic. The patients may complain of burning
or piercing pains in the urethra, frequent urge to urinate and
vesical pains. A discharge from the urethra is usually over-
looked or mistaken for a vaginal discharge, the vagina being
nearly always more or less involved. Inspection of the exter-
nal orifice of the urethra usually reveals nothing abnormal.
In acute cases there may be reddishness, swelling and a white-
yellow-greenish discharge from the urethra and perhaps also
from the vagina. If the trichomoniasis is limited to the urethra,
the examination of the urine for protein is usually negative.
The fact that the catheter urine is entirely clear does not
exclude the possibility of an infection with flagellates. Exami-
nation of the urethra may disclose nothing but a slight irrita-
tion, which may be ascribed to the mechanical manipulations
involved in the examination or may be interpreted as “irritable
bladder” or the nervous symptom of cystitis. It is charac-
teristic for infection with Trichomonas that psycho-antineurotic
therapy or the application of heat exerts no influence. Even
urinary disinfectants and the remedies used for vesical lavage
are ineffective. The diagnosis of trichomoniasis can be based
only on repeated, careful examinations of urethral slide prepa-
rations. Following remarks about the technic of the exam-
ination, the author says that in the local treatment of
trichomoniasis of the urethra he obtained the best results with
a 3 per cent aqueous solution of chiniofon. He applies this
solution by means of a tampon holder. Following saturation
of the tampon, it is introduced into the urethra and is left
there for about ninety seconds. This treatment is given every
second day, at least twelve times. The genitalia must be
treated simultaneously with the urethra. In cases of mixed
infections, the customary urologie therapy must be added.

Acta Medica URSS, Moscow

2: 219-366 (No. 2) 1939. Partial Index

New Observations Relative to Physiology of Digestion. I. P. Razenkov.
— p. 219.

Materials for Investigation of Stomach Function After Resection. V. S.
Levit. — p. 275.

Excretory Function of Stomach and Its Clinical Role. R. A. Lourja.—
p. 310.

Electrographic Study of Automaticity of Stomach and Duodenum. J. I.
Daichovsky. — p. 320.

'‘Remote” Symptoms (Repercussion) in Nervous Diseases. M. B. Kroll.
— p. 338.

"Pathogenicity of Pure Cultures of Spirochaeta Pallida. P. S. Grigoriev.
— p. 361.

Pathogenicity of Spirochaeta Pallida. — Grigoriev, work-
ing in the laboratory of the First Medical Institute of Moscow,
claims to have succeeded in growing a pure culture of Spiro-
chaeta pallida. Blood was taken from a vein of a patient with
a diagnosis of primary serum negative syphilis and cultured on
the Tarozzi medium. The patient gave a positive reaction three
weeks later. No spirochetes were detected fourteen days after
culture. However, reculturing yielded, six days later, a great
number of typical spirochetes. This first “Moscow” strain was
recultured every eight days and has yielded thus far thirty-
eight generations. Intravenous injection of the pure culture
caused in rabbits the appearance of typical primary lesions which
contained numerous typical spirochetes. The passage of cul-
tures in rabbits had the effect of increasing their pathogenicity.
The passage of infected material from rabbits through white
mice likewise did not attenuate the virulence of the organisms.
The author believes that his cultures may be utilized for the
preparation of antigen and for therapeutic and preventive
vaccines.

Maandschrift voor Kindergeneeskunde, Leyden

8: 427-465 (Aug.) 1939

•Treatment with Massive Dose of Vitamin D. Anny van Ormondt. —
p. 427.

So-Called Morbilii Builosi. J. L. Keyser. — p. 437.

Granulocytopenia. J. C. Schippers. — p. 450.

Treatment with Massive Dose of Vitamin D. — Van
Ormondt reviews the literature on the treatment of rickets with
a single large dose of vitamin D as well as on the prophylactic
administration of a massive dose. This review indicates that
rickets can be cured with a dose of IS mg., that is 600,000
international units of vitamin D. Vitamin D 2 as well as Dj
can be used for this purpose. For the prophylaxis of rickets,
from 7 to 10 mg. of vitamin D is sufficient. After discussing
the indication for this so-called vitamin D “shock” therapy and
vitamin D “shock” prophylaxis, the author describes three severe
cases of rickets in which favorable results were obtained with
this treatment. She says that in these cases improvement started
later than in those reported in the literature and thinks that
this is due to the fact that the required dose was given in two
injections, with an interval of two or three weeks, rather than
in a single dose. The treatment caused no harmful effects.
In view of the great number of good results and the absence
of symptoms of hypervitaminosis, vitamin D shock therapy and
vitamin D shock prophylaxis can be considered a valuable addi-
tion to the therapeutic armamentarium of rickets. The author
thinks that the vitamin D shock prophylaxis should be used
more generally in cases in which prophylaxis with repeated
small doses is difficult.

Nederlandsck Tijdschiift v. Geneeskunde, Amsterdam

S3 : 4201-4292 (Aug. 26) 1939

Necrosis in Diabetes. J. J. T. Vos. — p. 4202.

Stenosis of Isthmus of Aorta. P. H. Kramer. — p. 4208.

♦Acetonemia in Pregnancy. E. Tonkes. — p. 4216.

Conglomerate Tubercle in Spinal Cord. E. Hoelen and J. Tans.

p. 4223.

Acetonemia During Pregnancy.— Tonkes says that it is
generally assumed that acetone develops when, in case of insuf-
ficiency of carbohydrates, fats must be burned to meet the
energy requirements, and that ketone bodies develop also from
proteins. He cites investigators who demonstrated that during
pregnancy the acetone content is generally higher than is the
case outside of pregnancy and that in pregnancies complicated
by intoxications the acetone values are still higher. However
that a high acetone content of the blood and acetonuria may
exist also in the absence of the well known causes the author
demonstrates by means of a case recently observed by him. A
woman aged 28, who was pregnant for the second time, had

2002

CURRENT MEDICAL LITERATURE

Jouk. A. M. A.
Nov. 25, 1939

Iiypcracetoncmia and acctonuria, but no diabetes, hyperemesis
or gestosis could be demonstrated as a possible cause. Increase
of carbohydrates in the diet did not result in improvement; on
the contrary, the acetone values showed a further increase after
a diet with a high carbohydrate content had been given for a
week. It was now decided to administer twice daily 10 units
of insulin together with 100 Gm. of sugar. This combined
administration of insulin and sugar produced the desired results.
The author suggests that this is a ease of the type which
Broustet and Mahon referred to as “primary acetonemia of
gestation.” He also stresses that almost immediately after the
administration of insulin the water elimination was greatly
increased. He assumes that the Iiypcracetoncmia was caused
by a hepatic disturbance and directs attention to the fact that
acetonemia plays a part in the intoxications of pregnancy, many
investigators having observed increased acetone values in women
with gestosis. Pregnancy increases the functional requirements
of the liver, and the administration of sugar is an aid in the
hepatic function ; however, insulin is necessary for the utilization
of this sugar. In this connection the author stresses the value
of insulin in the treatment of the metabolic disturbances of
pregnancy, especially the toxemias of pregnancy.

Acta Medica Scandinavica, Stockholm

XOl:. 321-617 (Sept. 16) 1939. Partial Index

Intravenous Saturation with Vitamin A. II. Grotli ami I.. Skurnik.—
p. 333.

The QT Interval, Its Connection with Clinical Meets of Digitalis,
Strophantin ami Calcium. L. M. ter Ilorst. — p. 362.

Anorexia Nervosa and Hypophysial Emaciation. G. F. van llalcn. —
p. -133.

Transient Calcinosis Accompanying Ulcerative Colitis. II. Rasmussen. —
p. 491.

Treatment of Exogenous Pellagra with Stomach Preparations, and Con-
siderations on Possible Identity of Vitamin It: Complex with the
"Cyanide Insensitive Enzyme Complex.” E. Handier. — p. 496.
"Metabolism and Cardiac Output in Normal and Diphtheric Children.
T. Plum. — p. 511.

"Persistent Pain Localized at a Distance from the Heart (Shoulder,
Epigastric Region) in Coronary Insufficiency. F. Mainzer. — p. 541.

Chomlroitin Sulfuric Acids, Heparin, Albuminuria, Amyloid and Scrum
Proteins. M. C. Ehrsttom. — p. 551.

"Esophageal Spasm ns Cardiac Symptom. J. Wahlhcrg. — p. 568.

Metabolism and Cardiac Output in Children. — Plum
investigated the mechanism of circulatory impairment in diph-
theria. As these studies required control determinations of
the normal rate of metabolism and of the cardiac output, the
latter were examined first in a number of children who could
lie regarded as "normal.” Summarizing his observations on the
metabolism in normal children the author says that lie found
that the metabolism in children may be determined with about
the same degree of accuracy as in adults and that the intensity
of the metabolism diminishes greatly with age, both when cal-
culated per weight unit and per surface unit. The metabolism
per kilogram of body weight is about twice as great in a child
aged 3’/< as in a child aged 16. Also when calculated per sur-
face unit the metabolism is found to decrease noticeably with
age. In 100 experiments on twenty-two children the respira-
tory quotient was found to be on an average 0.83, varying
between 0.80 and 0.89. Regarding the cardiac output of normal
children, the author says that it, like the metabolism, is rela-
tively considerably higher in children than in adults and rela-
tively greater in younger than in older children. The tissues
of a child aged 4 years are supplied with about twice as much
hlood per weight unit as arc the tissues of a child aged 16.
The arteriovenous oxygen difference is independent of the age
of the subject and is the same in children as in adults. Atten-
tion is called to the fact that, in spite of their more intensive
metabolism, children show no greater arteriovenous oxygen
difference than do adults and that their circulation therefore in
this respect possesses the same reserve force as that of adults,
notwithstanding the relatively greater cardiac output. Sum-
marizing his observations on the circulation and metabolism of
children with diphtheria, the author says that the arteriovenous
oxygen difference and the cardiac output were found to lie
within normal limits throughout the disease. The skin tem-
perature in the lower extremities was decreased during the
stage of acute impairment of the circulation. Capillary micros-
copy showed decreased circulation in the capillaries of the skin.
The metabolism was slightly decreased immediately after the
cessation of the fever. The respiratory quotient was found to

be low in the febrile stage of the disease. These observations
suggest that an essential cause of the circulatory impairment in
diphtheria is to be found in paralysis of the peripheral vascular
system, especially the splanchnic blood vessels. Whether myo-
cardial changes are likely to bring about a fatal outcome cannot
be decided at present.

Pain at Distance from Heart in Coronary Insufficiency.

Mainzer says that since Heberden the paroxysmal pain of
angina pectoris radiating into the left or (more rarely) right
shoulder and arm has been the object of intensive investigation.
A considerable number of unusual types of radiating pain have
since been observed. All these types of pain, however, have
this in common, that they occur in paroxysms and arc usually
accompanied by manifestations of the heart itself (sensation of
constriction, dyspnea, “heart pain” and so on). In this report,
however, Mainzer directs attention to another type of pain,
which is felt at a distance from the heart but which is equally
associated with coronary insufficiency and must be carefully
distinguished from that paroxysmal pain which occurs in angina
pectoris. He considers cases in which during the period of pain
there arc no symptoms which can be connected with the heart
itself. If the pain, which may be severe and may persist over
weeks, occurs in a ease in which the history shows coronary
insufficiency, the diagnosis is not so difficult. If, on the other
band, the pain precedes the symptoms of coronary insufficiency,
great difficulty is encountered in its classification and treatment.
The author reports five cases in which coronary insufficiency
occurred and isolated persistent pain was felt at a distance from
the heart, namely in a shoulder or in the epigastric region. The
pain persisted for weeks. Examination disclosed no local cause
nor was the pain connected with circulatory symptoms. Four
of the patients bad myocardial infarction. The persistent pain
came on cither previously or subsequently to the infarction, but
always separated from this event by a considerable time. Its
localization was in every instance identical with that of the
radiating pain during the infarction, This fact as well as the
absence of any local lesions in the painful area indicates a causal
relationship between coronary insufficiency and the pain syn-
drome. Another patient had a similar pain in the right shoulder.
This patient had been suffering from aortic incompetence with-
out angina pectoris, the coronary insufficiency becoming apparent
by disturbances of the cardiac rhythm.

Esophageal Spasm as Cardiac Symptom. — Walilberg
reports three eases in which esophageal spasm concurred with
cardiac decompensation. The first patient complained that for
the last three days swallowing bad been accompanied by pains
behind the lower part of the sternum and the other two patients
had similar complaints. The connection between the cardiac
disturbance and the esophageal spasm was evident in all cases

and in two of them it could be demonstrated by roentgenoscopy.
The ages of the patients were 72, 69 and 76, respectively, and all
three had peripheral arteriosclerosis. The first patient had a
new cardiac infarct, the second one a chronic cardiac and coro-
nary insufficiency and the third one a chronic cardiac insuf-
ficiency without signs of disturbance of the coronary circulation-
The last two cases were in a stage of acute exacerbation. Flic
author thinks that on the basis of his observations esophagea
spasm can be classified with the symptoms that may develop-
in cardiac insufficiency. This small number of cases seems _ o
indicate that relatively advanced age, severe peripheral arterio-
sclerosis and possibly also disturbances in the coronary cir-
culation arc predisposing factors. The esophageal spasm >- s 0
practical significance in that in its presence it is advisable o
refrain from the diagnosis malignant tumor of the csop iagiu
until careful examination and observation have ruled on -
possible cardiac origin. The pathogenesis of esophageal spa-^
as a cardiac symptom is not readily explainable. X-ray exan
nation in the author’s eases indicated that mechanical Pt. c ' s A
from cardiac or aortic dilatation played no part ns an e >ci
factor. The author thinks that it is necessary to P ostl "^, ' f
visceral reflex mechanism from heart to esophagus by "’•>
the sympathetic. In this connection he points out that the
of the esophagus is supposedly regulated by the sympatn •
that it has been demonstrated that lesions of the ccrvica
thctic may elicit esophageal spasm. Finally it is known •
dominating part is played by the cervical sympat ic ic
elicitation of the pain in coronary disease.

THE STUDENT SECTION

of tlie

Journal of the American Medical Association

Devoted to the Educational Interests and Welfare of Medical Students, Interns and Residents in Hospitals

SATURDAY, NOVEMBER 25, 1939

STUDY OF ATTITUDES, PERSONALITY, SOCIAL FITNESS, ADAPTABILITY,
CHARACTER AND MOTIVATIONS OF MEDICAL STUDENTS

NORMAN R. FIELDER; M.A.

Program Director, West Side Professional Schools
Department, Y. M. C. A.

CHICAGO

The inter-medical schools council composed
of students in Chicago’s West Side medical
schools for years has sponsored a program of
extracurricular activities. Out of this experience
grew an interest in personal and social problems
of students which was further intensified by a
study of the reactions of students to different
types of school activities. In time many prob-
lems bearing on the life of medical students
were brought into bold relief. Usually the prob-
lems concerned student attitudes and beliefs as
they related to personal ethics and social issues.
Typical questions were:

1. What do medical students expect from their
education?

2. Is the general attitude of most medical students
selfish?

3. Are most students unwilling to assume more than
a minimum amount of responsibility in tile conduct
of community welfare?

4. Are students for or against greater socialization of
all community services?

5. How do students really feel about religion? How
do they regard the practices of the organized religious
groups?

C. Does the medical student’s professional training
make him more or less sympathetic with human needs?

7. What does the medical training period do for his
moral life?

8. What about his life philosophy?

Valid answers to such questions might be
expected to have important relations to the vital
personal problems uncovered in the routine
academic work of medical students. Members
of the inter-medical schools council agreed that
an effort should he made to gather reliable
information that might afford a sound basis
for the study of such problems. A careful
study of the activities and interest of medical
students of the entire local community was
instituted. Encouraged by the outcome in the
home community, the council extended the
investigation to include a wider field.

THE CLINICS

For the school season of 1939 a new type of
activity was planned in the form of a series of
student sponsored personal problems clinics.
The general theme of the clinics finds its origin
in a resolution on medical education adopted in
Kansas City at the eighty-seventh annual session
of the American Medical Association, which was
as follows :

Whereas, The relationship between physician and
patient embodies many factors that must be con-
sidered in the determination of an individual’s fitness
to be a doctor of medicine; and

Whereas, The entrance requirements to the degree
of Doctor of Medicine cannot be evaluated on a strictly
academic basis; therefore be it

Resolved, That the following factors be considered
in the selection of students who are to become doctors:
character, personality, social fitness, adaptability and
motivations.

PURPOSE OF CLINICS

It is the purpose of the council sponsoring the
clinics to deal concretely with personal student
problems growing out of the general ideas indi-
cated in the foregoing resolution.

The clinics serve as a focal point in a program
designed to meet the growing demand of the
large body of medical students for help in find-
ing answers to the complex social, economic,
religious and professional problems not touched
on in the scientific courses of medical schools.

PROGRAM

Each clinic is under the leadership of a com-
mission of several students and one or more
faculty resource persons who, because of their
experience, have a contribution to make to the
analysis and solution of the problems. The
personal problems to be faced by the various
commissions have been determined by a series
of student surveys and student sponsored ques-
tionnaires.

In the work of a clinic group no analysis
of a student problem is considered complete

2004

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Jour. A. M. A.
Nov 25, 1939

until the following control questions have been
answered :

1. What are the actual facts involved, especially the
underlying basic factors?

2. What makes this a problem of medical student
concern?

3. What proposals are being made or have been
made for dealing with this problem? (Be specific.)

4. Is there a recognized professional critique for the
solution of this problem? (How is it stated?)

5. If there are generally recognized standards and
critique commonly accepted in the judging of issues
involved, are they sufficient for fast changing social
requirements? (What concrete evidence do you have?)

6. What specific policy and suggestions can be made
as the result of the work of this commission and this
clinic.

LEADERSHIP

In conjunction with the clinic sessions, special
conferences have been held with leaders in the
field of medical and professional practice. Here
the seasoned medical practitioner, the recog-
nized medical educator and other qualified
experts examine the major problems and issues
arising out of the student clinics and in their
discussions seek to provide guidance and infor-
mation for the final analysis of such problems.
Those who have directed discussions and
advised with the student leaders are Dr. David
Davis, dean of the University of Illinois College
of Medicine; Dr. George E. Waklerlin, Uni-
versity of Illinois College of Medicine; Dr.
Morris Fislibein, Editor of The Journal; Dr.
Harry' A. Overstreet, head of the department
of psychology and philosophy at the College of
the City of New York; Dr. William H. Welker,
University of Illinois College of Medicine; Dr.
Howard Slieaff, Rush Medical College; Dr. T. T.
Job, Loyola University School of Medicine; Dr.
F. L. Lederer, University of Illinois College of
Medicine; Dr. Harry Oberhelman, Rush Medical
College; Dr. G. B. Hassin, University of Illinois
School of Medicine, and Mr. William H. Browne,
University of Illinois School of Medicine. Much
credit is due to these men for their leadership
in the work of the clinics.

What is the real meaning of such expressions as
Freedom and Responsibility as they pertain to the
individual life? In our present social order, must
the practicing medical man and woman accept the
idea and then live as though freedom and responsi-
bility are one and the same thing? How may the
medical student interpret the statement “To live* with
complete freedom is to take the entire responsibility
for one’s own life and the lives of others as well.”
Is it true that students are forever trying to wriggle
out of responsibility? What have students to say in
answer to the often repeated statement “What so many
students want is freedom from responsibility.” Isn’t
it true that the seasoned medical man and woman
must accept a great deal of responsibility that can
never be paid for in dollars and cents? What is your
attitude toward this?

Professional practitioners in the various fields of
social service are hearing with growing frequency
reference to group and state controlled schemes anil
plans for social service. Thought provoking ques-
tions pertaining to such subjects as socialized medi-
cine, group hospitalization plans and free public
clinics are raised and remain only to be unsatis-
factorily answered.

Any change in traditional ideas, personal customs
and institutions always brings conflict, disorder and
genera] chaos. As graduate students and as medical
leaders of tomorrow, students should be deeply con-
cerned about the future.

We believe that we should become thoroughly aware
of what is happening in the world today, both for the
sake of our own insight and for our ability to interpret
the changing social order. We believe that education
is meaningful only in relation to the economic, social
and persona] conditions of the times. We recognize
that it is all too easy to acquire a sideline attitude
toward important issues — to become satisfied with
mere intellectual speculation and to hold ourselves
aloof from the realities of social, political, professional
and personal problems. Social, health, professional
and personal problems take on new meaning in practi-
cal application.

As medical students, we are preparing not only to
be physicians but also to be active participants in the
social life of the community in which we shall live
and practice.

THE QUESTIONNAIRE

In order to provide a background for the dis-
cussions in the clinics and to establish then
proceedings on a reliable basis, questionnaires
were formulated and circulated among the stu-

POINT OF VIEW OF MEDICAL STUDENTS

Experience in the work of the clinics to date
emphasizes the importance of the investigations.
More than 600 different students have attended
and participated in the clinics; 3,200 different
students have returned questionnaires and
assisted with the surveys. The following
statement seeks to summarize some of the
observations :

There is evidence on every hand that an old order
is passing. Rapid changes are taking place in the
direction of greater social control. Individualism in
economics, politics and social practice is being chal-
lenged and curbed, while various forms of collectivism
are arising all over the world. There is much talk
about the value of human personality. What is the
real meaning of all this to medical students? Do
present day professional training methods make pro-
fessional leaders sufficiently sensitive to human need?

lents of all the medical schools.

The response to the questionnaires exceeded
ill expectations. Not onty did the replies pro
vide the desired basis of reliable data, but an
;ven more intensive study resulted from ns
source of student expression and the councn
xas decided to continue the clinics for anotner
year. Eighty-seven per cent of all the ques i
naires circulated among the entire enro ni
,vere returned and tabulated. According 0
ixperiments of statisticians, the answers ot e\t
ine tenth of a group, when it includes se *
lundred individuals, yields, results muc
hose which would be obtained if e ' c 9. , n0
,idual in the group bad answered, pro vine
election in the choice of the one tenU .

(roup has taken place. But our slue 3 p
:ontent to stop with one tenth of til g

Volume 113
Number *22

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

2005

The entire returns were tabulated and the final
results represent 87 per cent of the total ques-
tionnaires circulated. We feel certain that the
tabulations of this high percentage represents a
true picture of the general attitudes and beliefs
of medical students enrolled in the medical
schools on the questions included in the ques-
tionnaire.

MEDICAL STUDENTS’ QUESTIONNAIRE

Please do not sign your name! Your help is requested in gath-
ering honest information regarding what professional students do
and think. The answers to the questions, when compiled, will
provide a substantial basis for the discussions of the Medical
Students’ Problems Clinics> at the West Side Professional Schools
Y, M. G. A.

Please be honest. In no way will there be any attempt made
to identify you with your answers.

0 . — Sex? 0. — Age? A. — Average 26. 0. — Married? School?
Year? Years in college?

0 . — Parents: Profession? Race? Religion? A . — Protestant
first, Jewish second. Catholic third.

1. 0. — What arc your real reasons for entering the profession
for which you are studying? Please number them 1 for most
important and 2 for second, and so on.

A . — Easy work — . Social position 4.2%. Chances for marriage
— . Taste 30%. Aptitude 8.8%. Opportunity for service 49%.
Money 3.8%. Parental pressure — . Advice of others 4.2%.

2. 0. — Do you work outside? A. — 65% yes, 35% no. 0. — Do you
feel that outside work in moderate amount is a handicap? A . —
G0% yes, 40% no.^

3. Q . — Outside of studies and sleep, what arc your principal
activities? Please rank them in order of time spent, 1 for first
and 2 for second, and so on.

A.— Reading 40%; “Bull sessions” 6%; Drinking — . Opposite
sex 2%. Movies 8%; Outside work 44%.

4. Q . — Do you spend time on a hobby? A. — 16% do, 54% do
not. C?-' — If so, what? A. — Photography first, stamp collecting
second, books third.

5. Q . — What is your favorite magazine? A. — First choice
Reader's Digest , second choice Life Magazine.

C. 0. — Do you ever stay up the major part of the night to
study for an exam? A. — 52% do, 48% do not.

7. 0.~Do you follow a regular study schedule? A. — 51% yes,
49% no.

8. Q . — Do you ever carry “crib notes” to exams? A. — 75% do
not, 25% do.

9. 0 . — Do you condemn those who do? A. — 55% yes, 45% no.

10. Q .■ — Do you accept information from your neighbors dur-
ing an exam? A. — 30% yes, 70% no.

11. 0,— Do you give such information? A. — 56% yes, 44% no.

12. 0.— Do you think the honor system would work in your
class? A. — 21% yes, 79% no.

13. 0. — Do you always attend classes when attendance is not
taken? A. — 42% do not, >58% do.

14. 0. — Of 3 r our instructors the past term, how many would you
rate in each group? A. — Excellent fourth, good third, fair first,
poor second.

15. 0. — Please number, in order of importance, the character-
istics you believe an ideal instructor in your professional school
should have. A. — Technical knowledge first, pleasing personality
first, clarity of expression first, clear speaking second, general
information third, lucid thinking fourth and research ability fifth.

16. 0. — Do you feel that the students in your class are over-
worked? A. — 60% yes, 40% no.

17. 0. — Should an instructor take his personal opinion of a
student’s suitability to a profession into consideration when
passing him or failing him? A. — 70% no, 30% yes.

18. 0. — If it were legal, would you perform abortions on
unmarried women? A. — 68% 3 r es, 32% no.

19. 0. — Would you tell “white lies” to patients? A. — 98% yes,
2% no.

20. Q. — Would you do plastic surgery for beauty’s sake? A. —
64% 3'es, 3G% no.

21. 0. — Do 3’ou believe in “mercy deaths” in incurable disease?
A. — 22% yes, 78% no.

22. 0. — Has 3’our professional school made 3*ou more aware of
human need? .1.-74% yes, 26% no.

23. 0. — Of wliat political faith arc your parents? With wliat
political faith do 3’ou now S3’inpathize?

21* 0. — Do you believe in government control of production?
A.— -84% no, 16% 3'es.

25. 0. — Are you prejudiced against Jews? A. — 22% 3'es, 78%
no. 0. — Are you prejudiced against Gentiles? A. — 94% no. 6%
yes.

26. 0. — Would 3'ou date a person of a different race? A. — 80%
yes, 20% no. 0. — Marry one? A. — 95% no, 5% 3’cs. Q , — Room
with one? A.— 64% yes, 36% no.

27. 0. — Do 3'ou go out of your way to help others? A. — 21%

11 79% yes.

— Do 3'ou favor women smoking? A. — 10% no, 90% yes.
V P° y° u Pfefer modern women to the “old fashioned” girl?
A. 88% yes, 12% no.

29. 0. — How would 3’ou rate nurses moralty compared to other
groups of women? A. — 12% lower, 76% equal, 12% higher.

30. 0. — How do 3’ou rate male professional students moralli’ to
other groups of men? A. — 9% lower, 82% equal, 9% higher.

31. 0. — Do you believe that women are the mental equals of
men? A. — 93% 3'es, 7% no.

32. 0. — Do 3’ou use alcoholic beverages frequent^’? A. — 72%
do, 28% do not. 0. — Do 3’ou condemn those who do? A. — 92% no,
8 % 3'es.

33. 0. — As companions, do 3’ou prefer those who drink or those
who do not? A. — 76% 3'es, 24% no.

34. 0. — Do 3’ou ever indulge in extramarital sexual intercourse?
A. — 16% do, 84% do not.

35. Q. — Do 3’ou condemn engaged couples who do? A. — 58%
no, 42% 3'es. 0. — Do 3'ou condemn others who do? A. — 54%
3'es, 46% no.

36. Q. — Have you been in a house of prostitution more than
once? A. — -7% 3'es, 93% no.

37. 0. — Have 3 r ou ever had a veneral disease? A. — Three
reported 3’es.

38. 0. — Do 3’ou attend church regularly? A. — 15% 3’es, 85% no.
Q. — Would you be as well off if 3’ou did not? A. — 54% no, 46%
3’es.

39. 0. — Could 3’ou do as well without church? A. — 86% think
they could, 14% no. 0. — Do 3’ou believe in God? A. — 98% 3 f es,
1.5% no.

40. 0. — Are 3’ou tolerant of those who do not? A. — 95% yes,
5% no.

41. 0. — While attending professional school has 3’our attitude
substantial^' changed toward:

God? A.— Yes. 0.— Study? A.— Yes. Q. — Sex? A.— Yes.
0.— Your profession? A. — Yes. 0. — Church? A. — Yes. 0. — The
race problem? A. — Yes.

42. 0. — What could an ideal church do for y'ou? A. — Give
faith, inspiration, belief in mankind.

43. 0. — In a few words, tell what is 3'our greatest problem. A. —
Financial first, problem of adjustment to new ideals fourth,
getting through school fifth, famil3’ sixth, setting up practice
seventh.

Thank 3’ou! If 3'ou are interested in attending sessions of the
clinics you may secure application blanks at West Side Pro-
fessional Schools Y. M. C. A., 1804 West Congress Street, Chicago.

CLINIC DISCUSSIONS

Personality Clinics. — In this clinic questions 1,
4, 5, 14, 15 and 41 were discussed.

Summary of Clinic Session: Technical
knowledge and pleasing personality are major
requirements for the successful doctor, dentist,
pharmacist and nurse. Effective personality is
an absolute necessity. Persons with the highest
technical knowledge are not necessarily the best
but those with combined traits of personality
along with technical knowledge. Personality
is not a substitute for technical skill and techni-
cal skill alone cannot suffice for the lack of
personality. The professional student needs
technical knoAvIedge but it is also important
that he acquire that kind of personality setup
which makes him effective with his fellow men.
And this can come only through participation
in general interest and activities.

Motivations Clinic. — In this clinic questions 1,
2, 3, 22, 24, 27, 38, 39 and 42 were discussed.

Summary: Too many students seem to have
everything to live with and apparently nothing
to live for. They are rich in possession and
poor in purpose. Objectives that are sufficiently
large to command all the power we possess for
their achievement, and are good for all con-
cerned, must he earnestly sought as the basis for
a well balanced, healthy life.

Character Clinic.— In this clinic questions 8,
9, 10, 11, 18, 19, 21, 29, 30, 32 and 33 were
discussed.

Summary: The basic requirement of good
character is honesty. The great doctors, den-
tists, pharmacists and nurses have all been per-

2006

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Jour. A. M. A.
Nov 25, 1939

sons of integrity. Every student should ask
himself “Am I honest?” “Have I ever been
found guilty of dishonest practice?” In pro-
fessional practice a man is in the midst of some
of the most intense social problems and he may
also he tempted to engage in some of the worst
practices known to society. He must be basic-
ally honest if he is to be great in his chosen
profession.

Social Fitness Clinic . — In this group ques-
tions 1, 4, 5, 7, 8, 9, 12, 13, 19, 20, 25, 27, 32,
34, 37, 38 and 39 were discussed.

Summary: The social world has many ele-
ments and it is not divided into distinct eco-
nomic, political and historical parts. Not only
are the various social sciences closely related
hut it is becoming increasingly apparent that the
position one takes on numerous social questions
is in part determined by philosophical as well
as by r scientific considerations. We believe that
the time has come when it may he just as impor-
tant for students to know whether they believe
in the philosophy of the many different forms
of government current in the world as it is to

know how they are organized. In a word, the
professional student becomes socially fit through
his understanding of the philosophy of his pro-
fession, his government and his society as well
as through his participation in the various forms
of government.

Adaptability Clinic .— Here questions 5, 15, 18,
20, 21, 22, 23, 24, 31, 41 and 43 w'ere discussed.

Summary': In the discussions of the Adapt-
ability Clinic several conclusive points were
reached; mental, emotional and physical good
health must be regarded as fundamental to the
enjoyment of life. Mental, emotional and physi-
cal health in an individual signifies the adjust-
ment to living conditions. Every aspect of
college life affects the student’s mental, emo-
tional, spiritual and physical state. The indi-
vidual’s mental, emotional and physical health
program is necessarily interwoven into eacli
day’s activities. It is therefore imperative that
the student plan his schedule so that these
important phases of life will balance each with
the other.

1804 West Congress Street.

Comments and Reviews

STUDY OF THE PATIENT AS A
WHOLE AS TRAINING FOR
MEDICAL PRACTICE

Abridgment of an article by Dr. G. Canby Robinson,
Lecturer in Medicine, Johns Hopkins University School
of Medicine, Baltimore, published in the Journal of
the Association of American Medical Colleges, March
1939.

I wish to discuss the advantages of home visits
by medical students as bearing especially on
tlie study of the patient as a wdiole, which
includes consideration of his personality, envi-
ronment and social setting.

Medical practice requires an understanding
of the motives and circumstances that bring the
patient to the doctor. Except in cases of acute
serious disease or injury, patients usually seek
medical care because of social incapacity. The
great bulk of illness, representing progressive
disease or the processes of aging in their incipi-
ent stages, chronic infections and inflammations,
and disturbances of metabolism and of bodily
functions of psy'diogenic origin, reveals itself
to the patient as an inability to carry efficiently
the responsibilities of his family, of his work or
of other situations he is called on to face. It is
this sense of inability from which comes fear
or worry’, uncertainty and a feeling of insecurity.
The patient is primarily concerned with being
restored to his accustomed place in society
whether he consciously realizes it or not. For
this reason an understanding of the conditions

and obligations of the accustomed place in
society to which each patient hopes • to be
restored is a requirement of medical practice.
This concept should be appreciated by the medi-
cal student and should be incorporated into liis
attitude toward an understanding of medical
practice early' in bis clinical training.

The interaction between the patient and his
social setting is an important factor in the causa-
tion of illness and in its treatment, as there are
specific social problems related to various types
of disease which require consideration both m
diagnosis and in treatment. A systematic study
of an unselected series of medical patients
admitted to the Johns Hopkins Dispensary' has
show'n that in 65 per cent adverse social condi-
tions related to their illness existed and that
in 35 per cent these conditions caused emotional
reactions mainly' responsible for their illness.
It seems clear that if medical students are to
understand illness and its treatment in a broa<
sense they' must be taught to consider the
patient as a total individual. Activities in tins
field have recently' been introduced into t j c
curriculum of at least thirteen medical schools
in this country', and various methods for their
conduct have been instituted. I am convince!
that these new undertakings in medical edu-
cation are destined to have a useful influence on
the attitude of the future doctor toward illness
and on medical care in general, by developing
a wider interest and a better understanding 0
the patient as an individual.

vou^iw AMERICAN MEDICAL ASSOCIATION STUDENT SECTION 200?

IVVMDBn

DETAILS OF THE PLAN

Our plan is to assign at least one patient to
each third year student for study as a total
individual during liis work in the medical dis-
pensary. A suitable patient is selected from the
new cases assigned to each student, so that he
may participate in the broader study of a
patient he already knows both personally and
medically. A suitable patient is one who has a
more or less protracted illness, requiring treat-
ment in the medical clinic, and who lives near
the hospital so that a home visit can be made
conveniently.

The patient is selected by conferring with the
student and with the staff member responsible
for the case, and the patient is interviewed after
the clinical record has been reviewed. At this
interview the patient’s symptoms are reviewed
and expanded. A social history is obtained, and
the assets and liabilities in the circumstances of
the patient’s life in relation to his illness are
determined. The patient is given an oppor-
tunity to relate his social and emotional dis-
turbances, and at the same time characteristics
of personality are noted. Immediately after the
interview it is fully described by dictation,
thereby providing a record for future study.
This interview is usually conducted in an office
outside the clinic, where an intimate doctor-
patient relationship is easily established and
the student for practical purposes is, as a rule,
not present, but the record is reviewed with him
shortly thereafter. Plans for a home visit with
the student are made at the time of the inter-
view. .

After the study has progressed sufficiently to
give an understanding of the patient as a whole,
the patient is presented by the student at an
informal weekly conference attended by all the
students in the medical group, about twenty-five
in number, and covering the whole class in three
groups. The student presents the essential
medical aspect of the case with the patient
present, and after a brief discussion with the
patient in order to bring out his personality
the patient is asked to withdraw. Then his
social and personal problems are described and
discussed. Emphasis is placed on the relation
of these problems to the patient’s illness and its
treatment, and consideration is given to the
problems of health and hygiene which the
patient may present or suggest.

These conferences are attended by the public
health administrator of the district, by medical
social workers and frequently by staff members
of outside social agencies interested in the
patient presented. A psychiatrist has attended
constantly during the past two years, and
visitors from the board of health, from the
School of Hygiene and from other departments
of the medical school have attended and par-
ticipated in discussions.

There are eight conferences for each group,
and it is customary to present to each group
patients illustrating the social aspects of circu-
latory disease, pulmonary tuberculosis, psycho-
neuroses and syphilis, while patients with
diabetes, epilepsy or other chronic diseases have
been presented. Cases have also presented
opportunities to discuss the relation of illness
to industrial employment, the problem of
permanent invalidism, the methods of utilizing
the resources of various public and private
health and welfare organizations, and other
such topics.

BREADTH OF FIELD COVERED

The study of the patient as a whole frequently
leads the student to a consideration of problems
of public health and of mental hygiene, or it
demonstrates the significance of adverse social
conditions in the diagnosis and in the treatment
of illness.

This method of treatment is neither simple
nor easy. Much time and energy are required
to coordinate all the human elements that are
concerned with its successful conduct. These
human elements consist of patients, students,
doctors, medical social workers and representa-
tives of public health and social agencies. It
has not been possible to have all students make
a complete study, but about 60 per cent of each
class have done so.

This program of teaching has been combined
with systematic studies of the social aspects of
illness and with problems of treatment in con-
junction with the routine medical service of
the hospital staff. These activities have required
the full time of a physician, a social worker and
a secretary, constituting a small division of the
department of medicine, in which efforts are
being made to keep accurate records and to
accumulate recorded experience as material for
studj^, analysis and formulation.

Several points in this plan of teaching are
advantageous in the training of the doctor. The
medical student takes a broad view of at least
one patient in whom his interest has already
been aroused by taking the history and by mak-
ing the initial examination. When the student
has an opportunity to see the patient in the
environment of his home, the case becomes a
human as well as a medical problem. For this
reason it is more deeply impressed on him and
he invariably gains a lasting memory of the
patient, which includes not only the individual
but also the disease or disability from which
lie suffers. The method of teaching serves to
introduce the student to phases of hygiene and
public health as related to clinical medicine
and to demonstrate the integration of medical
practice and public health. It also serves to
indicate the relation of various social agencies
to medical care and the numerous factors

2008

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Jour. A. M. A.
Nov. 25, 1939

which may need to be coordinated in consider-
ing the total health needs of an individual.
Although only relatively few topics are con-
sidered by the students, the conferences serve
to cultivate an attitude of mind and to evoke
a humanitarian spirit that might otherwise he
repressed during the period of early clinical
training. The students have an interest in their
patients as individuals and are glad to have an
opportunity to give expression to this interest.
This field of study gives the student the idea
that there is no sharp line of demarcation
between medicine, psychiatry and public health;
that the psychobiologic concept of the patient is
applicable in various fields of medicine, and that
the study of the patient as a whole has a direct
hearing on medical practice.

There is need of placing greater emphasis
on the study and treatment of the patient as a
whole in these days of advancing specialization.

THE PLACE OF PHYSIOLOGY IN
CLINICAL TEACHING

Abstract of Mayo Foundation Lecture presented by
IV. II. Ogilvic, M.D., London, England, at Rochester,
Minn., Oct. IS, 1937, and published in Proceedings of
the Staff Meetings of the Mayo Clinic June 22, 193S.

Above all things the surgeon must he an
expert in topography. His anatomic knowledge
must he so detailed that no problem can find
him unprepared, so thorough that it is part of
his subconscious mental processes. He can
acquire this knowledge only by prolonged and
painstaking work. But anatomic learning,
which in the early days made up the whole
scientific equipment of a surgeon, is today
only the beginning and foundation of his art.
The surgeon who regards only structure cannot
advance his subject except in technical detail
or even do his day’s work with intelligence and
insight.

It may appear that intelligence and insight
are unnecessary to a manual worker, that the
limits of technic have been fully explored and
that nothing remains hut to repeat those pro-
cedures that have already been perfected. Yet
it does not follow, because no striking innova-
tions are to he expected, that further advance
is unlikely. It is impossible to visit several
centers in succession, as I am doing at present,
without being astonished at the great diver-
gence in the methods used by surgeons of ability
to treat the same disease. Which is right? Sur-
gery is not complete until we can give the
answer to this question, and we can only do so
by applying the test of function. We must turn
to physiology, the province of which is the study
of function.

Physiology inquires how the viscera are nor-
mally kept in position, how this normal mecha-
nism lias failed in visceroptosis, how far the

symptoms are due to altered position, and
how the normal function and support can be
restored. The viscera are kept in shape by the
tone of their own walls and in position by the
tone of the abdominal muscles and pelvic floor.
Failure is due to lack of tone, and tone in turn
is dependent on influences from higher centers,
and ultimately on psychologic control. The
treatment of visceroptosis is therefore the
restoration of tone, psychologic tone, tone of
the abdominal muscles and tone of the visceral
walls.

I may choose the muscular system to illustrate
the tendency toward departmental knowledge.
In anatomy we learn the attachments and nerve
supply of each voluntary muscle and regard its
actions as a piece of elastic. In physiology we
study the behavior of nerve muscle preparations
from the frog and pass on to the more general
characters of the activity of striated and plain
muscle. In clinical surgery we think of muscles
chiefly as things that may be injured or that
interpose barriers to structures we wisli to
reach. We seldom pause, except in orthopedics,
to consider them as the chief constituents of
the human body or to apply that knowledge
of the living muscular system as a coordinate
whole. This idea we owe, in the main, to the
work of Sherrington. Tin’s knowledge does,
however, color orthopedic leaching and practice
at present. We are taught to recognize two
types of activity, the phasic and the tonic. We
know that a muscle may be strong in the phasic
sense yet grossly deficient in tone. As surgeons
we should be alive to the need of preserving
abdominal tone which is lost after abdominal
operation.

We cannot go through the abdominal muscles
by peaceful penetration. We must cut them.
We should so plan our incisions that they do
no permanent harm and interfere as little as
possible during the process of healing with
abdominal movements, and we should so close
them that the muscles may be used from the
start without risk of damage. A perfect incision
would divide all structures along their lines o
stress, so that contraction tends to approximate
rather than to separate them and the stitches
do no more than obliterate dead space. Thus
the gridiron is the only incision against whic i
no criticism can be directed. For any but sma
operations, however, we must divide the recUt-
sheath although we should hesitate to cut nc
muscle itself. Such a wound, well healed, lea\ cs
the abdominal wall undamaged.

It is of little avail if we enable our P alien
to use his abdominal wall but do not a o'

him to do so. As a physiologic mechanism m

abdominal wall demands activity. A '
sutured wound has a tensile strength ol n >

40 per cent of that of the tissues before
were cut. During the first few days (he Us

• Volume 113
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AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

2009

undergo autolysis while the sutures are being
digested. Bj r the fourth day the strength of
the wound has sunk to some 20 to 25 per cent
of the original. From the fifth day onward
fibroblasts are laid down rapidfy and the
strength increases, so that by the sixth daj r it
is 50 per cent and by the tenth da3 r about 90 per
cent of the normal. It appears, therefore, that
wound rupture is most to be feared between
the third and the fifth day, and after that it
becomes increasing^ unlikely. But while repair
requires rest it is not necessary to rest the
whole muscular system, or even the whole
abdominal wall, nor need rest mean rest in
one position. Let us set our faces against the
routine use of the encircling bandage and the
Fowler position. As soon as the chart indicates
a reestablished circulation and freedom from
chest trouble, it is unnecessary to prescribe an}’
particular position. The patient ma3 r be allowed
to lie on his back, his side, his face or curled
up, as previous habits dictate and present com-
fort allows. His protective reflexes will guard
the wound from undue strain. But to allow or
force him to walk before the tenth day is to
permit plysiologic idealism to override patho-
logic common sense.

Before I leave the topic of the abdominal wall
I would touch on the layer that most concerns
the patient, the surface one. The skin has many
metabolic functions, but I shall think of it now
only as a flexible and almost indestructible
cover, 3 r ielding to all movements of the body
without pain and without tension. We must
traverse the skin to reach the underlying parts,
but the less trace we. leave of our passage, the
less shall we interfere with its free movements
afterward. Cosmetic surgeiy may seem to be
far from physiology and entirely out of place
in the abdomen, but a beautiful scar is more
than a work of art: it is an indication of heal-
ing not merely by first intention, but without
an3 r recognizable reaction of repair it means
that an3 r subsequent operation will find tissues
in appearance and texture equal to normal.
We can have s earless surgeiy onyiy operating
where there is a scar already. Creases are
scars, that is the3>- are fibrous intersections
passing from the skin through superficial fascia
to the aponeurosis below. Tlie3 r are fixed
because they lie in a plane of no movement, and
au incision placed along them will not merety
heal beautifully because it remains approxi-
mated with the aid of stitches but it will not
subsequently interfere with or limit movement.

My theme, in short, is to suggest that we 11103'
occasionally turn the torch of inquir3 r backward
as well as forward, look for that which has been
forgotten as well as that which has not 3 r et been
discovered, and tr\ r to piece the work of others
into our daih r task.

THE MEDICAL RACE

Abstract of an inaugural address delivered by Robert
Hutchison, M.D., D.Sc., LL.D., at the opening of the
session of the Westminster Hospital Medical School,
October 3, and published in the Lancet Oct. S, 193S.

I wish toda3 r to give you some advice on how
to run the medical race. I have been over the
course and can perhaps warn 3 r ou of some of
its difficulties. I should like to congratulate 3 r ou.
I would commend it on the grounds that medi-
cine is an interesting, intriguing and even
.amusing occupation in which, although with all
its labors and langors 3 r ou may often know
fatigue, 3'ou will at least escape boredom; that
it gives opportunity for the exercise of 3 r our
plysical, mental and moral powers and that it
offers an admirable field for the stiuh- of human
nature in the raw. It is customar3 r to sa3 r that
although it is eas3 r enough to earn a living in
medicine it is difficult to make a fortune in it.
But in no learned profession is it eas3 r to make
a fortune, and on the whole doctors are quite
well paid and the3 r have this further advantage
that their skill, once acquired, is marketable
all over the globe, for disease is everywhere the
same.

THE NUMBER OF COMPETITORS

Toda3 r ’s ceremoiyy corresponds for maiy of
you to the fall of the flag starting you off. Some
of 3 T ou may be feeling a little dismayed ly the
large number of competitors. I was half a
century ago, for there were more than 400 men
in my 3 T ear at Edinburgh. I advise you not to
be discouraged. The saturation point does not
seem even yet to have been reached and the
scope and amount of medical work are always
increasing. As Dean Inge, I think, has said,
though Democrac3 r ma3 r starve the clerg3 r and
the practitioners of the arts, it will always
demand doctors.

THE HURDLES

I want to remind you that this race is a handi-
cap race; you don’t all start level. Nor is there
any use in pretending that the handicapping is
fair. Some of you will carry weight all through
the course because of poor health, lack of intelli-
gence, inborn laziness, slyness or a bad manner.
Others may be burdened ly povery if that is
really a handicap. Rightly regarded it may be
a spur; indeed it might be said that the rich
parent can give his son evey advantage except
poverty. A few of you may handicap yourselves
by habitual idleness or Jy the acquisition of
vices or debts.

The race is not really very long. Eight laps
of five years each will see the end of it for most
of you ; and although forty years may seem a
long time to look forward to it is surprising how
short it is in retrospect. The first lap, as many
of you have already realized, is a hurdle race,
the hurdles being the examinations. I refuse to
di\ erge into a discussion of medical education,

2010

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Jouh. A. M. A.
Nov. 25, 1939

which will still be under consideration when the
day of judgment arrives, but, in the last resort
each of you will have to train himself. If I
have any guiding principle in teaching the medi-
cal art it might be summed up in the saying
You must get as early into contact with patients
as you can. We will suppose you then to have
completed the first lap. You are now out of
the hands of your trainers and in open country
where the race becomes a point-to-point and
each can choose his own line, and here you may
go astray in various ways.

You may run up a blind alley. There are
many of these opening out of the course and
some of them look attractive; so-called research
posts of one kind or another and small institu-
tional jobs are amongst them. Beware of these;
they offer an immediate reward in pay hut are
apt to lead nowhere. Above all, shun research
posts — the “lure of the laboratory” — unless you
feel in yourself the curiosity and restlessness
of the born investigator.

Second, you may be tempted out of your
course by the desire to make a good income
quickly. This is the bait which may draw you
down one of those blind alleys; but even if it
does not do that it may result in your starting
on a definite path when, if you had taken time
to study the country properly, you might have
found another that would have suited you far
better. I don’t like to make generalizations
about the rising generation, but I think that
the newly qualified man is more mercenary in
his outlook now than he used to be.

The third danger against which I would warn
you at this point is the premature engagement;
indeed, it may easity be the cause of your
running into either of the two false courses to
which I have already referred. Don’t make a
three-legged race of it too soon. I know the
sentimental reasons in favor of doing so — the
“stimulus of having some one to work for” and
so on. I remember too the advice of the old
lady : “Young man, don’t he a doctor. You
can’t marry till you get a practice and you can’t
get a practice till you are married.” It remains
true that at this stage of the race “he travels
the fastest who travels alone.” When Eros
calls, you are not likely to remember this
advice; but, as Sir William Osier used to say,
“You must learn to keep your emotions in cold
storage.”

CHOICE OF A LINE

Having escaped these hazards, you have to
choose your line of country. I would advise you
not to decide hastily but to have a good look
round first and get as much general experience
as you can by doing resident appointments. On
the other hand, it is unwise to hold such posts
too long; sooner or later you must strike out
on your own. Don’t become an appointments
addict.

There are plenty of lines to choose from, for
in the house of Medicine are many mansions;
but I suppose the majority of you will find
j'ourselves in general practice. I am not going
to throw boquets at the general practitioner,
for he needs no praise of mine. It is customary
to describe him as “the backbone of the profes-
sion,” but I prefer to regard him as the soldier
in the front line of the medical army who has
to withstand, often single handed, the first
assault of disease. He is all the more to he
envied on that account. A man in a good
country practice particularly is a real doctor,
not a mere sorting machine for consultants or
hospitals, and is probably living as full, useful
and happy a life as our profession offers.

I may warn you of another danger in the
race. Those of you who have read the Pilgrim’s
Progress may remember that at one point
Christian was joined by two men, Formalist
and Hypocrisjy who got into the way of climbing
over the wall instead of entering by the gate,
and you will find in the race of practice that
some persons get on to the course without
having first jumped the hurdles. We call these
quacks and, like the two men of Bunyan’s
vision, they' come from the land of Vainglory
and we may say to them, as Christian said to
Formalist and Hypocrisy, “You walk by the
rude working of your fancies.” I should advise
you not to regard them as real competitors and
above all never to imitate their methods of
running. They may beat you sometimes in
treatment, for patients still like magic, but in
matters of diagnosis you will always leave them
standing.

THE MEANING OF SUCCESS

If you ask what makes for success in the race
of practice I cannot tell you. It is not knowledge
or manners, for a doctor may achieve a large
practice without either of these. The power of
inspiring confidence is possibly the one thing
needful, but I really don’t know. Everything
depends on what one means by success. Some
estimate it in terms of money and it is foolish to
say that this does not count; some think of
honors of one sort or another, but these are of
little value unless bestowed by one’s fellow
competitors. Let us agree that so far as practice
is concerned that man has succeeded who has
gained both the affection of his patients and the
esteem of his colleagues.

When all is said and done, ours is a race m
which there are many kinds of success and no
one winner. Perhaps it is not so much where
vou come in as how you ran that matters.

They win who never near Ihc goal.

They run who halt on maimed feel,

Art has its martyrs like the soul
Its victors in defeat.

And that is true of the art of medicine.

Volume 113
Number 22

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

2011

Medical College News

Medical schools, hospitals and individuals will confer a favor by sending to these headquarters original
contributions, reviews and news items to be considered for publication in the Student Section.

Annual Meeting of Association of Medical Students
The fourth annual meeting of the Association of
Medical Students will he held at the Dctroit-Leland
Hotel, Detroit, December 22-29. Among the speakers
will be Drs. Morris Fishbein, Chicago, Editor of The
Journal; George W. Crile, Cleveland; Walter C.
Alvarez, Rochester, Minn., and Frederick A. Coller,
Ann Arbor, Mich. The registration fee, including
luncheon, dinner, dance and two or three nights at the
hotel, will be $8.50; the fee is $3.50 for those not stay-
ing at the hotel. At a meeting of the National Executive
Committee of the Association of Medical Students, New
York City, July 3-5, it was decided that chapter dele-
gates to the national conventions shall be elected on the
basis of one for every twenty paid-up members as of
December 1. Each delegate shall be entitled to one
vote.

Prizes to Encourage Writing
The University of Indiana School of Medicine,
Indianapolis, announces that Mr. II. Osterman, of
Seymour, Ind., has offered annual prizes for out-
standing papers by students in the medical school.
There will be three prizes of $30, $25 and $25 for
case reports; three prizes of the same amounts for sta-
tistical studies, and two prizes of $25 and $15 for
outstanding papers. The judges for the selection of the
winners comprise the editors of the Bulletin of Indiana
University Medical Center: Drs. Jacob K. Berman,
Willis D. Gatch, Robert L. Glass, Harold M. Trusler,
Ernest Rupel, Edgar F. Kiser and Frederick W. Taylor.

One in Ten Applicants Accepted at Temple
The thirty-eighth session of Temple University
School of Medicine, Philadelphia, opened September 20
with the following enrolment: freshmen, 110; sopho-
mores, 98; juniors, 118; seniors, 119. The total of
445 includes 127 students enrolled for the first time.
These students completed their premedical courses in
• sixty-seven colleges. The states represented are Cali-
fornia, Connecticut, Delaware, Florida, Idaho, Michi-
gan, New Hampshire, New Jersey, New York, North
Carolina, Ohio, Pennsylvania, South Dakota, Utah,
Washington and West Virginia; Puerto Rico is also
represented. There are seventy-two Pennsylvanians,
twenty-three sons and daughters of physicians and also
six women students. The freshman class was selected
from a total of 1,196 applicants who submitted formal
applications and credentials.

Student Opinion Surveys

For more than two years Student Opinion Surveys
of America, with headquarters at the University of
Texas, has been conducting research on public opinion
among the college students of America. Personal
interviews are used to gather opinions at regular inter-
vals in colleges throughout the United States, and the
ballots are then mailed to Austin, Texas, for national
tabulation. This is the only such college poll, it is
said, that uses personal interviews to gather opinions.
In this way a cross section is established, and the
opinions of the million and a half college students
are measured accurately. The project is concerned
only with disclosing facts about student sentiment and
does not seek to influence public opinion. Pressure
groups or student movements have no part in the sur-
veys. Ballots are carefully distributed according to

geographic sections, sex, age, class in college, political
affiliation, whether the student works or not, and
type of school. Among college papers which will
published these polls is The Tiger, Journal of Tulane
University of Louisiana School of Medicine, where the
personal interviews will be conducted by Malter
Salatich, member of The Tiger staff, with Spurgeon M.
Wingo editor of The Tiger acting as local director of
the polls.

Fellowships at Washington University School
of Medicine

Students at Washington University School of Medi-
cine, St. Louis, in the upper three classes of the school
who are deserving on the basis of need, scholarship
and character may obtain loans granted by the chan-
cellor on recommendation of the Committee on Loans
and Scholarships and the dean. For example, under
the will of the late Jackson Johnson, $250,000 was
donated to the university', the income from which is
used to aid worthy and desirable students in acquiring
a medical education. From this fund honor scholar-
ships are provided to exceptional students who are
applicants for the first year class, each scholarship
carrying an annual stipend of at least $300 and not
more than $1,000. The Eliza McMillan Student Aid
Fund comprises the annual income from $7,000, which
may be awarded to a deserving woman student in the
school of medicine. The T. Griswold Comstock
scholarships comprise the annual income from $12,000,
which is used for two scholarships for students who
otherwise would be unable to obtain a medical educa-
tion. There is also the Alumni Scholarship Award of
$100 to be applied on payment of tuition fee, given
for excellence in work during the preceding scholastic
year. Application for all these awards and aids should
be made to the dean of the medical school.

The Medical Son of an American Physician in Argentina
The son of an American doctor occupies a very high
place in the memories of Argentine physicians. Dr.
Aman Rawson, a United States Navy physician, on his
third trip to South America decided to settle in the
Plata region in 1818, the year when San Martin’s vic-
tory at Maipu secured its independence from Spain.
Dr. Rawson’s son, Guillermo (William), was named
after the Philadelphia colleague who had induced the
father to go to Argentina. Guillermo Rawson was
renowned not only as a physician but also as a
statesman. It has been said that he was too valuable
in politics to be allowed to be buried in his profession.
Rawson’s versatile personality and achievements have
recently been sketched (Araoz Alfaro, G. : Cronicas y
Estampas del Pasado, 1938; Un Vastago Norteameri-
cano en la Republica Argentina: Guillermo Raw-
son, 1939). Memorials have been raised to him in
Buenos Aires. He was the first professor of public
health in Argentina and his classes were the most
popular in the school. He submitted to the inter-
national congress in Philadelphia in 1876 the first
study of the vital statistics of Buenos Aires. In 1854
he foresaw aerial navigation by machines heavier
than air. Rawson, as a member of the cabinet, signed
the contract for the first cross counlrv railroad in
Argentina (1864), drew the bill for the "creation of a
department of agriculture and put through congress
the law on a national census. One of Rawson’s most
noted characteristics was liis devotion to the country
of his parents. No occasion was neglected by him to

2012

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Jour, A. M. A.
Nov 23, 1930

bring American principles to the attention of Iris
countrymen. One of liis books deals •with American
politics. His standards were high; not even a bid to
the presidency could make him change his stand.
At his death a state funeral was decreed, and former
President Mitre truly said that never had he known a
man more closely approaching moral perfection.

which each member receives a pro rata dividend at the
end of the school year. A member is charged a small
membership fee. The association is under the control
of a board of student directors.

Aid to Students at Western Reserve

Dr. Cannon Addresses North Dakota Students
Dr. Walter B. Cannon, Boston, gave three addresses
to the students of the University of North Dakota
School of Medicine, Grand Forks, October 11. His
subjects were “Chemical Mediation of Nerve Impulses,”
“Maintenance of Bodily States” and “Effects of Strong
Emotions.” The lectures were arranged through the
cooperation of the medical school, the Grand Forks
District Medical Society and Sigma Xi.

Loans to Students at Medical College of Virginia
The Medical College of Virginia, Richmond, has
certain funds from which limited amounts may be
loaned to assist worthy medical students in the pursuit
of their studies. Small amounts are available from
the William Karp Memorial Loan Fund and the Lewis
Z. Morris Memorial Fund. The Student Body Loan
Fund was appropriated from unexpended balances
from organized student activities for the purpose of
making loans to students through a committee of the
student body and the secretary-treasurer of the
college. There is the Benjamin Hobson Frayser Loan
Fund,- the General Loan Fund and the State Loan Fund,
the last derived from an appropriation by the state
of Virginia of $1,000 annually for loans to Virginia
students of ability and character who are in financial
need. The amount lent in any one session from the
State Loan Fund to students of medicine is limited to
$137.50. Preference will be given to applicants who
have completed the first year course.

Fees at the Medical College of Virginia

The tuition for medical students at the Medical
College of Virginia, Richmond, is $275 for Virginia
students and $400 for non-Virginians. There is a
matriculation fee of $10, as well as laboratory fees in
the first and second years of $15, a contingent deposit
of $20, student health service $12, student activities
$12 and certain few other fees connected with gradua-
tion.

Senior medical students at this school, unless
residents of Richmond or excused for special reasons,
are required to live and board at Hunton Hall, in
which the rate for the session, payable one half at
the beginning of each semester, is $150 for single
rooms; $130 per student for double rooms, with board
at $22 a month. The rate for board is subject to change
without notice. Suitable board and room may be
obtained in the ci ty r of Richmond from $30 to $35 a
month.

After the first year in the school of medicine it is
often possible for a student to find outside employment
to help pay expenses. There are junior internships
and other hospital positions, for example. Students
are not encouraged to seek employment which requires
any appreciable amount of time, as it frequently leads
to failure in college work.

Student Organization at Western Reserve
The student body at Western Reserve University
School of Medicine, Cleveland, has organized the Stu-
dent Cooperative Association for the cooperative pur-
chase of instruments, books and other supplies, from

Western Reserve University School of Medicine,
Cleveland, has available certain funds from which
limited loans to promising and needy students can
be made. These funds are provided by the Medical
Alumni Association, the Student Aid Fund and the
Biggar estate. During the last school year, twenty-five
students received fellowships, scholarships or loans.
The medical school feels that it is impossible for medi-
cal students to undertake any other work during the
school term without serious and perhaps fatal detri-
ment to their medical studies. However, the school
will endeavor to assist students to obtain suitable
employment should this become absolutely necessary.
In such cases the student should first consult the class
adviser. The total necessary expenses at the school for
thirty-four weeks, including books, instruments, board
and room, but exclusive of tuition and fees, according
to the Western Reserve University Bulletin, need not
exceed $800.

Loans for Women Students
A trust fund of $5,000 was established years ago in
the Woman’s Medical College of Pennsylvania, Phila-
delphia, by Elizabeth H. Francis for the purpose of
assisting needy students, for which loans interest is
charged at such a rate as the committee may decide.
These loans are secured by an endorsed note, a life
insurance policy or such other security as shall he
acceptable to the board of corporators. Repayment in
instalments begin not later than three years from the
date of graduation and must be completed within seven
years from that date.

Other means of assisting students are available,
including awards of scholarships and other loan funds.

Expenses of Woman’s Medical College
The Bulletin of the Woman’s Medical College of
Pennsylvania, Philadelphia, estimates that the expense^
for the first year in the medical school are as follows.

Matriculation fee

General tuition fee (admitting student to all lectures
and laboratory courses belonging to the year) . . . <

Library fee « 00

Credential fee

Medical service fee (entitling student to x-ray examina-
tion of chest, which is required on admission, jo
advice at the daily student dispensary hour aT Jd t°
emergency care at her room by the student piij’si-
cian; it docs not entitle the student to free care in g ^

the hospital) ^00

Materials fee g'oo

Breakage deposit '50

Locker charge

Getting Acquainted at Tufts College
At Tufts College Medical School, Boston, there s is, a
mique method of achieving a desirable student-la -
•elationship. Five of the faculty members an
lean, representing such diverse groups as tne ..
niltec on Admissions and the Alumni Council, •
ute the Student Relations Committee, lhc . c] ’ a '," ‘ v>
>f which, Dr. Benjamin Speclor, professor of anaw
s the first member of the faculty to come 0 f

vith the new class. During the first few .

he year Dr. Spcctor prefaces his lectures on • *
vith the introduction of some member of tJ • *

vho talks briefly to the new students. A V n0 \vn

er of the faculty have in this fashion bee .; on

a the new students, the entire faculty holds a P

Volume 113
Number 22

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

2013

for first year men and women. The Student Relations
Committee assists at this reception by rotating the
individual faculty members among the students from
group to group while a buffet supper is served. Infor-
mality is the keynote. Following the supper, the presi-
dent, the dean and others give brief words of greeting.
This procedure has been employed for several years
with much success.

Long Island College of Medicine
The Student Council at the Long Island College of
Medicine, Brooklyn, is conducting a survey of the
economic status of the students to determine what
percentage of them must earn tuition, room and board,
and how much assistance they receive from other
sources. Bob Hughes is directing the study for the
Student Council. Should the results of the survey
warrant, the Student Council may suggest that an
employment bureau be established at the college. Last
summer the majority of the present senior class served
junior internships; six members of the class, however,
worked on a statistical project in venereal diseases
being conducted by the U. S. Public Health Service.
Each one of these six students, among other things, had
to read many hundred of venereal disease case his-
tories. The present freshman class at the college has
ninety-nine members, graduates of forty-three colleges
and universities. The school year opened September 25
with a formal ceremony in the amphitheater at Pol-
hemus. At the last commencement the address was
delivered by Dr. Charles Gordon, professor of clinical
obstetrics and gynecology, and director of the teach-
ing division of that department at the Kings County
Hospital, Brooklyn.

History of Medicine for Freshmen
The series of lectures on medical history announced
for the freshman class at Tulane University of Louisi-
ana School of Medicine, New Orleans, was initiated
October 4 by a lecture on the “History of Tulane” by
the dean, Dr. C. C. Bass, and followed October 25 by
a lecture on the “History of Anatomy” by Dr. B. Ber-
nard Weinstein. Other lectures have been scheduled
in this series as follows : “Development of Microscopic
Anatomy,” Harold Cummins, Ph.D., November 15;
“History of Physiology,” Hymen S. Mayerson, Ph.D.,
November 29; “History of Physiology,” Dr. Mayerson,
December G; “Development of Biochemistry,” Sidney B.
Bliss, Ph.D., December 13: Dates are to be assigned
for the following lectures: “History of Pathology,”
Dr. Charles W. Duval; “History of Parasitology, Ernest
C. Faust, Pli.D.; “Landmarks in Medicine,” Dr. John H.
Musser; “The Instrumental Aids in Medicine,” Dr.
Roy H. Turner; “The Rise of Hospital and Public
Health Service,” Dr. William H. Perkins; “The Develop-
ment of Psychiatry,” Dr. Theodore A. Watters; “The
Development of Pharmacology,” Dr. Erwin E. Nelson;
“Medical Bibliography and the Use of the Library,”
Mary L. Hutton.

Scholarships at Maryland

Among the scholarships available at the School of
Medicine of the University of Maryland are the Dr.
Samuel Leon Frank Scholarship ($100) — no student
may hold this scholarship for more than two years;
the two Charles M. Hitchcock Scholarships ($100
each); the Randolph Winslow Scholarship ($100),
awarded annually to a needy student of the senior,
junior or sophomore class, who must have maintained
an average grade of S5 per cent in all his work; the
Dr. Leo Karlinsky Memorial Scholarship ($125); the
University Scholarship, which entitles the holder to
exemption from payment of tuition fee for the year,
awarded to a senior student in need of assistance;

the Frederica Gehrmann Scholarship ($200), awarded
to a third year student who has passed the best practi-
cal examinations in certain subjects; the five Clarence
and Generva Warfield Scholarships ($300 each), avail-
able to students of any of the classes, but a recipient
must, after graduation and a year’s internship, practice
for two years in the county of Maryland to which the
student is accredited or in a county selected by the
medical council; the Israel and Cecilia E. Cohen
Scholarship ($150), a recipient being obliged after
graduation and a year’s internship to practice for two
years in the county to which he is accredited; and the
Dr. Horace Bruce Hetrick Scholarship ($125) awarded
by the Medical Council to a student of the senior class.

Personal Expenses at Maryland
Estimates of a student’s personal expenses in Balti-
more for the academic year of eight months at the
School of Medicine of the University of Maryland have
been prepared by students based on actual experience.
The following estimates appear in the latest available
bulletin of the school; there is in addition a certain
expenditure for a microscope :

Items

Low

Average

Liberal

Books

.? 50

$ /i >

?100

College incidentals

20

20

20

Board, eight months

200

250

275

Boom rent

04

80

100

Clothing and laundry

50

80

150

All other expenses

25

50

75

Total '...

-?409

§556

8720

Aid for Students at Nebraska
Scholarships are available in the various depart-
ments of the University of Nebraska College of
Medicine, Omaha, in return for student assistance;
applications should be made to the chairmen of the
various departments. In addition, there is available
the income from the Jetur Riggs Conkling and
Jennie Hanscom Conkling Foundation, which is to be
used in providing scholarship loans for deserving
medical students, awarded only after the close of the
first year in medical college, and the scholarship
loans are not to exceed $200 a year; the Omaha Medi-
cal College Foundation Fund of more than $15,000,
the income from which is available to worthy students.
Students should make a written application for benefits
under this fund to the dean of the medical school.
The Nebraska Federation of Women’s Clubs makes an
annual grant of $200 to a student in the college of
medicine on the basis of scholarship and financial
need.

Student Society at Pittsburgh
The Students’ Medical Society "of the University of
Pittsburgh School of Medicine holds quarterly
scientific meetings at the Pittsburgh Academy o'f
Medicine, where papers written by medical students
are read. The society also sponsors an annual
reception for the freshman class, the medical school
year book and a student loan fund.

Expenses at Nebraska

According to the Bulletin of the Universiit / of
Nebraska College of Medicine, the expenses at this
school are estimated in part as follows:

board may be oMaincd in the vicinity of the college campus
at an average of ?G a week. Comfortable rooms for individuals
cost from ?10 to ?15 a month. Students rooming together may
obtain comfortable rooming quarters at approximately ?8 a month
each. The average expense of the student for a school year,
including boohs, instruments and all fees, is between S 700 ami

mo Students should provide an allowance of ^5 a vear for
books and instruments.

2014

AMERICAN MEDICAL ASSOCIATION STUDENT SECTION

Jour. A. M. A.
Nov 25, 1933

Loan Funds at University of Illinois

The University of Illinois College of Medicine,
Chicago, has available a number of loan funds for the
benefit of worthy students who are in need of financial
aid in order to finish their courses at the school.
Applicants should apply to the dean’s office for detailed
information.

Students having the following undergraduate
scholarships at this school are exempt from matricula-
tion and tuition fees but are required to pay all
laboratory and dispensary fees:

General Assembly Scholarships — One nomination each year by
each member of the general assembly. Nomination must be
received by the president of the university not later than the first
Monday in July.

State Military Scholarships — for World War Veterans, Special
provisions were passed by the General Assembly in 1919. Address
the registrar of the University of Illinois at Urbana for detailed
information about these scholarships.

Additional scholarships include the following:

Four Rea scholarships. These are awarded each year by officers
of the faculty for worthy students. These scholarships last year
were granted to Henry S. Bcrnet, Glenn A. Hoss, Leland J. Morten-
son and LeRoy E. Walter.

The Charles Spencer Williamson Memorial Scholarship. This
is awarded annually to a capable and needy student either
graduate or undergraduate, the award to be made by the dean
and head of the department of medicine. Last year this scholar-
ship was awarded to Harve W. Jour dan Jr.

The Theodore 13. Schnitzer Memorial Scholarship. This scholar-
ship of $100 annually is available to a needy Jewish student who
ranks in the upper half of his class and has completed at least
one year in the college of medicine. This scholarship is awarded
by a committee of the facultj' and in 1938 was awarded to
Milton Feinberg.

The late Dr. Frank Smithies endowed an annual
prize in memory of William Beaumont, which is
awarded by a committee to the student or faculty
member who submits the best original work on
diseases of the alimentary tract. In 1938 the twelfth
award was made to Dr. Alexander ,T. Nedzel.

A $100 prize is given every other year for the best
contribution in the field of allergy by any student or
member of the faculty of the college of medicine. This
prize will be awarded in 1939.

The annual Sigma Xi prize of $25 for the best
scientific investigation by any student in the college
of medicine, the college of dentistry or the graduate
school was awarded last year to Milton Engel and
Philip Wesoke for their paper entitled “A Cephalo-
metric Appraisal of Congenital Hypothyroidism.”

Georgia

A chapter of Alpha Omega Alpha, honorary medical
society, has been installed at Emory University School
of Medicine, Atlanta. Dr. Walter L. Bierring, Com-
missioner of Health of Iowa and national president
of the fraternity, was present and conferred the
charter of Beta chapter of Georgia. The student
initiates who were chapter members were Frederick W.
Cooper, Talbert Cooper, Cecil B. Elliott, John P.
Gifford, John R. McCain and John H. Ridley.

Fees at Stanford University School of Medicine

membership in the Associated Students. All students
registered in San Francisco are charged a student
health fee of $5 a quarter, a fee of $1 for student
athletic privileges and, during the winter quarter, a
student body fee of $1.

A general library fee of fifty cents a quarter is
charged each undergraduate and graduate student
registered in the university except students in the
school of medicine in San Francisco and students
registered in professional schools collecting their own
library fees.

In addition, students are charged for the materials
which they use. They also may be required by any
department to make a deposit to cover breakage or
loss of apparatus and materials, such deposits being
returnable, less charge for breakage, loss or wear and
tear of apparatus. The total deposits fordhis purpose
may vary from $10 to $20 a quarter.

Drafts and checks should be drawn for the exact
amount to the order of Stanford University School of
Medicine, as no change can be returned to students on
checks or drafts.

Aid to Students at Stanford
Among the scholarships, loan funds and fellowships
available to medical students at Stanford University
are the Florence Heclit Fries scholarship in medicine,
the income from a fund of $5,000 awarded annually to
a needy student; the Carrie Hassler Scholarship, tbe
income from a fund of $6,300 awarded annually; tbe
Agnes Walker Scholarship, the income from $12,000
awarded annually to a woman medical student; tbe
Alpha Omega Alpha Loan Fund administered by the
dean of the school of medicine; the Alumni Jordan
Medical Scholarship Loan Fund, for the purpose of
paying the tuition fees of several medical students of
high standing with the stipulation that at some future
time the amount will be returned; the Dr. Robert
Patek Memorial Loan Fund lo assist medical students
in completing their courses. The loans bear no interest
until one year after graduation and then bear 0 per
cent interest until paid; the Stanford Medical Alumni
Revolving Loan Fund, restricted to medical students in
San Francisco (loans are limited to $50 at any one
time); the Romaine Josephine Stanley Fund; the Dr.
Phil H. Weber Fund for deserving students, the loans
bearing 6 per cent interest annually until paid; tic
Women’s Auxiliary of the Alameda County Medici i
Association Fund, lending $100 to a third or four j
year student whose home is in Alameda County, an<
the Jane Darling Stevenson Memorial Fund, the loan
being restricted to women medical students in '
advanced classes. This particular fund is adminis ere
by the chairman of the National Committee of P ‘
Epsilon Iota, Dr. Monica Donovan, suite 1839, 4p
ter Street, San Francisco. Information concerning
other funds mentioned may he had from the ( - >
Stanford University School of Medicine, San run

Tiie tuition fee for students in the school of medicine
is $115 a quarter. A deposit of $20 is required of each
applicant admitted to the entering class or to advanced
standing in the school of medicine within ten days
after receiving notice of his selection, this deposit
being applied on the payment of his medical fees for
the first quarter.

The community fee for all students, except those
registered at San Francisco, is $15 a quarter. This
fee covers the privilege of the gymnasiums, athletic
grounds, the Hospital Fund, the Stanford Union or
Women’s Clubhouse, the Memorial Hall Fund, and

Wisconsin State Board Questions ^
The following questions in roentgenology were g'V^
the examination held in Milwaukee June - - > s;

the Wisconsin State Board of Medical Exai

1. What are the characteristics of a fracture line- rocn t1

2. What are the x-ray characteristics of a !>?“**"“ ’’ ,. pI „|U

3. What are the commonest x-ray charactcrist

of the bone? -himres?

i. Docs hyperpituitarism produce any hone c •«; slo nrs?
5. How would you differentiate gallstones from hldur.

AR ouestions were to be answered.

The Journal of the
American Medical Association

Published Under the Auspices of the Board of Trustees

Vol. 113, No. 23

Copyright, 1939, by American Medical Association

Chicago, Illinois

December 2, 1939

ACUTE PERFORATION OF PEPTIC
ULCER

IMMEDIATE AND LATE RESULTS IN
FIVE HUNDRED CASES

HAROLD LINCOLN THOMPSON, M.D., Ph.D.

LOS ANGELES

In the treatment of acute perforation of peptic ulcer
neither the immediate nor the late results are wholly
satisfactory. Immediate mortality is distressing and
subsequent morbidity often embarrassing. Yet, con-
sidering the percentage of deaths when the condition is
neglected, one is heartened by the fact that a majority
of lives are saved by surgical treatment.

Immediate mortality in peptic ulcer complicated by
acute perforation is dependent on many factors. The
more important factors are not always under the control
of the surgeon. Subsequent morbidity follows perfora-
tion largely because in most instances the risk to life is
such as to prevent the surgeon’s doing anything toward
the cure of ulcer at the time of operation. Obviously if
improvement in immediate and late results is to be
obtained it must be accomplished through better control
of the factors which affect morbidity and mortality. As
surgeons, we must accept the challenge from the mani-
fest need for improvement in end results.

LITERATURE

The literature on immediate results concerns itself
chiefly with mortality and early symptomatic relief. The
literature on late results revolves around the perma-
nency of symptomatic relief and the further medical or
surgical requirements of the patient. Published figures
on mortality range all the way from 0 to 85.7 per cent,
depending somewhat on the size of the series under
discussion*. For example, among Eliason and Ebe-
ling’s 1 collected cases there are seven reported series
consisting of from six to twenty-two cases each in which
there was no mortality.. However, in eighteen series
each consisting of 100 or more cases the mortality
ranged from 12.9 to 38.8 per cent.

In 1908 Moynihan, 2 a pioneer in gastric surgery,
reported a series of twenty-seven operations for per-
foration in which the mortality was 34 per cent. By
1928 his series had grown to 237 cases wherein the
average mortality was 25 per cent. In Eliason and
Ebeling’s collected American series of 1,940 cases the
mortality was 25.9 per cent, whereas in their European

Rend before the Section on Surgery, General and Abdominal, at the
Ninetieth Annual Session of the American Medical Association, St. Louis,
May 19. 1939.

1. Eliason, E. L., and Ebeling, W. W.: Am. J. Sure. 24 : 63-82
(April) 1934.

2. Moynihan, B. G. A.: Brit. M. J. X: 1092-1096, 190S: Practitioner
120: 137-174 (March) 1928.

series of 3,121 cases the mortality was 22.6 per cent.
The average mortality in 5,061 collected cases, there-
fore, was 23.9 per cent.

Other factors which play a part in mortality are the
interval between perforation and operation and the type
of operation performed. Storey 3 in 1936 reviewed a
series of 261 cases in which the mortality ranged from
6.1 to 85.7 per cent, depending on the interval between
perforation and operation. In a similar report by
McC'reery 4 in 1938 the mortality ranged from 4.3 to
80 per cent.

In 1924 Bundschuh 5 reported a small series of cases
wherein mortality following conservative surgical treat-
ment was 62.5 per cent whereas following radical pyloric
resection it was only 16.6 per cent. Yudin 6 in 1937
reported 331 Billroth I and Polya pyloric resections
with the remarkably low mortality of 7.8 per cent. In
1937 Shawan 7 reviewed 356 cases from the Detroit
Receiving Hospital wherein the mortality ranged from
9.5 to 50 per cent with active treatment, depending on
the type of operation employed.

Lewisohn 8 in 1928 reported failure to cure in 39
per cent of cases, and in 1929 Olson and Cable 0 found
persistent symptoms in 10 to 67 per cent of cases,
depending on the type of operation performed.

In 1932, Shelley 10 reported follow-up analysis of
fifty-nine cases traced for from one to five years and
found 67 per cent cures.

PRESENT SERIES OF CASES

This report is based on an analysis of 500 cases of
acute perforation of peptic ulcer collected from the
charity services of Los Angeles hospitals' between
Sept. 9, 1921, and June 30, 1934. Except for 1.8 per
cent of cases in which the clinical diagnosis was correct
beyond doubt, all the perforations were proved by oper-
ation or autopsy. This requirement of proof automatic-
ally excluded many cases in which the condition was
clinically diagnosed and medically treated, especially
those in which recovery took place. The mortality
figures are affected accordingly.

Operations were performed by fifty-seven surgeons,
with an average of 8.7 cases each. Such factors as
site of perforation, 11 causes of death 12 and other clinical
features 13 of the present series of cases are reported
elsewhere.

3. Storey, J. C.: M. J. Australia 1 : 52-59 (Jan 11) 1936.

4. McCreery. J. A.: Ann. Surg. 107: 350-358 (March) 1938

5. Bundschuh: Arch. f. klin. Chir. 129:281-296, 1924.

6. Yudin, S. S.: Surg., Gynec. & Obst. C4 : 63-68 (Jan.) 1937

7. Shatvan, II. K. : J. Michigan M. Soc. 3G: 629-632 (Sept ) 1937

8. Leivisohn, Richard: Ann. Surg. 87: 855-860 (June) 1928

1929 ° l5 ° n ’ F ' A " and Cab,e ' M ' L ' : ' M ‘ nn ' SIed ' 12:468 - 4;, 8 (Aug.) 9
JO. Shelley, H. J.: Am. J. Surg. 15: 277-30 3 (Feb.) 1932.

II- Thompson, H. L.: Surg., Gynec. & Obst. 64: 863-871 (May) 1937.
pp 1 25^2° mI>50n ’ d ^ * ^ r0C ' Second Cong. Pan-Pacific S. A., 1936,

1936 Thon,I,son ’ H - L ” California & West. Med. 44 : 469-474 (June)

2016

PERFORATION OF PEPTIC ULCER— THOMPSON

Jour. A. SI. A.
Dec. 2, 1939

IMMEDIATE RESULTS

Clinical Results, — According to the hospital records
206, or 41.2 per cent, of the patients were followed for
periods ranging from a few weeks up to eighteen months
(fig. 1). Among them 125, or 60.6 per cent, obtained
complete relief after operation, whereas sixty-five, or
31.5 per cent, required medical treatment and sixteen,
or 7.7 per cent, required further surgical treatment, as

Followed up to is months Complete relief

Further medical treatment Further surgical treatment

Fig. 1. — Immediate clinical results.

shown in the accompanying table. In seven cases, or
3.3 per cent, reperforation of peptic ulcer occurred,
whereas in twelve, or 5.8 per cent, massive hemorrhage
took place.

Of the cases in which further surgical treatment was
required, gastrojejunostomy for obstruction was per-
formed in eight, simple closure of reperforation and
pylorectomy each were performed in two, whereas
exploration, jejunostomy, pyloroplasty and sleeve resec-
tion were performed in one case each.

Gastrojejunal ulcer occurred in two of the cases in
which gastrojejunostomy had been performed.

Gross Mortality . — Gross mortality, the mortality
irrespective of the type, promptness or lack of treatment,
includes the entire group of 500 cases (fig. 2). In this
series 197 patients died, representing a gross mortality

of 39.4 per cent. In

60.6 per cent of cases
recover}' took place.

Type of Treat-
ment. — In seventy-
six cases nonsurgical
or expectant treat-
ment was used (fig.
3). In this group
there was only one
recover}', which rep-
resents a mortality of

95.6 per cent. In
424 cases surgical
treatment was used,
with a mortality of

28.7 per cent. It is
to be noted that be-
tween the two types of treatment the spread in mortality
amounts to 70 per cent.

Interval . — The interval between perforation and oper-
ation long has been known as one of the most important
efactors which concern mortality and one which it is
possible for the surgeon to control in only a portion
of the cases. Generally it is taught that the mortality
is directly proportional to the interval. That this is
not always the case is shown by this study (fig. 4).

RECOVERED

303 CASE 5 60.6 PERCENT

DIED

197 CASES 39.4 PERCENT/

Fig. 2. —Gross mortality irrespective of
surgical or expectant treatment.

The cases are divided into four groups. In the first
group the perforation had existed six hours or less;
in the second, for seven to twelve hours ; in the third!
thirteen to twenty-four hours, and in the fourth, twenty-
four hours or more. The first two groups comprise
130 and 168 cases, respectively. It is of interest to
note that the figures for mortality in these two groups
are within 0.5 per cent of each other, being 21.5 and
22 per cent, respectively.

Comparing the third group with the second, one finds
a sharp rise in mortality to more than double when
operation is delayed until the second twelve hour period.
On the other hand, in tire fourth group there is a reduc-
tion of mortality by 12 per cent among those whose
operation was delayed for twenty-four hours or more.
In view of the extremely high mortality in patients
treated expectantly, I am sure no one would wait until
the first twenty-four hours had elapsed to perform oper-
ation, other things being equal.

The most important point is that the lowest mortality
occurs when operation is performed within the six hour
period. However, it may be that sometimes operation
had better be deferred, just as is the case in appendi-
citis.

Surgical Procedure . — The type of surgical procedure
has a direct bearing on mortality (fig. 5). In 148 cases

424 CASES

SURGICAL

Fig. 3 . — Relation of treatment to mortality.

wherein simple closure, that is, without suture of a tag
of omentum over the perforation, was employed, the
mortality was 34.4 per cent. In tills connection it is

The Type of Operation Employed and the Complications IVhich
Required Early Secondary Surgical Procedure
in Sixteen Cases

No. of

Operation Cases

Gastrojejunostomy 8

Simple suture 2

Pylorectomy 2

Pyloroplasty . 1

Jejunostomy 1

Sleeve resection 1

Exploration only. 1

Complications p

Hemorrhage

Obstruction

Reperforation

Gastrojejunal ulcer

No. of
Cases
. 12
. 8
. 2
. 2

highly important to note that in 242 cases wherein a tag
of omentum was sutured over the perforation, the mor-
tality fell off 10 per cent.

In thirteen selected cases wherein some procedure
was added to closure, such as gastrojejunostomy or
pyloroplasty, there were not any deaths. Two things
should be taken into account with regard to this group-
first, that the series is small, and second, that the
patients were selected for their good general condition
before the additional procedure was begun.

Volume 113
Number 23

PERFORATION OF PEPTIC ULCER— THOMPSON

2017

Drainage . — As is well known, the recent tendency is
in the direction of employment of less and less drainage
in acute perforation of peptic ulcer, except perhaps when
purulent peritonitis is present. In a small group of fifty-
seven cases wherein drainage was not employed, the
mortality was 14 per cent (fig. 6) . In seventy-one cases
wherein a single drain to the site of the ulcer was used,
the mortality was 19.7 per cent. In seventy-five cases
wherein a single drain elsewhere was used, the mortality
was 32 per cent. In 208 cases drainage of multiple
areas was attended by a mortality of 34.4 per cent.
It seems fair to point out that in the cases wherein
drainage was not employed, the general condition of
the patients doubtless was better and the risk of opera-
tion less than in the others, particularly those in whom
multiple areas were drained.

Anesthesia . — In this series of cases only four types
of anesthesia were used, namely, ether (in some
instances gas followed by ether), nitrous oxide alone,
and spinal and local infiltration of procaine hydrochlo-
ride (fig. 7). In the first group there were 239 cases

130

CASES

6 HOURS OR LESS

168

CASES

7 TO 12 HOURS

54 75

CASES CASES

13 TO 24 HOURS 24 HOURS OR MORE

Fig. 4. — Relation of the interval between perforation and operation to
mortality.

in which spinal anesthesia was used with sixty-five
deaths, representing a mortality of 27.1 per cent. In
the second group there were 145 cases in which ether
was used with forty-one deaths, or a mortality of 28.5
per cent. In this group of eighteen cases in which
nitrous oxide only was used the mortality was over
10 per cent higher, with seven deaths and 38.8 per cent
mortality. In the group of seven cases in which local
anesthesia alone was used there were six deaths, or
a mortality of 90.7 per cent.

LATE RESULTS

Owing to the shift in population among persons who
make up this series of cases late follow-up study was
possible in only 10 per cent. However a group of
fifty-one cases allows some interesting deductions
(fig. S) . The time they were followed varied from three
to fifteen years. It was five years or over in thirty-four
cases, or 66 per cent ; four years in thirteen cases, and
three years in four cases.

Deaths . — Deaths were reported in two, or 3.9 per
cent, of followed cases. One patient died in the same
hospital fifteen years later, at which time mention of

gastrointestinal trouble was not made on his clinical or
autopsy records. The other patient was readmitted to
the hospital a few months after operation with a diag-
nosis of senile psychosis, for which he was committed
to a mental institution, from which he was reported to
have died some months later.

148

CASES

SIMPLE SUTURE WITH-
OUT TAfi OF OMENTUM

242

CASES

13

SELECTED

CASES

l

O

PERCENT

SIMPLE SUTURE WITH
TAG OF OMENTUM

EXCISION OF „

ULCER. PYLOROPLASTY.
GASTROJEJUNOSTOMY ETC

Fig. 5. — Relation of surgical procedure to mortality.

Relief . — When it was asked if complete relief was
obtained after operation the affirmative was reported
in nineteen cases, or 38.7 per cent, whereas incomplete
relief was secured in 61.2 per cent. However, it was
stated that symptoms had not persisted or recurred in
only twelve__cases, or 24.4 per cent. Correlation
between this opinion on the part of the patient and his
report of persisting symptoms was not possible from the
nature of these reports. .

Subsequent Treatment . — Some type of subsequent
therapeutic care was required in all but twelve cases.-
Self medication was sufficient in twenty, or 40.8 per cent,
but the care of a physician was necessary in fifteen, or

NO DRAINAGE

7ICASES

W9

^JLpercent^^^—

SINGLE DRAIN TO
REGION OF PERFORATION

75 CASES

206 CASES

SINGLE DRAIN DRAINAGE OF

ELSEWHERE MULTIPLE AREAS

Fig. 6. — Relation of drainage to mortality.

30.6 per cent. Only two patients had had further sur-*
gical treatment. One had had a gastrojejunostomy
for obstruction. The other had been symptom free for
ten years when hemorrhage occurred for which gastro-
jejunostomy subsequently was performed. However

2018

PERFORATION OF PEPTIC ULCER— THOMPSON

Jour. A. M. A.
Dec. 2, 1939

further surgical procedure was advised in two more
cases ; in one it was declined and in the other deferred
because of arterial hypertension.

Disability Inability to work since operation was
experienced in twenty-one cases, or 42.8 per cent. Dis-
ability was not experienced in twenty-eight, or 57.1
per cent.

COMMENT

The gross mortality reported in the present study
in comparison with that of other reported series of
cases is relatively high. This is partially explained
by the fact that in over 98 per cent of cases the diagno-
sis of acute perforation was proved by operation or
autopsy. Unless some such criterion of proof is estab-

Fig. 7. — Relation of anesthesia to mortality.

lished the inclusion of any considerable number of
clinically diagnosed cases in a study of this subject
will unavoidably admit cases of appendicitis, pancreatitis
and cholecystitis. The results will be modified accord-
ingly.

For the same reason the mortality in the group of
patients treated expectantly is extremely high. It is
fair to point out that most of the patients in this group
were moribund or beyond surgical aid when first seen.
None of the patients in this group were treated by the
continuous siphonage method. In the group treated
surgically, on the other hand, the mortality compares
favorably with that of other American series.

Regarding mortality with respect to anesthesia, it
should be noted that in most of the cases wherein
local infiltration of procaine hydrochloride was used
the condition of the patient was so poor as to make
the use of other methods of anesthesia objectionable.
Spinal anesthesia was the most recent addition to anes-
thetic procedures, and it is quite possible that the
patients in this group benefited also from other recent
improvements in the handling of acute perforation of
peptic ulcer.

While the group of cases on which the study of
late results is based is not large, it represents the most
important aspect of this study.

CONCLUSIONS

From this analysis of immediate and late results of
treatment in acute perforation of peptic ulcer several
• conclusions may be drawn :

1. The gross mortality in cases of proved acute per-
foration of peptic ulcer is approximately 40 per cent.

2. Mortality may be materially lowered by the appli-
cation of surgical treatment.

3. Mortality is lowest when operation is performed
within six hours after perforation, when spinal anesthe-
sia is used, when the operation consists of suture
of a tag of omentum over the closed perforation and
when drainage is not employed.

4. In approximately 40 per cent of cases continuation
or resumption of treatment is required within five years,
and in 10 per cent the treatment will be surgical.

1930 Wilshire Boulevard.

ABSTRACT OF DISCUSSION
Dr. Dan C. Donald, Birmingham, Ala. : Prompt surgery
in acute perforated peptic ulcer stands out in the lead of all
other factors governing the mortality rate. Among the sur-
gical procedures, simple closure of the perforated ulcer by
multiple interrupted sutures incorporating the omental tag is
favored by the majority of statistics, with a death rate mea-
sured chiefly by the time interval (inception of perforation
until patient reaches surgery). For late results, 39 per cent
of the patients with perforated peptic ulcer following simple
closure continue to have ulcer symptoms, and a small percent-
age of the ulcers will reperforate. In consideration of late
symptoms and complications of reperforation, I feel that simple
closure might be altered by pyloroplasty in the duodenal and
pyloric ulcer, provided the duodenum is mobile and peritonitis
is not present. Through pyloroplasty I have lowered the diges-
tive complaints to 10 per cent and the mortality rate to as
low as or lower than that following simple closure. Ninety
per cent of perforated peptic ulcers occur near the pylorus, and
the duodenal ulcer is ten to one greater than the gastric ulcer,
and rarely is it more than 2 cm. from the pylorus. In pyloro-
plasty the ulcer-bearing tissue is excised in an elliptic manner
along the course of the bowel, incision is carried through the
pyloric ring on to the stomach for 4 cm. more and the opening
is closed in transversely. The advantages from this type of
operation are: the ulcer is removed, pyloric spasm is overcome
and the opening between the stomach and the duodenum is
enlarged, permitting a reflux of the alkaline secretions from
the intestinal juices to aid in minimizing the acid chyme of
the stomach. The keynote of success resulting from surgery
in cases of perforated ulcer of the duodenum is to permit the
stomach to drain by duodenal route rather than by gastro-

408

pfKfnr .

306

PERCtNI

W

Self medication

Physician's

TREATMENT

Surgical

TREATMENT

f ADVISED IN 2 ADOfTJONW CASES)

Deaths

FROM OTHER CAUSES

.Complete relief

FROM SYMPTOMS

Disability

SUBSEQUENT TREATMENT REQUIRED

Fig, S. — Late results in fifty-one cases followed from three to fifteen
years.

jejunostomy, wherein the gastric content with a high hj ro*
chloric acid unit is permitted to flow into the jejunum, wnic t
is often followed by a marginal ulcer. Only in definite obstruc-
tion of the duodenal type of perforated ulcer should Eas p
jejunostomy be considered; such perforations are rare in 11
entity. In all acute attacks the perforated gastric ulcer shou
be excised by simple closure with interrupted sutures mcor
porating the omental tag.

Dr. J. William Thompson, St. Louis: We have mad e a
clinical study of the results in the surgical treatment o P-
forated peptic ulcers at the St. Louis City Hospita .

Volume 113
Number" 23

NUCLEUS PULPOSUS— SPURLING AND BRADFORD

2019

series of 152 cases compares in many ways with that from the
Los Angeles County Hospital. The diagnosis of perforated
peptic ulcer is usually not difficult. Occasionally an acutely
perforated ulcer is confused with acute appendicitis. We take
roentgenograms of the chest and abdomen as a routine in order
to reveal the presence of air under the right leaf of the dia-
phragm. I believe that this is a most important procedure
and should be used a great deal more frequently, especially
in making a differential diagnosis in doubtful cases. Our
investigations show no seasonal variation in tire incidence of
perforation. The mortality rate in perforated ulcer goes up
tremendously in patients past the age of 60. Therefore it is
important to consider surgical treatment of peptic ulcers in
patients past middle age. Peptic ulcer is an extremely com-
mon disease, and familiarity should not breed contempt leading
to overprolonged medical treatment. Ulcers on the gastric side
of the pyloric sphincter are frequently malignant, no matter
what size, and therefore should be operated on when there is
the slightest doubt as to the exact nature of the lesion. In
this way a few patients will be prevented from dying from
complications of perforation. The procedures used in our series
are essentially the same. ^.Icgt of them were simple closures,
and the results are better in those cases in which this method
was used. The mortality rate was 25 per cent, a little lower
than that of Dr. H. L. Thomp son. A policy of doing more
extensive operations such as pyloroplasty and gastro-enterostomy,

I think, should be frown ed orp In an exceptional case they
are occasionally justifiable. .

Dr. Charles Brown Odom, New Orleans : Dr. DeBakey
has reviewed 211 cases admitted to Charity Hospital in New
Orleans during the last ten years. It has been recognized that
the incidence of peptic ulcer is increasing. However, the fre-
quency of acute perforation is becoming disproportionately
greater. Although thf percentage of ulcers per hundred thou-
sand admissions increased from 0.0444 in 1929 to 0.0614 in
1938, comparable figures for acute perforations were 0.0139 and
0.0782. Contrary to the general impression that perforated
ulcer occurs rarely in Negroes, race incidence in our series
revealed almost equal frequency : 128 (60.6 per cent) white and
83 (39.3 per cent) Negro patients. Basing these respective
incidences on corresponding hundred thousand admissions, these
figures are' 0.0403 and 0.0364 per cent. There was no signifi-
cant seasonal variation in our cases. A review of more than
15,000 cases reported in the literature revealed variations too
wide to be significant. Mortality incidence in this series was
found to depend on several factors, one of the most important
being the number of hours after the perforation. All cases that
were not proved perforations were disregarded. In eig hty-two
cases operation was performed within six hours witK nine
deaths, a mortality of 10.9 per cent; sixty-six cases within
twelve hours with ten deaths, a 15.1 per cent mortality; nine-
teen cases within eighteen hours with five d eaths, a higher
mortality. After twenty-four hours there were nine deaths in
nineteen cases, or 47.3 per cent. I don’t believe one can treat
perforated peptic ulcer any other way than by surgery. I
think that Dr. Thompson's figure after the twenty-four hour
period is misleading. The type of operation was another factor
in the mortality rate : in 200 cases treatment was by simple
closure with thirty-three deaths. With other operative pro-
cedures the mortality rate immediately increased. In seven
cases in which other procedures were " used three deaths
occurred. The anesthetic was another factor in mortality. I
believe that block anesthesia is the best anesthesia to use in
these cases. Whereas of seven cases in which epidural block
and 154 cases in which spinal anesthesia were used, the mor-
tality incidences were 0 and 15.7 per cent respectively; of
forty-three cases in which general anesthesia and five cases
in which local analgesia were employed, the respective death
rates were 22.7 per cent and 60 per cent.

Dr. Harold Lincoln Thompson, Los Angeles: The etiol-
ogy, pathology and diagnosis in this group of cases have been
studied statistically and are reported elsewhere. I believe that
one can approach the truth in this condition only when a large
series of cases is considered. I know of no other way to
smooth out the marked variations that are found in reports
on smaller groups of cases. I hope to make a report on a

more recent series of 500 cases in the near future. I should
like to call attention again to the fact that these were proved
perforations. This authentication is the only means by which
to approach accuracy in a study of this kind. Regarding spinal
anesthesia, it is possible, since the spinal method is the most
recent addition to our methods of anesthesia, that the patients
in this group also benefited by other recent technical improve-
ments in treatment.

NEUROLOGIC ASPECTS OF HERNIATED
NUCLEUS PULPOSUS

AT THE FOURTH AND FIFTH LUMBAR
INTERSPACES

R. GLEN SPURLING, M.D.

LOUISVILLE, KY.

AND

F. KEITH BRADFORD, M.D.

HOUSTON, TEXAS

As recently as a year ago it was considered imperative
to confirm any presumptive diagnosis of herniated
nucleus pulposus of the lower lumbar intervertebral
disks by roentgenologic examination of the spinal canal
after injection of some contrast medium . 1 .However,
even a year ago in cases of severe, persistent sciatic
pain associated with pain low in the back and rigidity,
together with hypesthesia of the lateral aspect of the
involved Jeg and diminution of the ankle, jerk; surgical
exploration gave positive results regardless of the type
of defect demonstrated with iodized oil. Conversely, all
too frequently in cases of what were thought to be char-
acteristic defects demonstrable with iodized oil but in
which the neurologic; evidence was less characteristic,
exploration gave negative results. On the basis of our
experience with a series of eighty-five low intraspinal
lesions treated surgically we shall present what we have
found- to be the characteristic clinical picture of her-
niated nucleus pulposus at the fourth and fifth lumbar
interspaces.

The term “herniated nucleus pulposus” is used in
preference to “protruded intervertebral disk” because
disease of the disk is rarely responsible for nerve root
compression except when the annulus fibrosus has
ruptured and allowed the nucleus pulposus to extrude
through the defect.

It must be emphasized in the beginning that the
history and neurologic signs of herniated nucleus pul-
posus are not peculiar to this one clinicopathologic
entity. Neoplasm along the course of the sciatic nerve,
rectal or pelvic disease and disease of the osseous struc-
tures must be ruled out by regional and roentgenologic
examinations before the clinical diagnosis of herniated
nucleus pulposus can be made.

ANATOMIC CONSIDERATIONS

It is necessary to review the structure and innervation
of the lower lumbar region to obtain a better under-
standing of the symptoms and signs of herniated nucleus
pulposus. The relations between the fifth lumbar nerve
and the disk between the fourth and fifth lumbar
vertebrae and between the first sacral nerve and the
lumbosacral disk are especially important, since in more

from me Department ot Surgery, University of Louisville School ol
Medicine.

Read before the Section on Radiology at the Ninetieth Annual Session
of the American Medical Association, St. Louis, May 17, 1939

L Love, J. G., and Walsh, -Maurice: Protruded Intervertebral Disks*
Report of 100 Cases in Which Operation \Vas Performed TAMA*
1X1.: 396 (July 30) .1938. Spurling, R. Glen, and Bradford f! Keith'-
is' «« \ 9 to'° nS n a ii '\ c i use of Back and Sciatic Pain, J. Med.

f T 535 *' Bell, J. C., and Spurling, R. Glen: Concerning
y}ct*) ,a j938 IS ° f Les,ons ,n ttle f-otver Spinal Canal, Radiology 31:473

rJ . jr aND BRADFORD
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Volume 113
Number 23

NUCLEUS PULPOSUS — SPURL1NG AND BRADFORD

2021

Patients with herniated nucleus pulposus at the fourth
or fifth lumbar disk exhibit much the same appearance
of the lumbar spine as patients with other severe
articular disease of this region. This part of the spine
is usually straight, with spasm of the erector spinae
muscles, especially on bending forward. Listing to
one side is common, with the ilium usually higher on
the affected side. Limitation of flexion of the lumbar
spine is marked in all patients in whom pain in the
back is conspicuous and present to some degree in the
remainder.

As Lasegue 4 pointed out, many patients with severe
sciatic pain keep the knee flexed and are unwilling to
put the heel to the floor, thus preventing direct tension
on the sciatic nerve. The test that bears his name accu-
rately differentiates the patients with painful hamstring
muscles from those with lesions affecting the com-
ponents of the sciatic nerve. It is performed with the
patient supine. The thigh is raised to right angles with
the trunk, and the leg, which has remained flexed, is
extended on the thigh until pain begins along the course
of the sciatic nerve. Without further movement of the
leg or thigh, the foot is passively dorsiflexed to deter-
mine whether this additional pull on the sciatic nerve
exaggerates the pain. The results are positive in all
cases of lateral herniation of the nucleus pulposus.

Occasionally, pressure directly or laterally on the
spinous processes of the fourth and fifth lumbar ver-
tebrae or pressure just lateral to the spines over the
lumbar muscles will elicit pain in the distribution of
the sciatic nerve. If present, this sign is highly indic-
ative of herniated nucleus pulposus.

In a moderate percentage of patients with 'pain on
coughing or sneezing, sustained pressure over both
internal jugular veins reproduces or exaggerates the
sciatic pain. This, a positive Naffziger 5 reaction, is
pathognomonic of intraspinal disease.

Tests of the motor power are usually not of much
aid. Patients confuse pain on using the affected part
with weakness, and testing is unsatisfactory because
of the pain on exertion of motor power. However,
occasionally definite paresis or paralysis of the anterior
tibial, peroneal, extensor hallucis or extensor digitorum

Fig:. 3. — Approximate dermatome of the first sacral root: A, ventral
View; B, lateral view; C, dorsal view; D, mesial view.

communis muscles is seen. Fibrillation of muscles of
the leg is also seen in some cases. Much more impor-
tant is diminution or absence of the ankle jerk, which
usually occurs with herniation at the lumbosacral disk.

The sensory changes are most important in making
the diagnosis. Whether the herniation is at the fourth
lumbar or the lumbosacral disk, the lateral aspect of

4. Lasegue, Emst-Charles: Consideration sur la sciatique. Arch, r,,
de med. 2:55S, 1S64.

5. Naffriger, H. C., and Jones, 0. W.t Dermoid Tumors of the Soil
Cord, Arch. Neurol. & Psychiat. 3D: 941 (May) 19J5.

the leg will be hypesthetic in most cases. However,
herniation at the fourth lumbar disk (involvement of
the fifth lumbar and first sacral nerves) usually results
in hypesthesia of the anterolateral aspect of the leg with
inclusion of the great toe (figs. 2 and 3), while hernia-
tion at the lumbosacral disk (involvement of the first
and second sacral nerves) gives hypesthesia of the

Fig. 4. — Approximate dermatome of the second sacral root. A, ventral
view; B, lateral view; C, dorsal view; D, mesial view.

posterolateral aspect of the leg with inclusion of the
lateral aspect of the foot (figs. 3 and 4). Sensory
changes may also extend to the posterior aspect of
the thigh and the saddle region on one side, but, as a
rule, no diminution is observed above the knee.
Although the areas of hypesthesia can usually be deter-
mined with pinprick, testing with cotton wool or hot
and cold test tubes frequently reveals a definite area
of hypesthesia where results with pinprick were equiv-
ocal. Stimulation of the hypesthetic zone may produce
typical causalgic pain, limited to the area involved. The
causalgia may overshadow the hypesthesia.

Patients with herniation of the nucleus pulposus at
the fourth lumbar and the lumbosacral disk have in
common pain low in the back, severe sciatic pain, and
hypesthesia or anesthesia below the knee. If the ankle
jerk is unchanged and paresthesia or hypesthesia in
the leg is more anterior, including the great toe, the
fourth lumbar disk is more likely involved. If the
ankle jerk is diminished or absent and the hypesthesia
is more posterolateral, including the lateral aspect of
the foot, the herniation is probably at the lumbosacral
disk.

COMMENT

The recurrent episodes of pain low in the back which
usually precede the sciatic pain of herniated nucleus
pulposus are due to disease of the intervertebral disks
and posterior longitudinal ligament. Tearing of these
structures may result from frank trauma or as a result
of “wear and tear” on already degenerated structures.
The annulus fibrosus and posterior longitudinal liga-
ment are innervated by the recurrent branches of the
lumbar nerves. Pain predominates locally with perhaps
some spread to the gluteal regions or upper posterior
aspect of the thighs. But true sciatic pain is not caused
by involvement of the ligamentous structures alone.
Many patients with ligamentous injuries probably
recover without herniated nucleus pulposus developing
beneath the nerve roots. It must be remembered that
if the nucleus pulposus extrudes through the annulus
fibrosus without causing nerve compression the lesion
remains in the category of purely ligamentous injury.

However, in patients with disease of the annulus
fibrosus, herniation is likely to occur in a posterolateral
direction because of the poor lateral development of the
posterior longitudinal ligament which reenforces the

2022

MYELOGRAPHY— CHAMBERLAIN AND YOUNG

Jour. A. M. A.
Dec. 2, 1939

annulus fibrosus. At the fourth lumbar disk such a
posterolateral herniation compresses primarily the fifth
lumbar nerve just above its exit through the dural
sleeve. If it extends far laterally, it can and does,
rarely, compress the fourth lumbar nerve in its foramen.
If it extends medially, compressing the thecal sac from
the side, in addition to the fifth lumbar nerve, it will
compress the first and perhaps the second sacral nerve,
only displacing the other roots, whose fixation points of
exit are lower or on the opposite side. At either the
fourth lumbar or the lumbosacral disk an occasional
herniation is sufficiently large to compress a number of
roots against the ligamentum flavum or the lamina,
thereby producing more diffuse signs.

The first sacral nerve can be compressed by such a
posterolateral herniation without any indentation of the
dura mater, since its dural sleeve emerges above the
lumbosacral disk. Although herniation rarely extends
far enough laterally to involve the fifth lumbar nerve,
this can occur. Far more common is compression of
the dural sac in addition to compression of the first
sacral root, with resulting involvement of the second
and perhaps the third, fourth and fifth sacral roots.

It is the compression of one or more of these com-
ponents of the sciatic nerve which gives rise to the
severe “sciatica.” From involvement of either the fifth
lumbar or the first sacral root alone, pain can occur
along the course of the entire nerve. The sensory as
well as the motor innervation of the glutei, hamstrings
and leg muscles is contributed to by both these nerves,
which explains pain in these muscles. The absence of
pain in the iliopsoas, quadriceps femoris and adductors
is explained by their higher segmental innervation.

Although pain does occur in the dermatomes of the
involved spinal nerves, it is more often lacking. Pares-
thesias are far more frequent and important in accurate
clinical localization especially when coupled with objec-
tive sensory signs. Only in exceptional instances is
paresthesia or hypesthesia of the gluteal portions of the
dermatomes of the fifth lumbar and first and second
sacral nerves observed.

The usual absence of involvement of the ankle jerk
in herniation at the fourth lumbar disk (involvement
of the fifth lumbar nerve) and diminution (involve-
ment of the first sacral nerve) or absence (involvement
of the first and second sacral nerves) in herniations
at the lumbosacral disk are in keeping with the accepted
innervation of the gastrocnemius and soleus muscles by
the first and second sacral nerves. Confusing is the
fact that these muscles have rarely been found weak
and never paralyzed in cases of herniation of the nucleus
pulposus.

That these neurologic symptoms and signs are
accurate and reliable is attested by the fact that during
the past three months we have successfully removed
nine consecutive herniations of the nucleus pulposus
without confirmation with iodized oil or other contrast
mediums. In the same three months iodized oil was
used six times, with indication for operation in but two
instances. Even in these two cases the clinical evidence
pointed with reasonable certainty to the location of
the lesion, but as compensation was involved in both
cases verification with iodized oil was deemed advisable.
The present high incidence of positive results of explo-
ration, in contrast to our earlier results, 6 we owe chiefly
to the increased understanding of the neurologic

picture.

6 Bradford, F. Keith, and Spurlinc, R. Glen: Intraspiiml Causes of
J on- BacJr and Sciatic Pain: Results in Sixty Consecutive Low Lumbar
I-aminectomies, Surg,. Gvnec. & Obst., to be published.

SUMMARY

1. Although herniated nucleus pulposus of the fourth
lumbar and the lumbosacral disk has long appeared to
give an unorthodox neurologic picture, a more thorough
experience with this lesion has made possible accurate
diagnosis from clinical evidence alone in the majority
of instances.

2. The neurologic signs of herniated nucleus pul-
posus are not peculiar to this clinical entity, since neo-
plasm along the course of the sciatic nerve, pelvic and
rectal disease and disease of the osseous structures may
simulate the clinical picture.

Brown Building.

THE DIAGNOSIS OF INTERVERTEBRAL
DISK PROTRUSION BY INTRA-
SPINAL INJECTION OF AIR

AIR MYELOGRAPHY

W. EDWARD CHAMBERLAIN, M.D.

AND

BARTON R. YOUNG, M.D.

PHILADELPHIA

Air or oxygen serves as an excellent contrast medium
in the spinal canal for visualization of a protruded
intervertebral disk or any other space-taking lesion.
We have used gaseous contrast mediums as a routine
for the past three and one-half years with all patients
who have had sufficient symptoms and neurologic
evidence to make us suspect an intraspinal lesion. 1
Our experience, based on more than 300 spinograms,
indicates that the method is accurate and reliable, as
in each case in which operation was performed the

Fig. 1. — Normal lumbocaudal sac. Note the sharp definition of th
lateral margins of the sac as seen on the anteroposterior projection vni
the patient in the Trendelenburg position.

exact level of the lesion determined by myelograplnc
examination was verified by laminectomy. The pro-
cedure is harmless, so negative results cause no feeling
of apprehension as to unpleasant or dangerous sequelae,
such as might develop if the contrast medium were an
unabsorbable substance.

The use of air in the spinal canal was suggested by
Dandy = in 1918, but only in recent years has it been
possible to obtain sufficient contrast and detail m
roentgenograms to utilize gaseous contrast mediums.

From the Department of Radiology, Temple University
Medicine.

School of

Read before the Section on Radiology at the Ninetieth Session

of the American Medical Association, St. Louis, May IS, iJiJ- . {

1. We have used oxygen as a routine for more than a jear
it is absorbed faster than air and produces less discomfort.

2. Davdy, IV. E.: Ann. Surg. GS:5 (July)

Volume 113
Number 23

MYELOGRAPHY— CHAMBERLAIN AND YOUNG .

2023

In 1934 Coggeshall and von Storch 3 showed that the
lumbocaudal sac could be visualized by air, but their
report was limited to the results with three normal
patients. The same year Van Wagenen 4 reported three
cases of complete spinal block in which the lower level
of the lesion was visualized by injection of small
amounts of air. During the past year we and our asso-
ciates have reported our use of myelographic examina-
tion with air and oxygen in a number of articles. 5

The technic of injection varies somewhat, depending
on the level of the lesion. If a lesion is suspected below
the third lumbar vertebra, the patient is placed in a
lateral decubitus position, with the head of the table
lowered to an angle of from 20 to 25 degrees. An 18
or 20 gage spinal needle is inserted into the subarach-
noid space at the second lumbar interspace, and spinal
fluid and air are exchanged in 5 cc. quantities until air
escapes through the needle. Usually it takes from 40 to
50 cc. to fill the lumbocaudal sac in the adult (fig. 1).
In case the clinical evidence places the lesion above the
third lumbar vertebra, the spinal needle is inserted in
the third lumbar interspace with the patient in a hori-
zontal position and a Queckenstedt test is done. If this

Fig. 2. — Unilateral marginal indentation at the fifth lumbar interspace
due to a protruded intervertebral disk. A hypertrophied ligamentum
fiavura may produce a similar defect. There were complete disappearance
of the pain and restitution of function after removal of the disk.

test shows a partial or complete block, from 3 to 6 cc.
of spinal fluid is carefully replaced by an equal amount
of air so that the spinal fluid pressure is kept as con-
stant as possible. The patient is then placed in the
sitting posture with his back against a Potter-Bucky
diaphragm for the roentgenograms.

If the Queckenstedt test is negative, the dorsal sac
can be visualized by replacement of spinal fluid with air
by either lumbar or cisternal puncture. Nearly all our
patients had air introduced after lumbar puncture
because we are especially interested in the lumbocaudal
sac and have examined this area as a routine (even
though the signs pointed to a lesion in the dorsal
region) in order to obtain normal standards. If the
lumbocaudal sac is well filled there will be sufficient air
for visualization of the dorsal sac, but in order to get
the air into the dorsal region the patient is turned face
down and the table changed from the Trendelenburg to
the horizontal position. To visualize the subarachnoid

3* Coggeshall, II. C<, and von Storch, T. J. C.: Diagnostic Value of
Myelographic Studies of the Caudal Dural Sac, Arch. Neurol. & Psvchiat.
31:611 (March) 1934.

4. Van Wagenen, \\\ I\: Ann. Surg. 99:939-943 (June) 3934.

5. Scott, Michael, and Young, B. R. : Air Myelography in the Diag-
nosis of Lesions of the Spinal Canal, Arch. Neurol. & Psychiat. 38:
1126 (Nov.) 1937; Am. J. Roentgenol. 39:1S7 (Feb.) 1938; Confinia
Acurologica, to be published. Chamberlain, W. E., and Young, B. R,:
Radiology, to be published.

space in the cervical region it is necessary to do either
cisternal puncture with the patient in the Trendelenburg
position or lumbar puncture with complete drainage of
the cerebrospinal fluid as in encephalography.

Visualization of air in the spinal canal depends on
roentgenograms of good contrast and detail. We have
found that “overexposed” films give us more informa-

Fig. 3. — Normal posterior bulging of the ventral limiting membrane of
the lumbocaudal sac seen opposite each intervertebral disk when the patient
is in hyperextension. Hyperflexion produces flattening or straightening
of this ventral membrane.

tion, so we raise the kilovoltage from 8 to 10 above that
necessary for spinal detail. An ordinary horizontal
x-ray table equipped with a Potter-Bucky diaphragm
is used and, in order to get the necessary Trendelen-
burg position, one end is elevated by a chair or blocks.
The minimal film requirements in the lumbar region
are stereoscopic lateral and anteroposterior projections.
When the interest is centered in the upper dorsal or
cervical region, it is advisable to take stereoscopic
oblique projections as well as the lateral ones, because

rig. h.-— L hsplacement of the posterior longitudinal ligament dorsad by
a herniated intervertebral disk at the fourth lumbar interspace. (Compare
with the normal configuration of fig. 3.) Note the narrowing of the inter-
spa t ce ; u At .°P cratl ° n the sac below the protruded disk was almost oblit-
erated by the resultant arachnoiditis.

the superposed shadow of air in the trachea often inter-
feres with interpretation. The normal dorsal curve will
cause the air to remain below the fourth or fifth dorsal
segment, so the upper part of the thorax should be
elevated by small pillows or sand bags under the
shoulders, but the head must be lower than the air
column or air will ascend into the cranium and produce
headache.

2024

INTERVERTEBRAL DISKS— CAMP

We have been interested in the effects of hyperflexion
and hyperextension on the configuration of the ventral
limiting membrane of the lumbocaudal sac. For this
reason, as a routine we make additional stereoscopic'
lateral projections of the lumbar region in these special
positions. In every normal case the maneuver of hyper-
flexion is seen to flatten the contours of the ventral
surface of the sac, while hyperextension produces
plainly visible bulging of soft tissue contours into the
canal opposite each intervertebral disk. In a few cases
of intervertebral disk protrusion we have obtained some
evidence of accentuation of the disturbance during
extension of the spine and partial reduction of the pro-
trusion during flexion. Further studies along these
lines are being carried out.

The diagnosis of a herniated disk depends in most
cases on the indentation or encroachment of the limiting
membrane of the subarachnoid space. The one excep-
tion to this is seen when the disk has produced a com-
plete block of the canal and, if this is the case, the
inferior margin of the disk is easily demarcated by the
air bubble trapped under it (fig. 5). A herniated disk
nearly always carries the posterior longitudinal ligament
dorsad so that the indentation of the ventral aspect of
the air column is usually detected on the lateral projec-
tions (fig. 3). Commonly the defect is noted at the
level of the interspace, but if the protrusion is marked
the ventral limiting membrane of the canal will be
pushed dorsad for a variable distance below the inter-
space (fig. 4). The indentation of the air column due
to a herniated disk is not always seen on the lateral

Fie. S . — ^Herniated intervertebral disk producing incomplete block of the
subarachnoid space at the fourth ^ cervical segment. Three cc. of air
trapped under the disk revealed its level. The disk was removed at
laminectomy. The roentgenograms were taken immediately after the
patient was placed in an upright sitting position.

projections. In a number of cases the defect was visual-
ized only on the anteroposterior projections as a bilat-
eral waistlike constriction or a unilateral marginal
indentation (fig. 5).

SUMMARY AND CONCLUSIONS

Myelographic examination with air is a reliable and
harmless method of visualizing herniated intervertebral
disks and other space-taking lesions in the spinal canal.
The success of the method depends on proper technic
of air injection and roentgenograms of good contrast
and detail. We have had experience with more than
300 spinograms for which air or oxygen was the con-
trast medium. We consider the method reliable because
in ever}' case in which operation was performed the
level of the lesion predicted after myelographic examina-
tion was verified at laminectomy. Air studies have not
been misleading, as there were no instances in which

Jour. A. M. A.
Dec. 2, 12J9

the myelograms indicated a lesion without verification
at operation.

A major advantage of air and oxygen as contrast
mediums for myelographic examination is the fact that
their use does not entail leaving unabsorbable and pos-
sibly irritating substances in " the spinal canal. Even
those who believe that iodized oil is not contraindicated
for myelographic examination tend to reserve its use
to cases in which laminectomy is practically assured at
the time of the study. Because air and oxygen are com-
pletely absorbed from the subarachnoid space (oxygen
more promptly than air) there will be less hesitancy
about subjecting patients to myelographic examination
with such a contrast medium.

THE ROENTGENOLOGIC DIAGNOSIS
OF INTRASPINAL PROTRUSION •
OF INTERVERTEBRAL DISKS

BY MEANS OF RADIOPAQUE OIL
JOHN D. CAMP, M.D.

ROCHESTER, MINN.

Since Mixter and Barr 1 in 1934 emphasized the
significance of intraspinal protrusion of the inter-
vertebral disks as an important cause of low back pain
and sciatica, this condition has aroused no little interest.
During the past few years considerable literature con-
cerning the subject has appeared and the condition has
been firmly established as a definite clinical and patho-
logic entity. Pathologic studies of a large series of
protruded intervertebral disks by Deucher and Love 2
indicate that the protruded fragments are composed
of fibrocartilage, portions of the nucleus pulposus and
occasionally remnants of the notochord. These struc-
tures are not ordinarily opaque to roentgen rays and
cannot be demonstrated per se in plain roentgenograms.
Bone or calcium in quantities gross enough to be
revealed roentgenographically is so rare in these
protrusions that it is of little • practical diagnostic
importance.

For this reason the roentgenologist is dependent on
the use of some contrast agent for the indirect visuali-
zation of the protrusion. Several contrast agents, that
is, iodized poppyseed oil, 3 air 4 or oxygen, skiodan,
and colloidal thorium dioxide, 0 have been employed for
visualization of the spinal subarachnoid space. Each
of these substances has certain advantages and dis-
advantages. None of them so far have proved ideal
and sooner or later a nonirritating radiopaque agent
that can be absorbed and eliminated through the spinal
fluid will be developed. Such a substance should do
much to expand the usefulness of roentgenologic pro-
cedures in the study of neurologic conditions.

To date iodized oil lias been used more than any other
contrast agent for the roentgenologic, visualization of

From the Section on Roentgenology, the Mayo Clinic. .

Read before the Section on Radiology at the Ninetieth Aflflo bessi
of the American Medical Association, St. Louis, May 17, 1939.

1 . Mixter, W. J.. and Barr, J. S.: Rupture of ihc IntaverttM*
Disk with Involvement of the Spinal Canal, New England

21 T^,«:- a nd Love J. G.: Pathologic Aspect* of
Protrusion of the Intervertebral Disks, Arch. Path. 27:*-01-~Il (

I93 j! Sirard, J. A., and Forestier, T. : Methode Iterate a'«P
radiologique par Thuile iodee (Itprodof), Bull, et mem. Soc. tn
de Paris 1: 463-469 (March 17) 1922 . . . „ . . the Injection

4. Dandy, W. E.: Roentgenography of ^the Brain. After tl he Jnj
of Air into the Spina! Canal, Ann. Sure. 70: 39/-J03 fOrt.) 19i*

5. Araell, S., and Lidstrom, F.: Myelography with Skiodan lAoroc

Acta radiol. 12 s 287-288, 1931- . . , riar le

6. Radovici, A., and Meller, O.: Encepkalo-myclographie^

thorotrast sous-arachnoidien et ep' dural: R'jJ*** 1 * 1

Compt. rend. Soc. de bioi. 109: 138~-1384 (May 6) J93~*

Volume 113
Number 23

INTERVERTEBRAL DISKS— CAMP

2025

the spinal subarachnoid space and when employed
under proper circumstances it has resulted in an
accuracy of diagnosis that is shared by few other
roentgenologic procedures. The chief objection to the
use of iodized oil is that it is more or less of an irritant
to the meninges and is contraindicated in the presence
of inflammatory disease. The" significance of the irri-
tative action has been discussed pro and con in the
literature for some years but nevertheless it is the con-
sensus of observers who have
used it in a large number of
cases that in properly selected
cases the advantages of its use
far outweigh any disadvantages
that are known.

I have had no experience with
the use of colloidal thorium
dioxide for visualization of the
subarachnoid space. It is very
irritating to the cerebral menin-
ges, especially the ependyma,
and it is very probable that it
has the same effect on the spinal
meninges. The fact that it is
radioactive and has not been
accepted by the Council on
Pharmacy and Chemistry of the
American Medical Association makes it a drug to be
used with considerable discretion despite its desirability
from the standpoint of radiopacity alone.

The use of air or oxygen for the study of the spinal
subarachnoid space has been revived in recent years
and this procedure has much in its favor. 7 On the
other hand there are certain decided disadvantages. In
the first place, because of the difficulty in controlling
the position and distribution of the air (or oxygen)
its use with any satisfaction is restricted to the lumbar
canal. Secondly, the accuracy of the diagnosis with
air is not equal to that attained with iodized oil. My
own experience with the use of air as a substitute for
iodized oil in the case of lesions associated with low
back pain or sciatic pain indicates that iodized oil is
more accurate, that it will reveal certain structures
not demonstrated with air, and that it has localized
lesions that air has failed to disclose. There is no
doubt that air will reveal some lesions very satisfactorily
and can be used in many instances before iodized oil
is resorted to. However, the results of such an exami-
nation following the use of air should be carefully
appraised by the clinician in view of the limitations of
its accuracy.

INDICATIONS FOR THE USE OF IODIZED OIL

The indiscriminate use of iodized oil in cases of low
back or sciatic pain is not recommended. No contrast
agent should be used unless the clinical and neurologic
examination indicates the possible presence of an intra-
spinal lesion that cannot be localized by ordinary clin-
ical procedures. Increasing familiarity with the history
and neurologic examination in cases of protruded inter-
vertebral disks indicates that in a fair proportion of
cases the diagnosis and localization of the protrusion
can be made clinical 1}' without resorting to any con-
trast agent. 8 With this improvement in clinical diag-
nostic acumen the necessity for the use of a contrast

7. Young, B. R., and Scott, Michael : Air Myelography: The Substl-
tuhon of Air foT Lipiodol in Roentgen Visualization of Tumors and
Other Structures in the Spinal Canal, Am. J. Roentgenol. 39:187-192
(Feb.) 1938.

8. Craig, \V. McK., and Walsh, M. N.: The Diagnosis and Treat-
ment of Low Back and Sciatic Bain Caused by Protruded Intervertebral
Disk and Hypertrophied Ligaments, Minnesota Med. 22:511-517 (Aug.)

Fig. I.- — Protruded lumbo-
sacral intervertebral disk.
Classic unilateral deformity
of iodized oil shadow.

agent will probably diminish and be reserved for those
cases in which the diagnosis is in doubt and those in
which it is desirable to establish a very precise anatomic
'level of the lesion for the guidance of the neurosurgeon.

If the suspected level of a lesion is at the conus or
above, experience indicates that the use of air or
oxygen will not be helpful unless obstruction of the
subarachnoid space has occurred. This results from
the fact that air or oxygen is very difficult to hold in
position in the thoracic or cervical portion of the spinal
canal, and their use in these regions is further com-
plicated by the superimposition of the shadow of air
in the trachea, larynx and pharynx, which renders
the interpretation of resulting shadows exceedingly
difficult or impossible. Iodized oil, therefore, is the
medium of choice for the demonstration of lesions at
or above the conus.

Statistics indicate that the great majority of pro-
truded intervertebral disks occur in the lumbar and
lumbosacral regions where they are accessible to exami-

Multiple Protruded Intervertebral Disks

Affected Disks Number of Cases

Fifth and fourth lumbar 6

Fourth and third lumbar 14

Third and second lumbar . 1

First lumbar and twelfth thoracic 1

Twelfth and elev QT,fK 1

Eleventh dorsal i 1

Third, fourth an 1

Second, third ant 1

Eleventh dorsal, 1

Total 27

nation by either air or iodized oil.® Since there is a
reasonable chance that the protrusions may be disclosed
by air or oxygen, it is probably good judgment to
attempt their localization by this means before iodized
oil is resorted to. If the air studies are inconclusive
or unsatisfactory, iodized oil may then be used. If the
air studies are negative and the history and neurologic
examination are suggestive of the presence of a pro-
truded disk, iodized oil should be used to check the
spinogram. When the air studies reveal either a
deformity that will not account for the patient’s symp-

tig. 2.— Central type of protruded intervertebral disk. Various deformi-
ties occurring in the same case: (a) Deformity of iodized oil that results
when oil is allowed to collect above and below the protrusion, (b) Appar-
ent obliteration of defect when the mass of iodized oil is permitted to
pass over protrusion. The site of the protrusion is still revealed by the
area of diminished density at arrow a. (c) Prone-oblique position reveal-
ing deformity typical of protruded disk.

toms or a lesion the level of which is not compatible
with the symptoms, the results should be confirmed
with iodized oil before laminectomy is advised.

AMOUNT OF IODIZED OIL

It is well known that small amounts of iodized oil
(from 0.2 to 2 cc.) will localize the site of completely

♦ \ .^uuingxon, i\.: lmraspinal Lesions Asso-

Waidn".’^ and Thor Localization by Means of Lipiodol

'* ithm the Subarachnoid Space, Radiology, to be published.

2026

INTERVERTEBRAL DISKS — CAMP

obstructing lesions, but the neurologic examination in
these cases usually gives such results that nowadays
the level can be established without the use of iodized

oil. In the interest of
early diagnosis and for
the localization of lesions
before obstruction has
occurred, it is necessary
to use a quantity of
iodized oil sufficient to
fill the subarachnoid
space completely at any
desired level. For sev-
eral years I have advo-
cated the use of 5 cc. of
iodized oil because I have
found from previous
experience with smaller
amounts that this is the
optimal volume for
accurate and consistent
localization of nonob-
structing lesions. 10 Some
lesions can be shown with
lesser quantities but on
the other hand a number
o f surprisingly large
lesions and particularly
multiple lesions are easily
overlooked if amounts
less than 5 cc. are used.
The majority of protruded intervertebral disks do not
produce obstruction and 12 per cent of protruded
intervertebral disks in my experience have been

Fig. 3.— Protruded intervertebral
disk. Bilateral type of iodized oil
deformity.

Fig. 4 . — Primary hypertrophy of the ligamentum flavum without asso-
ciated protrusion of the intervertebral disk; (a) lateral view revealing
broad indentation on posterior aspect of column of iodized oil characteristic
of hypertroohied ligamentum flavum; (b) anteroposterior view revealing
broad bilateral indentation of iodized oil shadow resulting from hyper-
trophy of the ligamentum flavum. The deformity is more marked on the
left side.

multiple, as shown in the table. For this reason I still
believe that 5 cc. of iodized oil is the optimal amount
to use for the. demonstration of protruded disks even

10 Camp T. D.; Adson. A; W., and ShucrucyL J.: Rocntbenograrhic
Findings Associated with Tumors of f P \ 033 C ° Carcif

Associated Tissues, Am. J. Cancer 1 « : 34S-3/2 ! (Feb.) 1933. ^mp,
T D- Multiple Tumors 'Within the Spinal Canal: Diagnosis by Means
of I.ipiodol Injected into the Subaracnnoid Space (Myclographj), Am. J.
Roentgenol. SG: 775*7SI (Dec.) 1976.

Jour. A. Jr. A.
Dec. 2, 19 J9

though the majority occur, in a region of the spinal
column, that is easily: examined: . In 1 my" experience,
■ reactions. following the injection of. 5 cc. have been no
greater than those observed with '2 cc. '

; . TECHNIC OF INJECTION

The lumbar injection of iodized oil is preferred
because it is easier and safer to carry out than cisternal
puncture and will : facilitate the. keeping of "the. oil
together as one mass- in the lower part of the spinal
column — a point that is very important for the demon-
stration of smairiesions. It is important that the iodized
oil used be clear, transparent and only faintly yellow.
Oil that is brownish. should. be discarded, since this
indicates deterioration and 1 the' presence of free iodine,
.which is undesirable. Prior to injection the ampule is
warmed to a temperature of 105 F., which will increase
the fluidify of the oil and facilitate its injection. - If the

Fig. 5. — Protruded intervertebral disk between fourth and fifth lumbar
vertebrae and associated hypertrophy of the ligamentum flavum. ^r a I a< \
teristic deformity of iodized oil; (a) Lateral view. Iodized oil shadow
is indented anteriorly by the protruded intervertebral disk and posteriori/
by the hypertrophied ligamentum flavum. ( b ) Anteroposterior view. Fiotc
broad extent of deformity corresponding to site of ligamentum flavum.

injection is made with slow continuous pressure on
the syringe, droplet formation within the subarachnoid
space will he avoided.

ROENTGENOLOGIC TECHNIC
It is desirable that the roentgenologic study be carried
out as soon after the injection as possible, as delayed
examination and movements of the patient may lead to
separation of the mass of oil and droplet formation.
A tilting fluoroscopic table with appropriate foot and
shoulder rests is necessary for the roentgenologic
examination. Some method of quickly recording the
fluoroscopic image on films is highly" desirable. If a spot
film device is not available, excellent films may be made
by r sliding a cassette under the fluoroscopic screen,
delimiting the area by the fluoroscopic shutters and
changing from fluoroscopic to radiographic technic by
means of a quick change-over switch on the control
panel. In addition to localized “spot” films of the lesion,
a large film revealing several contiguous vertebrae is

Volume 113
Number 23

INTERVERTEBRAL DISKS— CAMP

2027

necessary in order to establish the anatomic level
accurately. This is extremely important when surgical
intervention is contemplated, because congenital vari-
ations at the lumbosacral junction or the presence of
additional lumbar vertebrae may easily mislead the
surgeon when counting spinous processes to determine
the site for laminectomy.

The details concerning the actual technic of the roent-
genologic examination for determining the presence of
a protruded interverte-
bral disk have been pub-
lished previously and will
not be repeated here. 11 If
the result of the exami-
nation of the lumbar
spinal subarachnoid
space is negative, I be-
lieve that it is important
to examine the subarach-
noid space higher up, as
recent observations 9
have revealed that 50 per
cent of patients with
tumors of the spinal cord
located in the thoracic
region and 30 per cent
of patients with such
tumors located in the
cervical region have low
back or sciatic pain or
both as an associated or
coincident symptom.

Quantities of iodized oil
less than 5 cc. are not
practical for this phase
of the examination because, smaller masses of oil are
rapidly diminished in size by the droplets that normally
separate out and lag behind as the oil moves cephalad
through the thoracic region. The quantity thus remain-
ing for study of the upper thoracic and cervical regions
is totally insufficient to portray even a large protruded
disk.

ROENTGENOLOGIC CHARACTERISTICS OF PROTRUDED
INTERVERTEBRAL DISKS

The deformity of the iodized oil shadow resulting
from a protruded intervertebral disk is influenced by
the following factors: (1) the position of the protru-
sion, (2) size of the protrusion, (3) associated hyper-
trophy of the ligamentum flavum, (4) changes in the
nerve roots (displacement, edema, nonfilling of affected
nerve root sleeve) and (5) anatomic variations of the
cul-de-sac.

Position of the Protrusion . — Except in very unusual
cases the protruded fragment is situated in the anterior
portion of the spinal canal and will produce its maximal
effect on the column of iodized oil when the patient is
lying in a prone or prone-oblique position. Since the
majority of protruded intervertebral disks present on
one side of the median line, the classic defect is a sharply
defined unilateral rounded indentation of the iodized oil
shadow opposite an intervertebral disk (fig. 1). It
occurs in about 65 per cent of cases. Midline protru-
sions when of moderate size may produce only a central
defect. They are most obvious when some of the oil is
allowed to accumulate just above and just below the

II. Camp, J. D.: Roentgenologic Findings in Cases of Protruded
Intervertebral Disks, Proc. Staff Meet., Mayo Clin. 12: 373-377 (June 16)
1937. Love, J. G., and Camp, J. D.: Root Pain Resulting from Intra-
Munal Protrusion of Intervertebral Disks: Diagnosis and Surgical
Treatment, J. Bone & Joint Surg. 19: 776-804 (July) 1937.

lesion (fig. 2 a). When the table is elevated and a large
quantity of iodized oil is permitted to flow over the
point of maximal protrusion, the central defect may
appear to be obliterated and convey the erroneous
impression that the region is normal (fig. 2 b ) . Repeated
observations at the site of such lesions will reveal that
the central defect will reappear whenever the oil is
allowed to move slowly away from the protrusion and
uncover the “hump” produced by the lesion. In the
prone-oblique or lateral position the defect of a central
protrusion will be quite obvious and the shadow of the
iodized oil that passes over the peak of the protrusion
will be clearly defined (fig. 2 c). Large central protru-
sions are easily recognized because the deformity that
they produce cannot be effaced regardless of the amount
of iodized oil at the site of the lesion. Partial obstruc-
tion is common in large central lesions.

Size of the Protrusion . — The extent of the iodized oil
defect is influenced naturally by the size of the protru-
sion. Any deformity to be of diagnostic significance
must be persistent, although the extent of the deformity
may be somewhat influenced by the volume of iodized
oil at the site of the lesion. In contrast to central pro-
trusions, unilateral lesions are usually most obvious
when a large mass of oil is present about it. Except as
the iodized oil deformity
may be influenced by the
presence of associated hy-
pertrophy of the. ligamen-
tum flavum, the larger the
protrusion the greater the
obstruction of the sub-
arachnoid space will be.

Partial obstruction occurs
in about 11 per cent of
cases and complete ob-
struction in only about 2.5
per cent of cases. The
larger the protrusion the
greater the tendency t o
produce a bilateral de-
formity, which occurs in
about 35 per cent of cases
(fig. 3). The presence or
absence of a bilateral de-
formity is also influenced
considerably by the pres-
ence or absence of hyper-
trophy of the ligamentum
flavum.

Hypertrophy of the
Ligamentum Flavum. —

This condition has been
found frequently by neuro-
surgeons in conjunction
with a protruded interver-
tebral disk. It generally
occurs at the same level-
as the protrusion but may
occasionally be found at
other interspaces. Local-
ized hypertrophy of the
ligamentum flavum without coincident protrusion of a
disk is not common, but when it does occur it may
imitate all the clinical phenomena of a protruded inter-
vertebral disk. Normally the ligamentum flavum forms
the posterior boundary of the intervertebral foramen
and extends posteriorly on each side to the midline
thus enclosing the spinal canal between the laminae.

Fig. 6 . — Protruded intervertebral
disk between fourth and fifth lumbar
vertebrae. Iodized oil deformity is
on the right side. Defect due to
edema of affected nerve root and ob-
literation of usual shadow of nerve
sleeve is indicated by arrow. Note
normal shadow of nerve sleeve on
opposite side.

7. — Protruded intervertebral
disk between second and third
lumbar vertebrae. Complete ob-
struction of iodized oil. a , shadow
of edematous right second lumbar
root, which is compressed by pro-
trusion.

2028

INTERVERTEBRAL DISKS— CAMP- jov*. a. m. a.

Dec. 2, 1939

Because of the anatomic location of the ligamentum
flavum, this structure when it hypertrophies will com-
press the column of iodized oil posteriorly and laterally.
Hypertrophy of the ligamentum flavum, when it occurs
without associated protrusion of an intervertebral disk,
is characterized in the lateral view by a broad or
rounded indentation on the posterior aspect of the

column of iodized oil be-
tween contiguous laminae 0
(fig. 4 a). In the prone
or supine position the
hypertrophy may be por-
trayed by broad indenta-
tion of the column of
iodized oil, sometimes
unilateral but generally
bilateral (fig. 4 b).

There is no constant re-
lation between the degree
of hypertrophy of the liga-
mentum flavum and the
size of the associated pro-
truded intervertebral disk.
It is not uncommon to find
a marked hypertrophy of
the ligamentum flavum in
association with a moder-
ate protrusion of the disk,
and under such circum-
stances the defect pro-
duced by the ligamentum
flavum is the predominant
part of the visible deform-
ity. Because of the size and extent of the normal liga-
mentum flavum, the iodized oil deformity that results
when it hypertrophies will extend over a longer area
than that occupied by the contiguous intervertebral
space and the area occupied by a protruded disk unless
the disk fragment is unusually large. Early in this
work, before the significance of hypertrophy of the liga-
mentum flavum was recognized, it was sometimes diffi-
cult to reconcile the large iodized oil deformity in certain
cases 'with the small protruded disk that was found at
operation. It is now clear that the defect was largely
the result of a hypertrophied ligament, the deformity
of which was not recognized.

When considerable hypertrophy of the ligamentum
flavum accompanies a large protruded disk, the iodized
oil defect is characteristic. The mass of iodized oil is
compressed between the protruded disk anteriorly and
the hypertrophied ligamentum flavum posteriorly and
laterally. The resultant deformity is shown in figure S a
and b. The narrow streak of iodized oil in the midline
represents the small quantity of oil that remains beneath
the angle posteriorly where the right and left halves of
the ligament meet. The upper and lower limits of the
defect are sharply defined owing to the termination of
the ligamentum flavum along its point of insertion on
the contiguous laminae.

Changes in the Shadozvs of Nerve Roots. The
shadows of nerve roots composing the cauda equina
are frequently visualized in the roentgenograms that are
made during the course of the study with iodized oil.
In about one third of the cases of protruded interver-
tebral disk, lateral or posterior displacement of the
nerve root shadows or both will be visible at the site
of the protrusion. The presence of such changes is
helpful in supporting a diagnosis of protruded inter-

Fig. 8. — Protruded lumbosacral
intervertebral disk. Iodized oil re-
veals narrow cul-de-sac and also
slight indentation on right side at
site of protrusion.

vertebral disk when the other iodized oil appearances
are atypical or are minimal in extent.

Edema of Contiguous Nerve Roots . — The significant
symptoms of a protruded disk are the result of pressure
exerted on the nerve roots by the protruded fragments.
Edema of an affected nerve root may result in three
ways; (1) by irritation of the root as it passes over
the protruded disk, (2) by compression of the root
between a protruded disk and the contiguous pedicle
of the vertebra or (3) by compression of the root
between a protruded disk and a hypertrophied liga-
mentum flavum either within the spinal canal or at the
point of emergence through the intervertebral fora-
men. In the latter case pressure on the nerve is
further increased by narrowing of the intervertebral
foramen, which results from the hypertrophied liga-
mentum flavum which forms its posterior boundary.
The edematous nerve root will displace additional
iodized oil at the site of protrusion and correspond-
ingly increase the deformity. An early change resulting
from edema of a nerve root is obliteration of the usual
shadow of the nerve sleeve where the root passes
through the dura (fig. 6). In some cases the shadow
of an edematous nerve root may extend one or more
segments above the level of the protrusion (fig. 7).
anomalies of the terminal portion of the cul-de-sac,
which occur in about 5 per cent of cases, may com-
plicate the roentgenologic diagnosis of a protruded
Anatomic Variations of the Cul-de-Sac. — Two
lumbosacral intervertebral disk. The first of these is an
anomaly in which the cul-de-sac terminates at the usual
site about the level of the second sacral segment but
is considerably narrower than normal below the level
of the fourth lumbar intervertebral space (fig. 8). In
such a case a moderate protrusion of a lumbosacral

disk may be present without
deforming the iodized oil in
the narrow subarachnoid
space and a large protrusion
may produce only a minimal
defect. The second anomaly
is one in which the cul-de-sac
terminates one or two seg-
ments more- cephalad than
usual with or without a vari-
ation in its diameter (fig. 9).

In a few instances the cul-
de-sac will terminate above
the level of the lumbosacral
interspace. In the presence
of either condition but espe-
cially of the latter, it is
obvious that a lumbosacral
protrusion may not be dis-
closed by iodized oil or any
other contrast agent. When
such anomalies are present
and the iodized oil examina-
tion is found to be negative,
the roentgenologist shown
state that the presence of a
protruded lumbosacral inter-
vertebral disk cannot be ex
eluded. This is important,
because if the history' and physical signs indicate tie
probable presence of a protruded intervertebral u' s *
an exploratory' laminectomy over the lumbosacral mte
space may be advisable.

Ftp. 9. — Protruded interver-
tebral disk between fourth and
fifth lumbar vertebrae. Note
absence of shadow of nerve
sleeve at site of protrusion.
Anomaly of the cul-de-sac,
which is short and terminates
just below the lumbosacral inter-
space. Compare with figure 1,
in which the cul-de-sac presents
the usual normal appearance.

2029

Volume 113 PROTRUSION OF

Number 23

ACCURACY OF THE METHOD

In a series of 203 cases in which laminectomy was
performed and in which a roentgenologic diagnosis of
protruded intervertebral disk bad been made, the diag-
nosis was confirmed by the surgeon in 194 instances.

In one case no lesion was found to account for the
iodized oil deformity (error of commission). In eight
instances a lesion other than a protruded disk was found
by the surgeon (error of interpretation) and they may
be listed as follows: chronic arachnoiditis with con-
traction of the dura, one; fracture of a twelfth thoracic
facet, one; vascular tumor, varices and so on, four;
hypertrophied ligamentum flavum, one; neurofibroma,
one. In the same period a protruded intervertebral
disk was found by the surgeon in seven other cases in
which the iodized oil examination had been reported as
negative. It is interesting that all of these occurred at
the lumbosacral junction, where there is a very good
anatomic reason for the error. At this level the spinal
canal is relatively large and the diameter of the caudal
sac may be small because of its fusiform termination.
Under such circumstances even a large protruded disk
may exist without indenting the sac. In five of these
seven cases an anomaly of the cul-de-sac, as referred to,
was present. It is obvious therefore that the iodized
oil studies revealed the presence or absence of a pro-
truded intervertebral disk with an accuracy of 92.3 per
cent in a series of 210 cases on which operation was
performed.

PROTRUDED INTERVERTEBRAL DISKS

WITH A NOTE REGARDING HYPERTROPHY
OF LIGAMENTA FLAVA

J. GRAFTON LOVE, M.D.

ROCHESTER, MINN.

Protrusion of intervertebral disks into the spinal
canal is a subject that has been much discussed during
the recent few years. 1 That it should assume a large
place in our daily efforts to relieve pain and suffering
is justified because of. the frequency with which we are
called on to treat intractable low back and sciatic pain,
which often is an expression of protrusion of an inter-
vertebral disk or disks in the lumbar region of the
spinal column. The protrusion of a portion of one or
more intervertebral fibrocartilages, with the consequent
compression of the spinal cord or of one or more nerve
roots, provides us with a real anatomic and pathologic
explanation for the disability experienced by many
patients. Such an explanation has been sorely needed.
Too many patients have been treated, all too often
unsuccessfully, for such incorrect and meaningless
diagnoses as “lumbosacral strain,” “sacro-iliac dislo-
cation,” “sciatic scoliosis,” “sciatic neuritis” and
“lumbago.”

Before proceeding further I should like to make
myself clear regarding the frequency of the condition
of protruded intervertebral disk which we are today
able to diagnose accurately, and I should like to warn
against considering every case of low back and sciatic
pain a case of protruded disk. There are many other
causes of pain in the lower part of the back and for
pain which extends into one or both lower extremities.

At the Mayo Clinic, every person with low back and
sciatic pain is seen by an orthopedic consultant either

From the Section or Neurologic Surgery, the Mayo Clinic.

Read before the Section on Radiology at the Ninetieth Annual Session
of the American Medical Association* St. Louis, May 17, 1939.

1. Articles on the subject (continued tn next column):

DISKS— LOVE

before the patient is referred to the neurologic section
or in consultation with the neurosurgeon. Dr. Hender-
son = has collected figures from the cross-index filing
system of the clinic which show that during the years
1935, 1936 and 1937 only 1.8 per cent of the patients
seen by the orthopedic consultants because of low back
and/or sciatic pain underwent laminectomy because of
a diagnosis of protruded intervertebral disk. After
the patients have been given their general physical and
orthopedic examinations and the majority of those
having low back and sciatic pain have been segregated,
so to speak, only about 40 per cent of the patients
suspected of having an intraspinal lesion as the causa-
tive factor in the complaint and referred to the neuro-
logic section for further investigation come to operation
for protruded intervertebral disk at the hands of the
neurosurgeons. 3

With this as an introduction to general discussion,
the analysis of our more than 300 proved operative
cases should excite no alarm about what might be
considered our “radical” treatment of sciatic pain. In
fact, it would seem that evidence is sufficient to justify
the statement that laminectomy accompanied by removal
of the protruded portion of an intervertebral disk is
possibly the least radical of any known curative treat-
ment for such a disabling condition.

During the past few years our experience with pro-
truded intervertebral disks has been so extensive that
we have been able, after a careful analytic study, to
formulate a characteristic symptom complex for the
lumbar lesions. 2

A patient presenting himself for treatment with a
complaint of intractable low back and sciatic pain, and
who on examination exhibits spasm of the. lumbar
muscles, loss of the normal lumbar lordosis, positive
Lasegue’s and Kernig’s signs, sciatic tenderness and
diminution or absence of the liomolateral achilles tendon
reflex, is very likely to be suffering from a protruded
intervertebral disk. If, in addition, there is a moderate
elevation of the total protein content of the cerebro-
spinal fluid obtained on puncture in the lower part of
the lumbar segment, and if there is a narrowing of
the fourth or fifth lumbar intervertebral space, the
picture is complete and a diagnosis of protrusion of a

Love, J. G.: Protrusion of the Intervertebral Disk (Fibrocartilage) into
the Spinal Canal, Proc. Staff Meet., Mayo Clin. 11: 529-534 (Aug.
19) 1936.

Love, J. G. : The Role of Intervertebral Disks in the Production of
Chronic Low Back and Sciatic Pain, ibid. 12: 369-372 (June 12)
1937.

Love, J. G.: Special Nerve Root Retractor Used in Removing Pro-
truded Intervertebral Disks, ibid. 12: 393-394 (June 23) 1937.

Love, J. G., and Camp, J. D.: Root Pain Resulting from Intraspinal
Protrusion of Intervertebral Disks: Diagnosis and Surgical Treat-
ment, J. Bone & Joint Surg. 19:776-804 (July) 1937.

Walsh, M. N., and Love, J. G. : Protruded Intervertebral Disk as a
Cause of Intractable Pain, Proc. Staff Meet., Mayo Clin. 13: 203-
205 (March 30) 1938.

Love, J. G.: Recurrent Protrusion of an Intervertebral Disk, ibid.
13: 404-408 (June 29) 1938.

Love, J. G., and Walsh, M. N.: Protruded Intervertebral Disks:
Report of One Hundred Cases in Which Operation Was Performed,
J. A. M. A. Ill: 396-400 (July 30) 1938.

Deucher, IV. G., and Love, J. G.: Posterior Protrusions of the Inter-
vertebral Disks: Pathologic-Anatomic Aspects, Proc. Staff Meet.,
Mayo Clin. 13 : 697-699 (Nov. 2) 1938.

Love, J. G.; Adson, A. W., and Craig, W. McK.: Chronic Recurring
Sciatic Pain Due to Protruded Intervertebral Disks, Journal -Lancet
5S: 479-481 (Nov.) I93S.

Dand}', W. E.: Loose Cartilage from Intervertebral Disk Simulating
Tumor of the Spinal Cord, Arch. Surg. 19: 660-672 (Oct.) 1929.
Mixter, W. J., and Barr, J. S.: Rupture of the Intervertebral Disk
with Involvement of the Spinal Cana), New England J. Med. 211:
210-214 (Aug. 2) 1934.

Naffziger, H. C.; Inman, Verne,, and Saunders, J. B. dc C. Mj
Lesions of the Intervertebral Disk and Ligamcntn Flava: Clinical
and Anatomical Studies, Surg., Gynec. & Obst. GG: 288-299 (Feb
IS) 1938.

Mixter, W. J.,
vertebral Disl
New England

2. Henderson,

J. G.: The Synd
Meet., Mayo Clin.

3. Woltman,

and Ayer, J. B.: Herniation or Rupture of the Inter-
: into the Spinal Canal: Report of Thirtv-Four Cases,
J. Med. 213:385-393 (Aug. 29) 1935. *

M. S., in discussion on Walsh, M. N. f and Love,
rome of the Protruded Intervertebral Disk, Proc. Staff
14:233-234 (April 12) 1939.

L W.: Personal communication to the author.

2030

PROTRUSION OF DISKS— LOVE

Jour. A. M. A.
Dec. 2, 1939

lumbar disk is justified. I have removed by surgical
intervention at the time of laminectomy a classic pro-
trusion of the disk in ten such cases without the use
of radiopaque oil. Dr. Craig. 4 up to Dec. 9, 1938, had
operated in twenty-seven cases in which the clinical
diagnosis was made without the use of a contrast
medium.

*"7k

Fj~ i — Anteroposterior view after operation showing the small amount
of the laminae of the fifth lumbar vertebra which it was necessary to
remove in order to remove a protrusion of the lumbosacral dish.

In spite of our ability to diagnose the lesion accurately
in some cases, it seems to me that it is the better pait
of wisdom to employ a contrast medium in almost a
routine way as a safeguard against overlooking multiple
lesions, which we found in 12 per cent of cases in
which radiopaque oil was used, 5 and to enable the
surgeon to perform as short a laminectomy as possible
ffigs 1 and 2). A shorter laminectomy naturally means
a shorter operation, a shorter period of anesthesia and,
to a certain extent, a shorter convalescence.

Tust as there are some cases which are so typical
that a clinical diagnosis of protruded intervertebral
disk can be made and operation advised without visuali-
zation of the lesion by a contrast medium there are
occasional patients for whom we have advised and
performed laminectomy for protruded intervertebral
disk in spite of the failure of radiopaque oil to disclose
an intraspinal lesion. I have operated on eleven such
patients up to Nov. 22, 1938." It was, in fact, tire
experience gained with these patients that led Dr
Craig and me to operate, without the employment o
a Contrast medium, on other patients having typical

03 The° following two reports will illustrate the points
(1) of negative roentgenologic study made with radio-
paque oil in the presence of a protruded ^rvertd) J
disk in the lumbosacral articulation and (2) a direct
exploration for protruded disk on the basis of a clinical

diagnosis.

4 Crnic U’. McK.: Personal communication to the author.

5- gunp’.,J. (£” pVmKderflnternertebral Disk (Fibrocartilage). to be
published.

REPORT OF CASES

Case 1. — A woman aged 48 registered at the clinic Sept. 20,
1938, with a history of intractable left sciatic pain. She had
sustained a slight injury to the back at the age of 12 or 13.
Between the ages of 14 and 47 she had experienced many
episodes of what was called “lumbago.” The attacks of “lum-
bago” were usually precipitated by unusual exercise. In April
1938 she made a misstep and felt something give way in her
back. It was necessary for her to sit down immediately;
then she noticed an inability to cross her legs. After ten
minutes she tried to get up, but she screamed with an excru-
ciating pain in the back in the left sacro-iliac region. For
four days she was unable to void urine or move her bowels.
After a few days the pain began to radiate down the posterior
surface of the left thigh. This pain was exaggerated by cough-
ing and sneezing. After two weeks’ time the pain began to
subside and she was fairly comfortable until ten weeks prior
to admission to the clinic, when she noticed gradually increasing
pain in the left thigh with tendency of the pain to radiate to
the left groin. The pain was so severe that it interfered with
sleep, and the usual methods of treatment failed to give relief.

On examination a positive Lasegue’s sign was elicited on
the left side. Reflexes of both achilles tendons were markedly
diminished. There was weakness of extension of the left toes
and definite tenderness along the course of the left sciatic
nerve. Roentgenologic examination of the spinal column
revealed a narrowing of the space between the bodies of the
fifth lumbar and first sacral vertebrae. Diagnostic spinal punc-
ture revealed a total protein content of 40 mg. per hundred
cubic centimeters of cerebrospinal fluid, with normal hydro-
dynamics. Roentgenologic examination of the spinal canal after
introduction of 5 cc. of radiopaque oil did not disclose any
intraspinal lesion. The patient was treated by Buck’s extension
of both extremities, a lumbar sling and diathermy. She was

Ccmrpre'ssed

nerve, '-rc\otp.

Protntxdeck-f

disk .’ A- J

" \

Fig. 2.— Hemilaminectomy in the lumbar region for remo’ v “* “aniln'a
lateral protrusion of an intevertebral disk. Only a portion
on the left side was removed in this instance.

closely observed but failed to obtain any benefit. . In
the negative results yielded by roentgenologic exaimna i ^
radiopaque oil Dr. Ghormley, Dr. \\ alsh and nec tomy

patient might have a protruded disk. Exploratory lam _ ec^ ..
for such a lesion was advised with the understanding
a protruded disk was not found the patient was to underg
operation for bone graft, to be performed by Dr. Ghormt }
October 10 hemilaminectomy of the left lamina 0 f

lumbar vertebra was performed As soon as th P nWin
bone had been removed, a marked thickening o ^ 1 was

fiavum between the fifth lumbar and first sacral vc

Volume 113
Number 23

PROTRUSION OF DISKS— LOVE

2031

observed. When the left half of the ligamentum flavum
was resected, characteristic edema of the nerve root was
observed and when the enlarged nerve root was retracted a
large unilateral protrusion of the disk between the fifth lumbar
vertebra and the first sacral vertebra was uncovered. The
protrusion was still partially maintained by the posterior longi-
tudinal ligament and, when this ligament was incised, two
large fragments of fibrocartilage escaped. The removal of these

fragments (fig. 3) re-
stored the spinal canal
to normal size and
shape and removed
pressure from the
edematous nerve root.
The radiopaque o i 1
was then removed
from the subarachnoid
space and the wound
was closed in layers.

Dr. Ghormley was
present at the oper-
ation and agreed with

Fig. 3. — Two fragments of fibrocartilage me fhat sufficient
which constituted the protrusion in case 1. cause for the patient S

symptoms had been
found and removed and that operation for bone graft was
unnecessary.

The patient's convalescence was uneventful except for the
flare-up of an old subdeltoid bursitis. She was dismissed from
our care October 27, at which time her wound was completely
healed and she was free of her low back and sciatic pain.

Case 2. — A man aged 35 came to the clinic with the chief
complaint of pain in the left area of distribution of the sciatic
nerve. Four years prior to admission to the clinic, while
stooping over, he felt a snap in his back, immediately followed
by severe pain in the lower part. Three years later severe
aching and shooting pain developed in the left sciatic distribu-
tion. The pain was worse at night and often was relieved
by getting out of bed and walking about. The sciatic pain
was aggravated by coughing, sneezing and bending the head
forward. For three months there had been constant low back
and sciatic pain and the patient was unable to work. He
walked with a distinct limp and a list. The left achilles tendon
reflex was absent. There was a total protein content of 90 mg.
per hundred cubic centimeters of cerebrospinal fluid. The
original roentgenogram disclosed narrowing of the space between
the fifth lumbar and first sacral vertebrae. Motions of the
spinal column were markedly limited and Kernig’s and
Lasegue’s signs were positive on the left. Because of the
classic history and signs, the patient was operated on for a
protruded intervertebral disk without the use of a contrast
medium. The spinous process and the laminae of the fifth
lumbar vertebra were removed. A large protrusion on the
left of the disk between the fifth lumbar and the first sacral
vertebrae was removed with complete relief of the patient’s
symptoms.

If the neurosurgeon undertakes to perform laminec-
tomy for protruded lumbar disk without a previous
demonstration of an intraspinal defect as outlined by
the contrast medium, or if laminectomy is done after
a study with radiopaque oil in which results were nega-
tive, the patient should be told of the possibility of an
exploratory operation which may show nothing. How-
ever, in the light of our experience, a clinical diagnosis
can he made with a degree of accuracy that is far above
that of other commonly made diagnoses.

Before undertaking such an operation, it is essential
to know what disks are most likely to be involved and
it is well to hear in mind that the lesion is not infre-
quently multiple (10 per cent of all lesions were mul-
tiple in the series in which operation was performed).
Of 300 patients operated on, fifteen suffered disk
protrusions in the cervical or thoracic region of the
spinal canal. I do not believe a neurosurgeon is justified

in operating for a cervical or thoracic protrusion with-
out first obtaining a roentgenologic demonstration of
the suspected lesion with a contrast medium, unless
there is a definite sensory level, which is always suffi-
cient to justify laminectomy for an intraspinal lesion.
However, since 96 per cent of all protrusions in the
aforementioned 300 cases occurred at the third, fourth
or fifth lumbar vertebral interspace, a direct operation
for a lumbar protrusion based on a careful analysis
of the observations should not often fail to disclose the
lesion, and since in 84 per cent of the 300 cases referred
to the protrusions occurred at the fourth or fifth lumbar
interspace, the disks at these two interspaces should be
exposed first. A removal of the laminae of the fifth
lumbar vertebra and a resection of the fourth and fifth
lumbar ligamenta fiava will result in adequate exposure.
If there is a protruded disk, its presence usually will
be signalized by a marked thickening of the ligamentum
flavum at that particular interspace (fig. 4). In a con-
secutive series of 175 cases of protruded disk, a note
was made on the surgical cards of 155 cases' that there
was a definite, abnormal thickening or hypertrophy of
the contiguous ligamentum flavum. In our earlier cases
we came to look on the edema of the involved nerve
root as the sentinel which led to detection of the pro-
truded disk. 7 In the light of subsequent experience we
have been warned, and usually of the site, of the pro-
trusion by the thickening of the ligamentum flavum
even before the edematous nerve root can be seen: 8

But the yellow ligament which bridges the space
between the laminae of adjacent vertebrae is by no
means always thickened. It may be normal in; thick-

.f'£- 4.--How the protruded part of an intervertebral disk was removed
without the performance of laminectomy. This was the second instance
in which the protrusion of the disk was exposed and removed after the
resection of a very thick ligamentum flavum without the resection of
any portion of the laminae of the adjoining vertebra: a, resection of the
hypertrophied portion of ligamentum flavum; b, exposure of the protruded
intervertebral disk; c, the spinal canal restored to normal after the
removal of the protruded fragments of the disk.

ness; in a few cases I have seen it thinned as if it had
been eroded by the protruded fragments of disk sub-
stance. In one case I found tha t a long fragment of

J 'i G A Protrasion of the Intervertebral Disk (FibrocartUajrel
19° 19 J 6 Sl ' Cana ’ Proc - StafI Mcct - Mayo Clin. 11:529-534 (Aug.

S-LOV'. X G., and Walsh, M. N.: Protruded Intervertebral Disks-
Only 30> m 0pera,ion was Pcrf °™'4

2032

PROTRUSION OF DISKS—LOVE

Jour. A. M. A.
Dec. 2, 1939

mentum flavum, much as a straw has been known to
perforate a wood post during a tornado. 9

The important point to remember about the liga-
mentum flavum is that although it may be of sufficient
size to compress the nerve roots, causing intractable
pain, this phenomenon without an associated protrusion
of the disk is rare. In operating on 300 patients who
had proved protruded disk, we have encountered only
twelve cases of hypertrophy of the ligamentum flavum
without an associated disk protrusion. Whenever a
hypertrophied ligament is found, a diligent search
should be made for protrusion of the underlying disk.
The following case report is illustrative:

Case 3. — A man aged 40 had had recurrent attacks of lumbago
for twenty-four years. The attacks would occur once or twice
a year and usually necessitated the patient's remaining in bed
for a week or ten days. For ten years he had suffered a con-
stant dull, aching pain in the lower part of the back. This
pain was aggravated by motion. At no time was there any
sciatic projection of the pain. Eight months prior to operation
the patient experienced a sharp pain in the right lumbar region
while bending over to pick up an object from the floor. This
sharp pain in the right lumbar region persisted until the time
of operation. At epidural injection there was a marked exag-
geration of the severe, sharp pain in the lower part of the
back, but at no time was there any extension of the pain into
the hips or legs. The total protein content of the spinal fluid
was 120 mg. per hundred cubic centimeters of cerebrospinal
fluid. Roentgenologic study aided by radiopaque oil revealed
a persistent defect opposite the interspace between the eleventh
and twelfth thoracic vertebrae which was interpreted as a
classic defect for a hypertrophied ligament without disk pro-
trusion. At the time of laminectomy, a hypertrophied liga-
mentum flavum and a protrusion of the underlying disk at the
eleventh thoracic interspace were removed. The patient has
obtained complete relief from his backache since operation and
he states that he now feels better than he has felt for many
years. It is interesting to observe that this patient had suf-
fered a marked narrowing of the space between the fifth lumbar
and first sacral vertebrae with some hypertrophic changes yet
at no time did he experience sciatic pain. Clinically, an intra-
spinal lesion occurring in the lower thoracic region was con-
sidered to be a diagnosis much more likely to be proved at
operation as a cause of this patient’s symptoms than the
diagnosis of a lesion at the lumbosacral articulation, where a
definite abnormality was seen on the usual roentgenologic
examination.

TREATMENT OF PROTRUDED INTERVERTEBRAL DISKS

When the presence of a protruded disk has been
diagnosed, a decision as to the proper treatment must
be reached. If the patient’s symptoms are mild and
do not interefere to any great extent with his usual
activities, some one of the more common therapeutic
measures may be employed. However, the presence of
the lesion must not be disregarded or passed over
lightly, because another slight injury to the back may
result in further protrusion of the involved disk, with
sufficient narrowing of the spinal canal to produce
paralysis of the legs. Case 4 emphasizes this point :

Case 4.— A man aged 38 had for twenty-one years experi-
enced a yearly recurrence of pain in the lower part of the
back. The first attack had occurred following the lifting of a
heavy sack, and each subsequent attack followed unusual stress,
such as the lifting of heavy objects. One week prior to admis-
sion there was a sudden onset of severe pain in the lower
part of the back, with bilateral sciatic extension, occasioned
by the patient’s efforts while cranking a tractor. Three days
before admission a “dead feeling 9 developed in the right leg
and there was gradually increasing motor weakness m the

i love J. G : IntractaWe Low Back aod Sciatic Pam Doe to Pro-
Intervertebral Disks: Diagnosis and Treatment, Minnesota Med.
S32-S3S (Dec.) 193S.

right lower extremity. For two days he had suffered incon-
tinence of both bladder and bowel. The patient had noticed
the development of a cough during the same day on which
he had injured his back while cranking the tractor.

The neurologic examination showed a reduction of severe
degree in motor power of the right leg. The achilles tendon
reflexes of both extremities were absent. There was anesthesia
in the cutaneous areas supplied by the fifth lumbar and first
sacral nerves on the right. A diagnostic spinal puncture in
the fifth lumbar interspace was performed and a specimen of
cerebrospinal fluid was removed which contained 160 mg. of
total protein per hundred cubic centimeters and 2 lympho-
cytes and 2 polymorphonuclear leukocytes per cubic millimeter
of cerebrospinal fluid. The initial pressure of the cerebrospinal
fluid was 20 cm. of water. The Queckenstedt test could not
be performed because trial of it precipitated a paroxysm of
coughing referable to the fact that the patient had an infection
in the upper part of the respiratory tract and accurate readings
could not be taken.

By the time the patient was considered to be in condition
for operation (approximately two weeks after admission) both
legs were paralyzed. A differential diagnostic spinal puncture
was performed in order to localize the lumbar intraspinal lesion,
which, because of the history, was suspected of being a protruded
intervertebral disk. A spinal puncture needle was introduced
into the twelfth thoracic interspace and clear fluid was obtained
without evidence of spinal subarachnoid block. Another needle
was introduced into the first lumbar interspace, once more with
normal results. At the fifth lumbar interspace, yellow fluid
was obtained with a complete spinal subarachnoid block. This
fluid on examination revealed 1,200 mg. total protein per hun-
dred cubic centimeters of fluid. Laminectomy was then per-
formed under paravertebral anesthesia and a large fragment
of a protruded disk was removed at the site of the fourth
lumbar interspace.

Two months after this operation there was a marked improve-
ment in the patient’s condition. He was able to walk without
aid, whereas it had been possible for him to walk only with
the aid of crutches on leaving the hospital; and he volunteered
the information that his back felt better than it had felt for
five years and that there was no pain or soreness in his back
or legs.

If the patient is very uncomfortable or is experi-
encing enough trouble to warrant bed treatment for
two weeks, surgical treatment of the lesion should be
advised. The surgical treatment consists of the removal
of the protruded portion of the involved disk through
a laminectomy wound.

Case 5. — A man aged 35 had felt pain in the back and left
leg intermittently for the past twelve years, occasioned by the
patient’s sustaining an injury. It was alleged that he had
suffered fracture of the fourth and fifth lumbar vertebrae.
There was no paralysis at the time of injury. The pain was
exaggerated by coughing, sneezing and activity. Pain did not
disappear during rest. The left achilles tendon reflex was
slightly diminished. Roentgenologic examination of the spinal
column produced negative results. The cerebrospinal fluid had
a total protein content of 60 mg. per hundred cubic centimeters
of fluid. Roentgenologic examination with radiopaque oil
revealed an extradural defect on the left, opposite the lumbo-
sacral articulation. Laminectomy, with resection of the hyper-
trophied ligamentum flavum and removal of a large protrusion
of the disk between the fifth lumbar and first sacral vertebrae,
was done. The patient made an uneventful convalescence. Post-
operative neurologic examination yielded negative results. Com-
plete relief of pain was achieved.

This is an operation which should not be undertaken
unless the surgeon has had considerable experience
with intraspinal surgery. The lesions are at times
small and can be overlooked easily. The cauda equina
must be handled only with extreme care, and hemostasis
must be very accurate or a postoperative hematoma may
nullify the relief that should ensue following the
removal of the protruded disk.

Volume 113
Number 23

PROTRUSION OF DISKS— LOVE

2033

If radiopaque oil is used to localize the lesion, it
should be injected into the subarachnoid space in the
lumbar segment and the roentgenologic examination
should be carried out on the day of operation. It has
been our experience that injection of radiopaque oil
in the presence of a space-occupying intraspinal lesion
is much more likely to be followed by an exaggeration
of the patient’s symptoms than it would be if there
were no intraspinal lesion. The larger the lesion, the
greater the compression of the subarachnoid structure
and the greater the chance for exaggeration of previous
symptoms will be. This fact is not surprising, for I
have noted that even a diagnostic spinal puncture in
the presence of a large intraspinal tumor will result
in the development of marked neurologic signs (and
even paraplegia) which were not present prior to the
withdrawal of cerebrospinal fluid from the region about
the tumor.

If a protruded disk has been demonstrated and opera-
tion is to follow, the patient should be prepared for
laminectomy. If the roentgenologic study with radio-
paque oil is negative and if the other signs are not
sufficient to warrant an exploratory laminectomy, the
patient should be kept in bed overnight and allowed to
leave the hospital the next morning, unless he was
previously a hospitalized patient receiving other treat-
ment.

Radiopaque oil is, of course, a foreign substance,
and it is eliminated very slowly from the subarachnoid
space. 10 It should therefore be used only in carefully
selected cases. An intraspinal inflammatory lesion is
a definite contraindication to its use.

More recently we have employed air 11 in the sub-
arachnoid space as an aid to roentgenologic localiza-
tion of protruded disks (fig. 5 a and b). When a
definite defect can be shown, air is an excellent contrast
medium, but the accuracy achieved by this method in
our hands has not approached that resulting from the
use of radiopaque oil.

The operation for the removal of a protruded disk
is laminectomy. The laminectomy should be as short
as possible, yet adequate to permit a satisfactory expo-
sure of the protruded disk. The removal of one pair
of laminae will ordinarily provide adequate exposure.
In many cases I perform what I call a “partial laminec-
tomy” (see fig. 1) ; that is, a removal of the edges of
the laminae above and below the interspace at which
the protrusion has occurred. The articular facets
always should be preserved. On one occasion I was
able to remove a protruded disk without the removal
of any bone. Resection of the hypertrophied liga-
mentum flavum permitted exposure and removal of
the underlying protrusion with complete relief of nerve
root pressure and the intractable sciatic pain.

Case 6. — A man aged 54 registered at the clinic Nov. 28,
1938, at which time he came seeking relief of intractable left
sciatic pain of tour months’ duration. He had experienced
onset of the pain in July 1938 while on a motor trip. The
first symptom to appear was a difficulty in sitting. He noted
that he had to rest first on one buttock and then on the other.
There was a dull aching pain in the left lower lumbar region,
which had become progressively worse. He had been kept in
bed for several days in August, and he began to limp in
September. He had discovered that the limp minimized the
pain in the back. In October the pain was projected along

10. Walsh. M. N., and Love, J. G.: Menineeal Response Following
Subarachnoid Injection of Iodized Oil, Froe. Staff Mere, Mayo Clin.
13: 793-796 (Dec. 14) 1938.

11. Voung, II. R., and Scott, Michael: Air Myelography: The Sub*
stitution of Air for Lipiodol in Roentgen Visualization of Tumors and
Other Structures in the Spinal Canal, Am. J. Roentgenol. 3f): 187*192
(Feb.) 193S.

the left sciatic nerve. The patient volunteered the information
that pain was worse while he was in the sitting position and
when he turned in bed. The pain was exaggerated by coughing
and sneezing. The usual conservative treatment had failed to
give relief.

Examination disclosed that the patient walked with a distinct
leftsided limp. There was tenderness over the lumbosacral
articulation and along the left sciatic nerve. The straight
leg-raising test for the left extremity gave a positive reaction.
The left achilles tendon reflex was somewhat diminished oyer
that of the right. Roentgenologic examination of the spine
disclosed a partial sacralization of the fifth lumbar vertebra
with a definite narrowing of the fourth lumbar interspace. A
spinal puncture by the patient’s local physician had revealed
a total protein content of 60 mg. per hundred cubic centimeters
of cerebrospinal fluid. A combined diagnostic lumbar puncture
and spinogram (air injection into the spinal subarachnoid space)
were made at the clinic. After introduction of the lumbar
puncture needle into the first lumbar interspace the air was
injected under slight pressure, and 45 cc. of air was used to
replace 40 cc. of fluid. When the fluid in the lumbar sac had
been displaced by air, roentgenograms disclosed a left antero-
lateral defect opposite the fourth lumbar space. A diagnosis
of protruded intervertebral disk was made and operation was
advised.

December 1 a classic protrusion of the fourth lumbar disk
was removed without the performance of laminectomy. The

operation was planned as

Fig. 5. — a, Anteroposterior view of the lumbar portion of the spinal
column after the cerebrospinal fluid had_ been replaced with air*. The
point of the arrow indicates the defect in the air column caused by a
protruded intervertebral disk; b, drawing to indicate the defect seen in
the roentgenogram.

ligamentum flavum was found to be unusually thick. When the
left half of the ligament was resected characteristic edema of
the underlying nerve root, with posterior displacement such as
is seen with an underlying protrusion of the disk, was noted
(see fig. 4). The involved nerve root was retracted and a large
fragment of fibrocartilage was removed from the disk. This
operation relieved the cauda equina of pressure and the wound
was closed without removal of any hone.

postoperative treatment
The care of patients on whom laminectomy has been
performed for the removal of a disk protrusion has
gradually evolved into a very simple system. Since
but little bone is removed and since the incision in the
skin and fasciae is short and the heavy erector spinae
muscles are reflected subperiosteally, there is little that
could have an adverse effect on such a wound if an
accurate anatomic closure has been effected. As has
been stated, no bone grafting or fusing is done, there-
fore there is no need for splinting, casting or even
keeping the patient quiet in bed. Instead, these patients
are left to their own inclinations, so to speak, when
they are placed in their beds after leaving the operating
room, and they are encouraged to move their toes,
feet and legs as soon as they recover from the effects
protruded disk had completely perforated the liga-

2034

DISCUSSION ON INTERVERTEBRAL DISK

of anesthesia. After every laminectomy the ability of
the patient to move his toes should be observed and
charted frequently during the first six hours after
operation. After that his power should be determined
several times a day for the first few days. If there
is weakness that was not present prior to operation,
hemorrhage should be suspected and the wound should
be opened to exclude such a possibility. We have
encountered only one postoperative hemorrhage in 300
laminectomies performed for the condition of protruded
intervertebral disk. There has been one postoperative
death in the series.

ABSTRACT OF DISCUSSION

ON PAPERS OF DRS. SPURLING AND BRADFORD, DRS.

CHAMBERLAIN AND YOUNG, DR. CAMP
AND DR, LOVE

Dr. William Jason Mixter, Boston: I will accept Dr.
Love’s change in nomenclature. The term “ruptured interver-
tebral disk” was used at first because it was not realized that
in some of these cases the annulus was not ruptured but was
protruded without being ruptured. I must disagree with Drs.
Spurling and Bradford and say that the annulus is involved in
the process as well as the nucleus pulposus, and so the term
“extrusion of the nucleus pulposus” is not a good one. The
differentiation between the fourth and the fifth disk, in my
hands, has been rather more difficult than Dr. Spurling has
indicated. I agree that air will show a certain percentage of
extrusions. I doubt whether it will show small defects which
will be shown by iodized oil ; I doubt whether it will show
some of the larger and more diffuse defects which will be shown
by iodized oil. Air can be used in a certain number of cases
which lie on the borderline in which one would not -be willing
to use iodized oil. If one gets a positive effect with the injec-
tion of air iodized oil is unnecessary, the dural sac will not
have to be opened and it will make the surgeon's job a shorter
and an easier one. But I am afraid that one has to admit a

considerable percentage of error on the negative side. I believe
that one is justified, as both Dr. Love and Dr. Spurling said,
in operating in a certain number of cases in which there are
classic signs without the use of a contrast medium. The
greatest difficulty is in cases in which the signs are not classic,
and here I come to the point that there are many patients with
low back pain, possibly with sciatica, who should not under
any circumstances have iodized oil injected because, as Dr.
Love has already stated, a very large percentage of patients with
sciatica and low back pain will recover spontaneously. It is
only by picking out severe, intractable cases extending over
months that one can eliminate the promiscuous and pernicious
use of iodized oil in the spinal canal. The use of iodized oil in
the spinal canal should be carried out only in the clinic when
the patient is to be operated on. It is unfair to the roentgenolo-
gist who will have to examine that patient in the operative clinic,
and it is unfair to the surgeon who is going to operate on the
patient to use iodized oil, run it around in the spinal canal and
then send the patient down to the ultimate operative clinic. One
does not like to use iodized oil if one can help it, but the sub-
ject was developed on the basis of the use of iodized oil. We
never would have gotten anywhere with protrusion of the inter-
vertebral disk except by the use of that drug.

Dr. Claude Moore, Washington, D. C.: As Dr. Mixter
said, it is not. fair to throw the burden of the responsibility of
the diagnosis on the roentgenologist without definite indications.
I would like to call attention again to the very definite and
clear-cut pathologic changes demonstrated on the films shown
by Dr. Camp and Dr. Love using iodized oil as compared with
those of Drs. Chamberlain and Young using air. I admit that
the use of air is an excellent preliminary procedure, but when
the patient is going on to neurosurgery _ the added risk of
iodized oil and colloidal thorium dioxide injected into the spinal
canal is only slight compared to a major neurosurgical operation.

Dr L H. Garland, San Francisco: Dr. Chamberlain has
again demonstrated the value of air myelography in the diag-
nosis of large space-occupying lesions of the spinal canal (spe-
cially with thin patients and perfect radiographic technic), and

Joue. A. M. A.
Dec. 2, 1939

Dr. Camp has pointed out the usefulness of the lateral projec-
tion for the diagnosis of hypertrophy of the ligamentum flavum.
In my experience at the San Francisco Hospital I have found
satisfactory diagnostic results with air in only about one tenth
of the cases ; in the remainder, iodized oil had to be used, either
because preliminary air films were inconclusive or because the
patient was so thick that we did not deem it advisable to use
air- Now, Dr. Chamberlain uses air because he thinks that
iodized oil, if left in the cerebrospinal system, may produce late,
harmful changes. Dr. Mixter stated that if it gets into the
skull it may produce intractable headaches. It seems to me
that neither of these opinions is correct. We have made careful
x-ray and clinical follow-up studies of twenty-five patients who
had iodized oil injected into the spinal canals from one to four-
teen years prior to the check-up, in amounts varying from
2 to S cc. (and in one remarkable case 10 cc.). In not one of
these twenty-five cases is there any subjective or objective
evidence to indicate damage to the central nervous system. We
did an autopsy on one patient; it revealed the usual lepto-
meningeal thickening about some of the collections of iodized
oil but absolutely no neural tissue changes. About two thirds
of the patients had small intracranial collections of iodized oil
in and about the basal cisternae without having any headache
or other symptoms. As long as the roentgenologist or clinician
knows that this intracranial oil is asymptomatic, and apparently
harmless, he will not be disturbed by finding it. I do not
advocate the indiscriminate intraspinal injections of any sub-
stance, gaseous or oleaginous, but I do believe that, in selected
cases, the use of small amounts of fresh iodized oil is harmless.
Its diagnostic value is far greater than that of air.

Dr. J. Daniel Willems, Chicago: The general tone of
conservatism of these papers has been gratifying. I am in a
different position from the speakers; I am placed in somewhat
of a referee position. These patients come to me after they
have been operated on. I cannot talk in figures of 300 but I
have several dozen by this time, patients who have been oper-
ated on in some of the best clinics in this co untry; they come
back to me with all sorts of complications, weeks later and
months later. Most of them are workmen; they should return
to work, and I cannot for the life of me get them back to
work. Of all the complications, the worst is the presence of
iodized oil as shown by the x-ray film. I would make a plea
for conservatism, especially in the use of iodized oil such as
can be shown in x-ray films later.

Dr. R. Glen Spurling, Louisville, Ky. : I proposed on two
occasions before this Association the use of iodized oil for
diagnosis of these intraspinal lesions, and I have used it with-
out any fear of dangerous reaction or permanent disabling
effects. However, I have always had more or less difficulty
convincing orthopedic surgeons and others that iodized oil is an
innocuous substance, and we know it is not entirely innocuous
because after the immediate reactions there is always inflam-
mation. I had this brought to my mind forcibly three months
ago by a doctor who saw a relative of his with one of these
lesions. I told him that I felt reasonably sure that there was

a herniated nucleus pulposus at the fifth lumbar interspace.
He said “You can operate, but you can’t inject lipiodol. ‘
think that represents the attitude of many in the profession
regarding this drug, and if that argument could be eliminated
from the whole picture of disease of the intervertebral disk
some progress in the final solution of the problem would haie
been made. I do believe that with more mature consideration

of the neurologic aspects, both subjective and objective, "C
can arrive at a definite, accurate diagnosis in a large per-
centage of cases that require surgery. I do not doubt tha
there are many acute cases in which localization cannot e
made, but in my opinion most of these patients should n ot
be treated surgically. It is only intractable cases that require
surgery, of which I was speaking in my paper. As regar 5
the terminology, I believe that in those cases in which there
is a frank mass present beneath the posterior longltudma
ligament it is usually composed chiefly of nuclear materia
with fragments of annulus fibrosus attached to it. Our f ,l>r _
gical specimens have been carefully examined grossly and his o
logically, and they have shown predominantly nucleus pulposu i •
Furthermore, when we remove one of these masses and insp-

VpLUME 113
Number 23

2035

OBSTETRIC ANALGESIA— KOTZ AND KAUFMAN

the operative site carefully we see that the protrusion is imme-
diately relieved, that the gaping edges of the posterior longi-
tudinal ligament fall back together, and there is very little to
tell the story of the former disruption. That, to me, is fur-
ther argument that the presenting lesion is composed chiefly
of nuclear material. Furthermore, that would bear out our
conception of the symptomatology, since we feel that the low
back pain is due to stimulation of the sensory nerve endings
supplied by the recurrent branches of those nerves, and the
root pain is due to ' a pressing mass beneath or outside the
posterior longitudinal ligament which has impinged on one of
the nerves at its point of fixation.

Dn. W. Edward Chamberlain, Philadelphia: Our use of
oxygen instead of air as the contrast medium for myelography
is due entirely to the fact that oxygen disappears from the
lumbocaudal sac (is absorbed) more rapidly than air. After
the use of air the patient's sacrum must be kept higher
than the foramen magnum for at least twenty-four hours,
whereas after the introduction of oxygen, three or four hours
of the special posture seems to suffice. However, Dr. Adson
called my attention yesterday to an effective way of hast-
ening the absorption of ordinary air. He simply has his
patient breathe pure oxygen through the new Loveless mask.
This reduces the nitrogen tension in the blood and brings the
rate of absorption of ordinary air up to about that of oxygen.

I wish to commend Dr. Spurling for his emphasis on the
clinical neurologic study. There has been too much emphasis
on studies with contrast mediums to the exclusion of clinical
methods of examination. Just as too many radiologists have
adopted the attitude that oxygen myelography is too difficult
and iodized oil cannot be supplanted, too many clinicians have
adopted a defeatist attitude toward the neurologic examination.
In our many contacts with Dr. Fay and his associates in
the Department of Neurology and Neurosurgery at Temple,
we have learned to appreciate the value of the clinical neuro-
logic examination as stressed by Dr. Spurling. When these
intervertebral disk protrusions were first recognized, I think
most of us took it for granted that symptoms from such
a cause could be relied on to be either progressive or at least
constant. But now we know that, as stressed by Dr. Mixter
and again by Dr. Love, 80 per cent of patients with disk
lesions manifest a distinctly intermittent symptomatology.
This intermittent feature has aroused our special interest,
for it is so marked as to suggest that the mechanical
factor, the actual disk protrusion itself, must also be inter-
mittent. That this may be the case is suggested by our recent
demonstration, in quite a series of cases, that flexion of the
spine tends to “withdraw” disk material from the spinal canal,
while extension tends to produce or emphasize protrusion. In
one of our surgical cases Dr. Fay demonstrated, on the
operating table, this “withdrawal” and recurrence of the disk
protrusion with flexion and extension of the spine.

Dr. John D. Camp, Rochester, Minn. : I do not believe
that any of the substances that have been talked about today
are ideal substances for this work. Sooner or later somebody
is going to perfect a radiopaque substance which can be injected
into the subarachnoid space and be eliminated rather rapidly
by the spinal fluid. When that time comes I feel that roent-
genology will have added another great step forward in the
study of many neurologic conditions.

Dr. J. Grafton Love, Rochester, Minn.: Dr. Mixter has
warned about the injection of iodized oil, and we have adopted
the attitude. We have stopped injecting iodized oil for diag-
nostic purposes unless the patient has already planned — if the
study is positive — to proceed with the operation, preferably the
same morning. The injection is made in the operating room,
Dr. Camp does his fluoroscopy, then the patient is taken back
to the operating room and a laminectomy is performed. Walsh
and I have collected, at the time of laminectomy, a number
of specimens of fluid, and we have been able to show that there
is an increase in lymphocytes following injection. They reach
their height within one or two hours and subside in from
twenty-four to forty-eight hours, and the iodized oil, if removed
immediately, appears as it did when it came out of the ampule,
whereas if it is removed the next day it has the appearance
of clabber or sour milk, and it is during that period that there

are irritating properties to the iodized oil, and if there is a
nerve compressed the symptoms are apt to be more marked.
The same thing is seen in spinal tumor; the symptoms tnay
be remarkably exaggerated following removal of a sample of
fluid. So if there is an intraspinal injection, operation should
not be delayed. In some of my earliest cases I purposely left
the iodized oil in and did not open the dural sac because of the
marked extradural bleeding which sometimes occurs. Some
of my first cases were so troublesome that I wanted to main-
tain the hydrostatic effect in the caudal dural sac. . Certainly,
the large number of patients who had been chronic invalids
and had been incapacitated for any type of work and who
were relieved by laminectomy and were out in a short time
following use of iodized oil is some proof.’ The patients we
deal with are incapacitated, patients who have been in bed for
six months, patients who have had various ’ operations, who
have had bone grafts, who have had manipulations under anes-
thesia, who have been in bilateral spica casts for three to six
months. A protrusion iof the fourth' lumbar disk cannot be
differentiated from a protrusion of the fifth disk. , One can
show a protrusion - of' any - of- the' lumbar disks with the same
clinical and neurologic manifestations. There is an important
point about the intermittence of symptoms that has intrigued
all of us. Why will these patients get relief? my orthopedic
colleagues ask me. In the past, we have brought about fusion
in some of these cases, seeing the number of protruded inter-
vertebral disks. It is my feeling that, if the protrusion is at
the lumbar sacral disk and a massive bone graft is applied,
the patient may be cured. If a sacro-iliac joint is fused it
would have no effect on the patient. I think that as time goes
on some of these patients cure themselves, the edema subsides
and the tissue contracts, because this is not neoplastic.

THE EFFECTS OF OBSTETRIC ANAL-
GESIA ON THE NEW-
BORN INFANT

JACOB KOTZ, M.D.

AND

MORTON S. KAUFMAN, M.D.

WASHINGTON, D. C.

■ The effect of obstetric analgesia on the newborn
infant has been the subject of considerable discussion
during the past few years both in medical literature

Chart 3. — Average weight in complete series: solid line normal, dotted
line McCormick modification of Gwathmey technic, dashes paraldehyde,
dots and dashes pentobarbital sodium.

and in the lay press. Analgesia has been accused of
depressing the vital functions during the first few days
of life, of causing permanent damage to the cerebral
centers and of increasing fetal mortality.

Since obstetric analgesia is becoming so widely used,
it is important to determine whether such is the case.

From the Department of Obstetrics and G}-necology, George Wash-
ington University School of Medicine.

Read before the Section on Obstetrics and Gynecology at the Ninetieth
Annual Session of the 'American Medical Association. St. Louis. Mav 18
1939. # '

The group in which the McCormick technic of analgesia was used
is presented through the courtesy of Dr. Prentiss Wilson, Washington,

2036

OBSTETRIC ANALGESIA— KOTZ AND KAUFMAN

A comparative study of large groups of newborn infants
under the same environmental conditions, some of whose
mothers received analgesia while those of others did
not, would appear to be the logical method of approach
to this problem. If obstetric analgesia is harmful to
the infant, it should be reflected in the mortality rate

DAYS i 2. 3

Chart 2. — Average weight in paired series: solid line normal, broken
line paraldehyde.

and the records of the vital functions during the first
ten days of life. We have completed such a study and
herewith submit a summary of our observations.

METHODS

Eight hundred consecutive babies born of mothers
delivered by the vaginal route in private practice were
selected for this study; in 500 instances the mother
received paraldehyde either alone or in combination
with some other drug, in 100 instances she was treated
by the McCormick modification of the Gwathmey tech-
nic and in 100 she received pentobarbital sodium and
scopolamine. The babies of 100 mothers who received
no analgesia were used as controls.

In these groups the following factors were studied:
(1) the mortality rate, (2) the initial loss of weight,
(3) the rate of gain for the first ten days of life, (4) the
temperature curve for the first ten days of life and
(5) the pulse and respiration curve for the first ten

9RS, rr— | j

W —

Chart 3. — Average temperature in complete series: lines as in chart 1.

days of life. Also due consideration was given to the
duration of labor, the type of delivery, the dosage of
the analgesia used and its effect on the subsequent
clinical course of the infants after birth.

One hundred additional cases were selected for a
more detailed study. In fifty the mother received paral-
dehvde analgesia. In each of these cases the infant
was' matched with another child, born on the same day
and of approximately the same birth weight but v, hose
mother received no analgesia. The two babies were

Joux. A. M. A.
Dec. 2, 1939

fed identical formulas and the environmental conditions
were the same. In these cases the temperature, pulse
and respiratory rates were recorded every four hours
and the weight was checked twice a day for the first
three days of life.

The time interval between delivery and . the initial
respiration was checked with a stopwatch on 100 paral-
dehyde babies and 100 control babies.

Dosage of Analgesia. — The average dosage of paral-
dehyde was 17,5 drachms (66 cc.) given with an
average of 11 /g(> grain (0.012 Gm.) of morphine sulfate.
The usual initial dose was from 6 to 8 drachms (23 to
31 cc.) of paraldehyde by rectum and one sixth or
one fourth grain (0.011 or 0.016 Grn.) of morphine
hypodermically, the paraldehyde being repeated in 3 or
4 drachm (12 or 15.5 cc.) doses as often as necessary.
The largest total dose given was 38 drachms (142.5 cc.)
of paraldehyde and one fourth grain of morphine. It
is apparent and we wish to emphasize the fact that in
this series of cases large doses of analgesia were used.
If analgesia has an effect on the child, such effects
would certainly be demonstrable in this group.

In the group of mothers treated by the McCormick
technic, the average amount given was 1.53 doses of
the mixture and 4.99 grains (0.32 Gm.) of pentobar-
bital sodium.

In the group receiving pentobarbital sodium and
scopolamine the average total dose was 6.78 grains
(0.44 Gm.) of pentobarbital sodium and %oo " rain
(0.0003 Gm.) of scopolamine.

<?£>
?7.5t

I

m

u

i

m

m

a

M

m

m

m

9

a

m

m

m

■

■

■

HOURS | 16 M- 8

Chart A . — Average temperature in paired series: solid line normal,
broken line paraldehyde.

RESULTS

Duration of Labor. — The average duration of labor in
this series of cases was seventeen and one-half hours for
primiparas and thirteen and one-half hours for nmltip-
aras. This is corroborative of the observations made
by Rosenfield and Davidoff, 1 Colvin and Bartholomew •
and Kane and Roth 3 ' and definitely demonstrates that
labor is not prolonged by the use of any of these types
of analgesia.

Incidence oj Operative Delivery. — It has long been
recognized that any factor which increases the incidence
of operative delivery adds to the fetal risk. The type
of delivery in the various series of cases is summarized
in table 1. The high incidence of forceps is due to the
fact that we use prophylactic forceps as a routine and
do not consider it an increase in operative intervention.

Effect of Analgesia on Fetal Mortality Rate. — In the
500 cases in which paraldehyde analgesia had been
given there were eleven fetal or neonatal deaths. Tins
represents a gross mortality rate of 2.2 per cent. Table 2

3. Rosenfield, H. H-, and Davidoft, R. B.: Paraldehyde as a Fsdot
in Painless Labor, Surg., Gynec. & Obst. 00:235*238 (Feb.) 1935*

2. Colvin, E. D., and Bartholomew, R. A.: Advantages of l arm*
hyde and Basic Amnesic Agent in Obstetrics, J. A. M. A,

<Ft 3.' Kane^H. F., and Roth, G. B.: Use of Paraldehyde in OhjajT'“f
Obstetric Analgesia and Amnesia, Am. J. Obst. & Gynec. **0:3
(March) 1935.

Volume 113
Number 23

OBSTETRIC ANALGESIA — KOTZ AND KAUFMAN

203 7

lists the cause of death in the individual cases. There
were seven instances in which the cause of death could
be ascribed definitely to factors other than the analgesia.
In the remaining four cases death was attributed to
atelectasis. Of these four cases, one mother received
only 6 drachms (23 cc.) of paraldehyde and another
10 drachms (3S.8 cc.). One mother received 34
drachms (127.5 cc.) of paraldehyde and one sixth grain
of morphine in a period of forty-four hours. This
infant’s urine gave a strong reaction for paraldehyde.
If one considers these four deaths to be due to the

Table 1. — Types of Delivery

Pentobarbital

Normal Paraldehyde McCormick Sodium

Low forceps 2% 81.4% 21% 87.5%

Midforceps 1% 10.3% 3% 4.0%

Breech 2% 3.3% 5% 8.0%

Version extraction 0 0.9% 1% 0

Spontaneous 94% 4.5% 70% 4.0%

paraldehyde, the fetal mortality rate from the drug is
0.8 per cent. Adair states that in many stillbirths there
is no demonstrable lesion at autopsy other than atelec-
tasis. Dr. Choisser, 4 pathologist of the George Wash-
ington Hospital, reports that actelectasis is a common
finding in stillbirths but that it is not more frequent
in cases in which the mothers have received paraldehyde

ing interval recorded on 100 babies whose mothers
received no analgesia. The average intervals in the
two groups were 39.5 and 9.8 seconds respectively.

Granting that the initial respiration is slightly delayed,
the question still arises “Does this slight delay have
any injurious effect on the baby?”

Birth Injuries . — There was only one birth injury in
this series of cases: Erb’s paralysis developed as the
result of traction on the neck exerted to deliver the
impacted shoulders. In the follow-up studies of these
babies during the past five years there has been no
instance of convulsions, mental retardation, spastic
paralysis or other evidence of neurologic defects. From
these data it seems reasonable to conclude that cerebral
injuries in the newborn are due to mechanical factors,
usually faulty obstetric manipulation, rather than to the
drug given the mother.

MORBIDITY

Pediatricians have repeatedly stated that babies whose
mothers are given analgesia during labor are sluggish
and drowsy for the first three or four days of life and
that they fail to nurse properly and therefore lose more
weight and become more dehydrated than babies whose
mothers receive no analgesia. This has not been our
experience, as the following data will show :

Weight . — The average daily weight changes of the
489 babies whose mothers had paraldehyde, the ninety-

Table 2. — Cases of Fetal Death

Dose oi Analgesia

A — - _

f A V

Duration Pnrnldc- Morphine

Weight

oi Labor,

hyde,

Sulfate,

Grain

A.

Foupds

\

Case

Hours

Drachms

Type of Delivery

Ounces

Time of Death

Maturity

Autopsy Results

1

4

12

Breech

2

o

24 hr. post partum

CM: months

Premature

2

,,

Spontaneous

2

0

24 hr. post partum

0% months

Premature

3

50

2G

Low forceps

*>

12

3d day

TV- months

Anencephnlic

4

12

21

>/«

Low forceDS

1

G

24 hr. post partum

Pull term

Congenital, hydro-
nephrosis. broncho-
pneumonia

5

16

14

Breech extraction,
forceps to after
coming head

4

9

24 hr. post partum

814 months

Tentorial tear

G

16

D

%

Breech extraction,
forceps to after
coming head

C

3

Stillbirth

Pull term

Tentorial tear

7

12

14

%

Low forceps

4

2

Stillbirth

8 months

Congenital fetal edema,
erythroblastosis

8

8

10

y*

Low forceps

C

24 hr. post partum

Full term

Atelectasis

D

4

6

y*

Low forceps

4

13

24 hr. post partum

SVa months

Atelectasis

10

20

28

Vr

Low forceps

5

1

14 hr. post partura

S months

Premature

11

44

Zi

V,

Low forceps

8

0

Stillbirth

Pull term

Asphyxia, urine positive
for paraldehyde

than in those in which no analgesia was given. We
can conclude only that the paraldehyde may or may
not have been the cause of death, but we feel that in
any group as large as this a like percentage of babies
will die from atelectasis or unknown causes resulting
in atelectasis, regardless of whether analgesia was used
or not.

In the group of McCormick babies there were two
deaths, representing a gross mortality rate of 2 per
cent. One of these babies had hydrocephalus and the
other was premature with atelectasis.

In the pentobarbital sodium group there was one
neonatal death of a baby with exomphalos, giving a
gross mortality of 1 per cent and a corrected mortality
of 0.

THE EFFECT OF ANALGESIA ON INITIAL
RESPIRATION OF INFANT

In 100 cases in the paraldehyde group the interval
between delivery and onset of respiration was deter-
mined by a stopwatch and compared to the correspond-

4. Choisser, Roper: Personal communication to the authors.

eight babies whose mothers were treated by the McCor-
mick technic and the 100 babies whose mothers had no
analgesia are shown in chart 1. The maximum loss of
weight was reached on the third day in all groups.
Thereafter all the babies gained steadily and at approxi-

Table 3.— Percentage of Babies with Temperatures Over 100 F.

Day Post Partum

, A

1st 2d 3d 4th 5th 6th 7th Sth 0th 10th

2 1 4 5 2 2 1 0 1 0

1.4 2.2 3.0 1.0 1.8 1.4 1 0.4 0.2 0.4

1124111111
1 8.3 4.1 8.3 8.3 S.3 2 4.1 4.1 1

mately the same rate. The average total loss of weight
on the third day was 4.5 ounces (128 Gm ) in the
paraldehyde group, 4.1 ounces (116 Gm.) in the McCor-
mick group and 4.7 ounces (133 Gm.) in the control
group. We were surprised to find that the control
babies lost more weight than those whose mothers had

Normal..

Paraldehyde

McCormick

Pentobarbital sodium

2038

NEONATAL ASPHYXIA-COLE ET AL.

Jour. A. M. A.
Dec. 2, 1939

received analgesia. Recently Cole 6 has published simi-
lar observations.

The average daily change of weight of the fifty pairs
of babies is shown in chart 2. The average total loss
at the end of three days was 1.9 ounces (54 Gm.) in
the paraldehyde group and 2.5 ounces (71 Gm.) in
the control series. Here again the greater loss of
weight of the group without analgesia is striking. Cole
believes that this increased loss of weight of the group
of spontaneous deliveries without analgesia is due to
increased trauma to the fetal head, which causes shock.

CONCLUSIONS

Obstetric analgesia, properly administered, does not
increase the infant mortality or morbidity rates above
those which occur in a series of infants whose mothers
were delivered without analgesia.

1835 Eye Street N.W.

ETIOLOGIC FACTORS IN NEONATAL
ASPHYXIA

TEMPERATURE, PULSE AND RESPIRATION
The average daily temperature of the four series of
cases is represented in chart 3. There is no significant
difference between the group whose mothers received
analgesia and those whose mothers did not.

It is often stated that analgesia results indirectly in
dehydration of the infant owing to its disinclination to
take fluids. Dehydration is usually accompanied by an
elevation in temperature. Analysis of the series of cases
reveals that the percentage of babies whose temperature

Chart 5. — Average pulse rate in paired series: solid line normal,
broken line paraldehyde.

Chart 6. — Average respiration rate in paired series: solid line normal,
broken line paraldehyde.

rose above 100 F. (table 3) was less in the paraldehyde
and McCormick groups than in the control series. The
largest percentage of babies with elevation of tempera-
ture above 100 F. was in the pentobarbital sodium

roup.

The average daily temperature (chart 4), pulse
chart 5) and respiration rates (chart 6) of the paired
eries of paraldehyde and control babies showed no
ignificant difference. The temperature ranged between
>7.8 and 98.7 F., the pulse rate between 115 and 127
md the respiratory rate between 30 and 40 in the two

; ' ln P these paired babies the nursing personnel was
inable to note any significant differences between the
woup in appetite, food consumption, degree of dehy-
Iration or attitude except that the babies whose mothers
lad had analgesia were slightly more drowsy for the
rrst twenty-four hours.

r r- , «> r r ■ Obstetrical Influences on the Weight Curve of

Obst. 65=179-186 (Feb.) 1939.

W. C. C. COLE, M.D.
DAVID C. KIMBALL, M.D.

AND

L. E. DANIELS, M.D.

DETROIT

Asphyxia of the newborn infant has assumed an
entirely new significance in recent years for two rea-
sons : a greatly modified conception of the inauguration
of respiration and the demonstration of the various
pathologic changes that may be produced in the central
nervous system by anoxia. Until very recently it had
always been supposed that the normal baby was born
in a state of physiologic apnea and that as the placental
circulation ceased to function the accumulation of carbon
dioxide in the blood stimulated the respiratory center
and caused respiration to begin.

The studies of Snyder and Rosenfeld 1 have caused
us to change this conception almost completely. They
have shown beyond much question of doubt that the
movements of respiration do not start suddenly at the
time of birth but occur in regular rhythm during the lat-
ter third of intra-uterine life. According to them there
is little essential difference between intra-uterine and
extra-uterine breathing except that amniotic fluid
instead of air enters the lungs in the former and that
of course gaseous exchange does not take place. More-
over, once these movements are established they are
continuous and not interrupted unless some profound
influence is exerted on the fetus. If this conception is
correct, the normal infant should take its first extra-
uterine breath within a very few seconds after delivery,
and a new importance attaches to the baby that is not
breathing at birth. It means that any baby who does
not breathe within at the most thirty seconds after
delivery must be profoundly affected by something,
whether it is strangulation, anesthesia, narcosis, or
shock as a result of the trauma of labor.

Of even greater importance, however, than this
changed conception of the inauguration of respiration
has been the demonstration of the devastating pathologic
changes produced in the central nervous system when
it is deprived of an adequate supply of oxygen for even
short periods of time. Yant and his co-workers * have
shown experimentally that the cells of the brain are
much more sensitive to oxygen want than most ot
the other cells of the body and that one minute o
complete lack of oxygen may be sufficient to cause
their death. Courville 3 has described similar changes
following nitrous oxide asphyxia and in the newborm

From the Woman’s Hospital. . , ...

Read before the Section on Obstetrics and Gynaecology at the 4 .g
Annual Session of the American Medical Association, St. Louis, * /

193 l‘. Snyder, F. F- nnd Rosenfeld, Morris: Juva-Uterine Retpira^rr
Movements of the Human Fetus, J. A. M. A. 108:1946*1948 U

1937.

. and

~2. Yant, \V. P.; Chornyak, John; Schrenk, H. II* » Fatty* F*

Savers. R. R.: Pub. Health Bull. 211, August 1934. .. 0 %idc

*3. Courville. C. B.: Asphyxia as a Consequence of Mtrou*
Anesthesia, Medicine 15: 129 (May) 1936.

Volume 113
Number 23

NEONATAL ASPHYXIA— COLE ET AL.

2039

Extensive areas of “devastation necrosis” have been
observed in the brains of infants dying a few days
after severe asphyxia at birth which are apparently
identical with those observed in death from known
anoxic states such as nitrous oxide anesthesia, acute
alcoholic intoxication and hyperpyrexia. Schreiber 4
has emphatically brought to our attention the relation-
ship of asphyxia at birth to serious degenerative changes
in the brains of older children and has suggested that
in many cases excessive sedation of the mother may
be the causative factor.

Schreiber’s contention that these serious changes are
the result of anoxia, frequently resulting from sedatives
given to the mother, places a tremendous responsibility
on obstetricians who administer such drugs and pedia-
tricians who care for infants after delivery. If it is
true that severe degrees of anoxia produce these severe
devastating lesions, then is it not possible that lesser
degrees of anoxia will produce lesser lesions ? It opens

Table 1. — Incidence of Asphyxia in Entire Series

Percentage

------ - -A- - - — ^

Spontaneous

No. of Still- Severe Mild , *— v

Cases bom Asphyxia Asphyxia Delayed Immediate

Entire series 5,000 1.9 9.4 6.5 9.2 72.8

Table 2. — Immaturity as Factor in Asphyxia

Percentage

Spontaneous

No. ot Still- Severe Mild , — -

Cases bom Asphyxia Asphyxia Delayed Immediate

Prematures and twins 302 14.5 20.7 10.2 0.0 48.0

Pull term 4.003 0.8 8.5 0.2 9.5 75.0

Table 3. — Incidence of Asphyxia Among Primiparos
and Multiparas

factors which might produce asphyxia were evaluated.
Accordingly, we have reviewed the records of 5,000
mothers and babies delivered at the Woman’s Hospital
in Detroit during the years 1936 and 1937. The data
were tabulated according to the punch card method,
which permits the recording of a large amount of data
in such a way that
they may be accu-
rately cross ana-
lyzed in any desired
combination of cir-
cumstances.

The material at
the Woman’s Hos-
pital is particularly
well adapted to this
type of study be-
cause 55 per cent
of the patients were
delivered by general
practitioners, 33
per cent were de-
livered by obstetric
specialists and 12
per cent were de-
livered by the resi-
dent staff. This

provides for a wide variety of methods and skills. More-
over, all social groups and nationalities are well repre-
sented.

Chart 1. — Neonatal deaths In relation to
degree of asphyxia.

SERIES AS A WHOLE

Table 1 shows the incidence of the various degrees
of asphyxia in the entire series.

It is necessary to state at this point our method of
determining the various degrees of asphyxia. Tech-
nically, asphyxia is a decrease in the amount of oxygen
in the circulating blood and only indirectly associated
with the respiratory movements. It is obviously impos-
sible by present methods to determine the oxygen
concentration of the infant’s blood at the exact moment

Percentage

— - -- A ___

Spontaneous

No. ot Still- Severe Mila , a.

Cases bora Asphyxia Asphyxia Delayed Immediate

Primiparas 2,578 0.7 11.1 7.0 11.2 70.0

Multiparas 2,030 0.S 5.2 5.2 7.3 81.8

up a whole new field of speculation with regard to the
possible etiology of such conditions as epilepsy, psycho-
pathic personality and lesser degrees of mental infe-
riority.

Certainly the seriousness of these implications calls
for an explanation regarding the role of sedatives and
anesthetics in the production of neonatal asphyxia and
an appraisal of their comparative importance with other
factors leading to this state. Certainly asphyxia was a
common occurrence before sedatives or anesthetics were
ever administered during childbirth. Such factors as
prematurity, the age, parity and health of the mother,
accidents of labor, the various forms of dystocia, the
duration of labor, the use of oxytocics and operative
delivery must all be considered.

It occurred to us that a great deal of valuable infor-
mation might be obtained from the analysis of a large
series of deliveries in which as many as possible of the

4. Schreiber, Frederic: Apnea of the Newborn and Associat
Cerebral Injury-. J. A. M. A. 111: 1263-1269 (Oct. 1 ) 1938.

Chart 2. Relation of cases of immediate spontaneous respiration to
those of severe asphyxia when no sedative bad been given the mother.

of birth. We chose as the best available criterion the
condition of the baby at birth and the duration and
amount of resuscitation necessary to establish indepen-
dent breathing. The. methods of resuscitation employed
at the Woman’s Hospital are the tracheal catheter, car-

2040

NEONATAL ASPHYXIA— COLE ET AL.

Jour. A. M. A.
Dec. 2. 1939

bon dioxide and oxygen inhalations, respiratory stimu-
lants such as coramine and alpha-lobeline, mouth to
mouth breathing and artificial respiration. We con-
sidered that any baby who required two or more of
these methods of resuscitation was severely asphyxiated,
particularly when it was noted on the chart that the

100
90
80
70
60
50
40
30
20
10
0

Chart 3. — Effect o£ scopolamine on respiration of infant.

631

Cases

671

Cases

714

Cases

1031

Cases

515

Cases

255

Cases

136

Cases

188

Cases

X

Dvrin

»PONt-

& < 'T|C

A

s

-

jpO-

• —

No

Sedative

Scop.

lunit

Scop

2 units

Scop

3 units

Scop

Jurats

Scop

S units

Scop

Gunits

Scop

7-!6urats

child was in poor condition for several hours or days
after birth. If only one method of resuscitation was
employed the baby was classified as mildly asphyxiated.
If respiration was spontaneous but delayed for more
than thirty seconds the baby was classified as “spon-
taneous delayed.” The stillborn group is obvious.

This method of classification is open to certain errors.
One obstetrician might employ more resuscitation than
another under similar circumstances, and the reverse

is also true. More-
over, the retarda-
tion of respiration
is not necessarily
an accurate index
to the oxygen satu-
ration of the blood,
but it cannot be
very far off. How-
ever, we feel that
in as large a series
as 5,000 cases these
differences are
smoothed out and
equalized. At any
rate, it forms a con-
stant standard of
classification which
applies to all sub-
groupings.

It is important to
note that these data
were collected from
records made be-
fore this study was contemplated and accordingly are
free from any prejudiced influence by the attending
physician or the recording nurse. Furthermore, the
relationship of neonatal death to the degree of asphyxia
shown in chart 1 bears out the point that a reasonably
accurate method of classification was developed.

Chart 4. — Effect of pentobarbital
on respiration of infant-

During this same period the incidence of stillbirths
in the city of Detroit was 2.5 per cent. Otherwise we
have no basis of comparison with results in other
clinics, as no similar classification has ever been made.

Chart 1 shows the relationship of the degree of
asphyxia to neonatal death (during hospital stay). In
tire “spontaneous immediate” group the rate was 0.5
per cent. In the “spontaneous delayed” group it was

Table 4. — Age of Primiparas

Percentage

Spontaneous

No. ol Still- Severe Jllld , — » — ,

Cases bom Asphyxia Asphyxia Delayed Immediate

Under 20 years 490 0.4 0.9 5.2 9.0 74.8

20-30 years...., 1,603 0.0 11.2 8.0 10.7 CD.5

30-40 years 272 1.8 12.1 3.3 10.0 Cj.S

40

30

20

10

0

1 per cent, or twice as great. In. the “mild asphyxia”
group it was 3.5 per cent, or about seven times as great.
In the “severe asphyxia” group it was 12.1 per cent,
or about twenty-five times as great. This direct rela-
tionship is most
striking and can
hardly help being
highly significant.

FETAL FACTORS

The importance
of immature devel-
opment as a fac-
tor in asphyxia is
shown in table 2.

Prematurity un-
doubtedly is the
most important
single factor caus-
ing stillbirth and
severe asphyxia.

The relationship
of the size of the
baby to the occur-
rence of asphyxia was studied by dividing the cases
into groups for each pound of variation in their birth
weight.

The three groups 6-7 pounds, 7-8 pounds and o-J
pounds, which represent the general average, were
essentially the same with about 8 per cent severe
asphyxia and 76 per cent spontaneous respiration.

124

Cases

1759

Cases

1673

Cases

535

cases

159

Cases

75

Cases

if

foot

.. a. spy}

— ..

5^

No Ether
Aneslhete *15 min

Ether

530mm

Ether

30'40sm

Ether

SfOflWl

Ether

1hr.+

Chart 5.— Effect of ether anesthesia on
respiration of infant.

Table 5. — Age of Multiparas

Under SO years.

20-30 years

30-40 years

Over -10 years..

Percentage

No. of
Cases

55

1,103

73S

37

Spontaneous

Still- Severe Mild , —

born Asphyxia Asphyxia Belayed Imoicu

0.0

o r

U.O

C.9

S.G

0.7

4.7

5.1

7.1

0.7

5.9

5.1

7.7

8.1

10.S

8.1

5.4

81.0

82.4

SO.O

103

However, the group of the smallest infants, 5-6 ponnds,
showed 14 per cent severe asphyxia and only 6S per
cent spontaneous respiration, while the group made up
of the largest, over 9 pounds, showed but 5.5 per ecu
severe asphyxia and slightly over 80 per cent sponta-
neous respiration. This gives additional evidence o
the importance of mature development in helping 0
withstand the forces tending to produce asphyxia.

iLUME 113
!M HER 23

NEONATAL ASPHYXIA— COLE ET AL.

2041

maternal factors gests that there is increased trauma to the baby in

Certain factors pertaining to the mother show a deft- precipitate deliveries. The same relationship exists

te influence on the incidence of asphyxia in the infant : between the length of the first stage but in a much

A. Parity . — There were 2,578 primiparas and 2,030 less pronounced degree. The trauma exerted on the

ultiparas in the series. The incidence of the asphyxia baby during the first stage of labor is from the con-

these two groups is shown in table 3. A decided tracting uterus as contrasted to the direct trauma

to the baby's head, as occurs during the second
stage.

It will be shown later that the amount of seda-
tive administered to the mother also has a direct
relationship to the incidence of asphyxia. It might
be argued that as the duration of labor increases
the amount of sedative given also increases and
that therefore the results shown in the foregoing
tables are produced by the sedatives given rather
than by the trauma of labor. In an effort to
answer this point, the study was repeated on those
mothers who received no sedatives whatever
during labor. The result of this study is shown
in table 9.

It is evident from a study of these tables that
the same relationship obtains as in the preceding
series, which included all cases, so that the effect
is apparently due to the forces of labor and not

Chart 6. — Elective cesarean section at full term with general anesthesia in tO the Sedatives.

jcty cases.

FACTORS OF DELIVERY

lcrease in asphyxia in the babies of primiparas is The influence of the type of delivery on the incidence
cident. of asphyxia was next studied. If trauma to the infant

B. Age of Mother .— The relationship between the age is a factor in causing asphyxia, the type of delivery

f the primiparas and multiparas to the incidence of should be very important. The various types of delivery
splyxia in their babies is shown in tables 4 and 5. were further divided into those with and those without

unong primiparas, then, the incidence of severe some known type of dystocia. There were 2,660 cases

sphyxia increases and spontaneous immediate respira- in which delivery was spontaneous. • The incidence of
on decreases with each advancing age period. In asphyxia in this group is shown in table 10. There

rultiparas the opposite of the situation in primiparas were 1,151 deliveries by low forceps, as shown in

ccurs; the incidence of severe asphyxia decreases and table 11.

mmediate spontaneous respiration increases with
ach advancing age period until after 40, when
n extreme reversal sets in. The high percentage
if stillbirths by women over 40 is especially
worthy of note.

C. Health of Mother . — Major illness of the
nother is one of the very important factors tend-
ng to increase asphyxia in the baby, particularly
n the case of premature birth. This is shown
n tables 6 and 7.

FACTORS OF LABOR

One of the most important factors in the pro-
luction of asphyxia is the trauma which the baby
lustains from the forces of labor. Table 8 shows
he influence of the duration of the second stage
if labor. An inspection of this table shows very
dearly that, with the exception of the first very
short period, there is an increase in the incidence
if asphyxia and a decrease in spontaneous imme- .

bate respiration with each increase in the dura- forty-eight cases. cctuc cesarean scct,on at ful1 term wt *> 5 i' lnal anesthesia m

:ion of the second stage of labor. Chart 2 presents
n graphic form this relationship. Severe asphyxia
ncreases from a low of 4.6 per cent to a high of
18.6 per cent, and immediate spontaneous breathing
decreases from a high of 84.6 per cent to a low of
50 per cent. It would seem clear that there is a direct
relationship between the duration of the second stage
of labor and the incidence of asphyxia in the baby. The
high incidence of stillbirths in the longest two period
groups is wortly of note. The somewhat greater inci-
dence of asphyxia in the very' short period group sug-

Asphyxia occurs with considerably greater fre-
quency in low forceps delivery than in spontaneous
delivery'. However, in most of these cases episiotomy
is also performed, which necessitates anesthesia. As
will be shown later, this is an important factor and
probably accounts for a good deal of the increase in
asplyxia m the low forceps group.

There were eighty'-seven deliveries by version and
extraction, in which group the incidence of asphyxia
is extremely high, as shown in table 12.

2042

There were 1 18 deliveries by breech extraction. The
incidence of asphyxia in this group is shown in table 13.

There were 264 cases of other types of operative
delivery, mostly mid forceps rotations and the like. The
incidence of asphyxia in this group is shown in table 14.

Table 6. — Health of Mother — Premature Birth

Percentage

No. of
Cases

Spontaneous

Still- Severe Mild , * ^

born Asphyxia Asphyxia Delayed Immediate

Mother Avell 324

Mother ill 6S

12.3 38.3

25.0 30.9

9.9 7.4 51.9

11.8 3.0 29.4

Table 7. — Health

of Mother—

-Full Term Birth

Percentage

No. of
Cases

Spontaneous

Still' Severe Mild , * >

bora Asphyxia Asphyxia Delayed Immediate

Mother well 4,450

Mother ill 156

0.7 8.2

2.6 10.6

6.2 9.2 75.3

6.7 10.2 64.7

Jour. A.

Dec. 2, 1939

The incidence of severe asphyxia is only 3 per cent
as compared to 8.6 per cent for the series as a whole,
and immediate spontaneous respiration is 88.1 per cent
as compared with 75 per cent. This is a very impres-
sive difference.

Morphine . — There _ were eighty-one mothers who
received morphine within four hours of delivery. It
has been said that morphine given during this time
exerts a marked effect on the baby. There were 147
mothers who received morphine more than four hours
before delivery. While the effect is not nearly as strik-
ing as in the preceding group, it is still very marked.
The incidence of asphyxia in these two groups is shown
in table 17.

Scopolamine . — The effect of scopolamine was studied
by dividing the cases into groups based on the number
of units administered; %oo grain (0.0004 Gm.) was
considered as a unit. It should be noted that in the
group receiving only 1 unit the incidence of severe
asphyxia is twice as great as in the group receiving
no sedatives and that immediate spontaneous respiration
is 10 per cent less.

NEONATAL ASPHYXIA— COLE ET AL.

Table 8. Relation of Duration of Second Stage of Labor Table 10. — Incidence of Asphyxia in Spontaneous Delivery
to Degree of Asphyxia ■■ — . .

Percentage

Spontaneous

No. ol Still- Severe Mild r * ,

Cases bom Asphyxia Asphyxia Delayed Immediate

Less than 15 minutes 201 0.7 5.4 5.1 8.5 80.3

15-30 minutes 739 0.7 4.6 5.0 5.6 84.6

30-60 minutes 1.G10 0.4 6.7 6.6 9.3 77.0

1- 2 hours 1,154 0.7 9.9 6.6 10.S 73.0

2- 3 hours 330 0.7 13.3 6.4 13.9 05.S

3- 4 hours 517 1.9 15.3 5.7 13.4 63.7

4- 5 hours 70 0.0 18.6 10.0 11.4 60.0

5- 0 hours 40 7.5 15.0 10.0 15.0 52.5

Over 6 hours 42 4.8 2S.6 4.8 11.9 50.0

Table 9. — Influence of Duration of Second Stage of Labor of
Mothers Receiving No Sedative

Percentage

Spontaneous

No. of Still- Severe Mild , * ,

Cases bora Asphyxia Asphyxia Delayed Immediate

Less than 15 minutes 72 2.8 1.4 1.4 1.4 93.0

15-30 minutes 169 0.6 1.8 2.4 2.4 92.9

30-60 minutes 277 0.9 l.s 3.5 4.0 90.0

1-2 hours.. 8S 2.3 5.8 3.5 3.5 85.0

Over 2 hours .'. .. 22 4.5 ... ... 13.6 81.9

A very brief inspection of this series of tables dealing
with the type of delivery is sufficient to show what
a tremendously important factor this is, especially when
associated with dystocia. It serves to emphasize most
emphatically that trauma to the infant is of major
importance in producing asphyxia.

There were 108 cases of elective cesarean section and
sixty-four in which labor had started. In the former
the element of trauma is almost completely avoided, but
the factors of anesthesia and sedation are not, as will
be brought out later. In the latter group some element
of trauma is added. The incidence of asphyxia in these
two groups is shown in table 15.

SEDATIVE FACTORS

There were 631 mothers who received no sedative
whatever during labor. Slightly more than one third
of these were primiparas. so that it forms an excellent
control group. The incidence of asphyxia in this group
is shown in table 16.

Percentage

Spontaneous

No. ol

Still-

Severe

Mild

Cases

bom Asphyxia Asphyxia Delayed Immediate

All cases

. 2,660

0.4

4.4

5.2

6.6 83.4

With dystocia

359

0.3

5.5

5.6

7.3 61.2

Without dystocia...

. 2,301

0.3

3.9

5.8

6.4 W.O

Table 11. — Incidence of Asphyxia in Lour Forceps Delivery

Percentage

Spontaneous

No. of Still- Severe Mild , — *- ~"T

Cases bom Asphyxia Asphyxia Delayed Immediate

AH cases 1,151 0-9 10.3 6.3 10.2 72.3

With dystocia 125 2.4 16.2 5.2 12.0 W O

Without dystocia.... 1,026 0.7 9.6 6.5 10.0 73.3

Table 12. — Incidence of Asphyxia in Version

and Extraction

No. of
Cases

All cases 87

With dystocia 46

Without dystocia — 41

Percentage

Spontaneous

Still- Severe Mild ( — ^

born Asphyxia Asphyxia Delayed Immediate

4.6 17.2 17.2 24.2 26-5

8.7 21.7 19.6 19.6 20.4

0.0 12.2 17.1 20.8 43.9

Table 13. — Incidence of Asphyxia in Breech

Extraction

Percentage

No. of
Cases

AH cases 118

With dystocia 23

Without dystocia.... 93

Spontaneous

Still- Severe Mild , ,2

bora Asphyxia Asphyxia Delayed Inuneow

o.s

22.0

5.9

2 4.6

4.0

44.0

23.0

0.0

10.1

7.5

23.7

40 .0

21.0

Chart 3 shows in graphic form the relationship o
severe asphyxia to immediate spontaneous respiration
with successively increasing dosage of scopolamine,
will be seen that with each additional dose of the < ri„

the incidence of spontaneous respiration decrease. ,

starting at S8.1 per cent and dropping to a6.9 per ceni,

Volume 113
Number 23

NEONATAL ASPHYXIA— COLE ET AL.

2043

and that likewise the incidence of severe asphyxia
increases correspondingly from 3.3 per cent to 18.6 per
cent. It should also be pointed out that the number
of cases in each of these groups is of such size that
all variables should be satisfactorily smoothed out, so

Table 14.— Incidence of Asphyxia in Mid Forceps Eolation

Spontaneous

No. of Still- Severe Mild , »

Case s bora Asphyxia Asphyxia Delayed Immediate

All cases 264 1.9 22.8 5.3 15.2 54.9

With dystocia. 158 2.5 29.7 5.7 13.9 48.1

Without dystocia.... 197 1.S 12.1 4.7 17.7 63.5

Table 15. — Incidence of Asphyxia in Cesarean Section

Spontaneous

No. o£ Still- Severe Mild , * .

Cases born Asphyxia Asphyxia Delayed Immediate

Elective 108 1.8 15.0 4.7 5.6 * 72.9

After labor 64 1.5 21.5 0.3 12.5 57.8

Table 16. — Incidence of Asphyxia in Group in Which Mothers
Received, No Sedative

Paraldehyde . — Table 21 shows the incidence of
asphyxia in cases in which paraldehyde was given.

ANESTHESIA

Ether . — Cases in which ether anesthesia was given
were divided into groups on the basis of the length of
time during which ether was administered before the
birth of the baby. The results of this study are shown
in table 22.

Chart 5 presents in graphic form the relationship of
severe asphyxia to immediate spontaneous respiration
on a basis of the duration of ether anesthesia. A direct
relationship of asphyxia to the amount of ether given
is apparent.

Table 18. — Incidence of Asphyxia with Scopolamine
C/ir.o Grain Unit)

Percentage

Spontaneous

No. of Still- Severe Mild r *

Cases bora Asphyxia Asphyxia Delayed Immediate

No sedative 631 1.9 3.0 3.2 3.8 SS.l

limit 671 0.G 6.6 5.8 9.1 78.0

2 units 714 1.1 7.3 5.G 11.1 75.1

6 units 1,031 0.5 8.5 6.5 8.8 75.7

4 units 515 0.8 9.5 7.6 10.1 71.7

5 units 255 0.4 15.3 7.1 13.3 63.9

6 units 138 0.0 12.3 10.2 1S.1 59.4

7-16 units 18S 0.5 18.6 11.2 12.8 56.9

No sedatives..

Spontaneous

No. of Still- Severe Mild , <

Cases bora Asphyxia Asphyxia Delayed Immediate
631 1.9 3.0 3.2 3.8 88.1

Table 17. — Incidence of Asphyxia in Group in Which
Mothers Received Morphine

Within 4 hours of

delivery

More than 4 hours
before delivery

Spontaneous

No. of Still- Severe Mild t * *

Cases bora Asphyxia Asphyxia Delayed Immediate

Table 19. — Scopolamine Without Other Factors
{%so Grain Unit)

Percentage

Spontaneous

No. of Still- Severe Mild , — * ,

Cases bom Asphyxia Asphyxia Delayed Immediate

No sedative..

1 unit

2 units

3 units

4 units

5-9 units

Table 20. — Pentobarbital Sodium (V/ 2 Grain Unit)

that this actually represents a scopolamine effect. In
order to answer this point more fully, however, the
cases that presented any other known factor which
could have contributed to asphyxia were eliminated and
the study was repeated in the remaining uncomplicated
cases. All cases of operative delivery or of dystocia,
all cases in which the second stage of labor lasted more
than one hour, all cases in which any other sedative
was given in combination with scopolamine, all acci-
dents of labor and all cases in which the mother was
not well were excluded. The analysis of this group is
shown in table 19. It can readily be seen that the
same effect is produced by administering scopolamine
when as many as possible of the other contributing
factors are eliminated.

Pentobarbital Sodium . — The same procedure was
followed in cases in which pentobarbital sodium was
given. The unit of pentobarbital sodium was taken as
IfA grains (0.1 Gm.).

Chart 4 shows in graphic form the relationship of
severe asphyxia to immediate spontaneous respiration
with increasing doses of pentobarbital sodium. It
seems evident that pentobarbital sodium has a direct
effect in increasing the incidence of asphyxia.

Percentage

, »

_ _ , „„„ Spontaneous

No. of Still- Severe Mild , — * ^

Cases born Asphyxia Asphyxia Delayed Immediate

No sedative..

1 unit

2 units

3 units

4+ units

Table 21. — Paraldehyde

Paralydehyde..

Percentage

— — *

,, , „ Spontaneous

No. of Still- Severe Mild r * *

Cases born Asphyxia Asphyxia Delayed Immediate
131 0.0 26.0 10.3 16.0 47 7

Nitrous Oxide . — There were only 240 cases in the
series in which nitrous oxide either alone or in combi-
nation with ether was given. The incidence of asphyxia
in this group is shown in table 23. The small number
of cases in this group does not permit of further
analysis, but the somewhat higher incidence of asphyxia
in this group seems very definite.

2044

DISCUSSION ON OBSTETRIC ANALGESIA jo«.a.m. a

Dec. 2 , 1939

Anesthesia in Cesarean Section. — The most striking
effect of general ether anesthesia on the baby is shown
in cases in which cesarean section was done. There
were 108 full term, elective cesarean sections done in
tins series. Sixty of these were done under general
ether anesthesia with a high incidence of severe
asphyxia and stillbirths and a very low incidence of
spontaneous respiration. Forty-eight sections were
done under spinal anesthesia. These two groups of
cases are entirely comparable in every way. All fac-
tors of labor and delivery are eliminated, so that the
striking results shown are clearly due to ether. This
is shown graphically in charts 6 and 7. There are
100 babies represented on each chart. The four corners
are shaded to indicate the number of babies showing
varying degrees of respiratory disturbance. The black
squares represent the stillborn babies, the dark gray
severe asphyxia, the lighter gray mild asphyxia, the off
white spontaneous, delayed respiration and the white
spontaneous, immediate respiration.

Table 22. — Ether Anesthesia

Spontaneous

Duration of Ether No. of Still- Severe Mild , «- — —

Spontaneous

Duration of Ether Xo. of Still- Severe Mild

Anesthesia Cases born Asphyxia Asphyxia Delayed Immediate

None 124 1.6 1.6 4.S 8.8 83.0

Less than 15 minutes 1,790 0.4 G.O 4.7 7.6 81.2

15-30 minutes 1,673 0.4 9.5 7.3 10.9 72.3

30-45 minutes 533 1.8 12.7 G.5 9.1 69.7

45-GO minutes ISO 1.9 12.5 10.1 17.0 58.5

Over 1 hour To 5.3 12.0 4.0 13.3 65.3

ABSTRACT OF DISCUSSION

OX PAPERS OF DRS. KOTZ AND KAUFMAN AND
DRS. COLE, KIMBALL AND DANIELS

Dr. C. O. McCormick, Indianapolis: Dr. Cole and his
associates in their analyzed study of 5,000 newborn infants
verify the relation of each of the several known causative factors
ot asphyxia and emphasize the underrated influence exerted by
analgesia and anesthesia. The benefit of analgesia is no longer
directed to the mother alone but to the infant as well. This
view is substantiated by another recent study by Dr. Cole, which
demonstrated that babies born to analgesialized mothers suffer
less birth shock and a less and briefer "physiologic" weight loss.
However, since Sciireiber has indicated the remote effects of
prolonged apnea on the fetal brain, every obstetric attendant
administering relief for labor pains should feel more keenly
his responsibility. Analgesia and anesthesia administered with-
out intelligent regard can be justly criticized. Dr. Cole shows
the definite asphyxia-producing power of the old standby inhala-
tion ether; likewise of nitrous oxide, and less so of the bar-
biturates. From all this comes the necessity of revaluating our
analgesics and anesthetics in labor. The ideal method from the
infant’s interest must not interfere grossly with the oxygen
content of the maternal blood. In this behalf rectal ether oil
is to be commended in that the mother receives the usual amount
of oxygen at all times, the respiratory rate is unaffected and
the respiratory tract is not obstructed by mask or mucus. From
the point of view of anoxemia, the best form of an obstetric
anesthesia is either ethylene or cyclopropane, preferably the
latter, which allows an oxygen content of as much as 80 per
cent; or, better still, local or spinal anesthesia. 1 should like
to ask Dr. Cole how he accounts for the lower incidence of
the stillbirth rate of 1.9 per cent among his 5,000 cases com-
pared with 2.5 per cent in the city of Detroit, when 88 per cent
of his series of patients were delivered under sedation or anes-

Table 23. — Nitrous Oxide Anesthesia

Spontaneous

No. of Still- Severe Mild , ,

Cases bom Asphyxia Asphyxia Delayed Immediate

Xitrous oxide anes-

thesia, 55 per cent of whom were handled by the genera! prac-
titioner? The relationship between duration of second stage
labor and the incidence of asphyxia shown by Dr. Cole endorses
prophylactic forceps and, in the minds of some, the routine
internal podalic version. Dr. Kotz assists us in three ways:
1. He further demonstrates that proper analgesia does not pro-
long labor, increase incidence of operative delivery or affect
infant mortality or morbidity. 2. He contributes additional evi-

thesia 240 o.o 14.2 G.6 U.t G7.5 dence that proper analgesia lessens birth shock and diminishes

SUMMARY

Five thousand consecutive deliveries at the Woman's
Hospital in Detroit have been analyzed with a view
of determining the relative importance of the various

initial weight loss. 3. He evaluates three popular and success-
ful methods of analgesia and indicates their respective efficiency.
The favorable showing of rectal ether is noteworthy. The
incidence of low forceps was only one fourth that of either the
paraldehyde or the pentobarbital sodium method, and spontaneous
delivery occurred seventeen times as frequently as under either
of the two.

factors which contribute to the production of asphyxia
in the newborn. The maturity of the infant, the age,
parity and health of the mother, the duration of the
various stages of labor, the type of deliver}' and the
use of sedatives and anesthetics all exert important
influences on the incidence of asphyxia. It should
be noted that these factors frequently operate in
combination.

CONCLUSIONS

1. The most important single factor in the etiology of
neonatal asphyxia is prematurity.

2. The next most important factor is the trauma of
labor, whether it is the normal forces of normal labor
or whether it is accentuated by dystocia and operative
delivery.

3. Sedatives in any amount definitely increase the
incidence of asphyxia in the baby in direct proportion
to the amounts given.

4. General anesthesia in any amount definitely
increases the incidence of asphyxia in the' baby in direct
proportion to the duration of the anesthesia.

1077 Fisher Building.

Dr. Franklin F. Snyder, Chicago : Because labor itself is
by no means a simple process but is complicated often unex-
pectedly by unforeseen events, the addition of still another
factor, namely, the use of narcotic drugs, adds one more clement
which must be taken into account in the calculation of ho"'
normal birth is to be attained. How can one measure the effect
of drugs on the fetus, keeping separate this factor from the
mechanical trauma of labor? Direct observations of the intra-
uterine respiratory movements of the fetus provide an approach
to this problem. In an experiment, the rate of fetal respiratory
excursions of the rabbit was 30 per minute, pentobarbital
sodium was given to the mother rabbit. Fetal respiratory move-
ments were promptly depressed and finally abolished. Tl' c
mother, however, showed no such effect, being alert and haring
normal reflexes. If the fetus were not under direct observation,
the striking depression of the respiratory system before birth
would not have been detected, in view of the normal appearance
of the mother. After inhibition of respiratory movements for
an hour the fetus was delivered and breathed actively following
birth, thus showing that there was no irreversible damage to
the fetus despite the depressant effect. This experiment >>m 5 '
trates that intra-uterine respiration is a sensitive indicator '™ 1
can detect the earliest effects of narcosis and permit evaluation
of the extent to which a narcotic agent affects the fetus. T m
degree of narcosis may be expressed quantitatively in terms o

Volume 113
Number 23

DISCUSSION ON OBSTETRIC ANALGESIA

2045

change in rate of fetal respiratory movements. Applying this
method to compare various drugs used in obstetrics— morphine,
paraldehyde, chloral, nitrous oxide, ether— the results show that
most anesthetics of both nonvolatile and volatile types sup-
press intra-uterine respiration long before surgical anesthesia is
reached in the mother. On the other hand, results with cyclo-
propane show that the attainment of one important objective of
obstetric anesthesia is not beyond reach, namely the production
of full surgical anesthesia of the mother without interruption of
fetal respiration.

Dr. Joseph B. De Lee, Chicago : I want to talk particularly
of the improvement in late infant morbidity. 1 want to call
attention not to the toll of death but to their immediate and
postponed sufferings later on in life. Imagine yourself put into
a human manikin of appropriate size and driven by vis a tergo
through the parturient canal. How would you like it? I know
you would all demand cesarean section. But that is too danger-
ous. The milder cerebral injuries show up in the early months
of life or in infant life or in late life by the finer macroscopic
and even microscopic damage to the brain. Many years ago I
used to do all my own postmortem examinations on babies and
I noticed the great frequency of minute hemorrhages in the
adrenal glands and at the base of the brain, which was some-
times sprinkled with them, and in the basal ganglions. Schreiber
of Detroit has proved incontestably that asphyxia causes cere-
bral damage. Why may not some endocrinopathies seen by
obstetricians be due to injuries which the baby suffers at birth?
Regarding anesthesia causing asphyxia I think that we had
better retrench a little; we have gone entirely too far in reliev-
ing the pain of childbirth. 1 do not mean that we should stop
relieving the pain of childbirth but I should like to call a halt
in the indiscriminate use of narcotics and anesthetics. I should
like to recommend local anesthesia and get the patient’s mind and
the public mind into the proper receptivity for its widespread use.
The damage to the baby’s brain is produced not alone by the
asphyxia but by the mild and severe traumatisms of even normal
labor. Let us try to reduce the traumatisms of normal labor.
The most important villain in increasing the traumatism of the
baby’s brain is solution of posterior pituitary. Mr. Chairman,
I should like to recommend for next year that one whole morn-
ing, or possibly two, be devoted to these exclusive subjects :
the use and abuse of anesthetics and narcotics in labor, and the
use and abuse of solution of posterior pituitary in labor.

Dr. L. Mason Lyons, Pierce City, Mo.: It is the duty of
the members of our section to evolve unquestionably safe
methods and procedures which will be available to and practical
for the use of rural physicians. The great majority of babies
born in this country are actually born in the country. Dr.
McCormick spoke of the lesser danger of using cyclopropane
and ethylene. It is impossible for me to take cyclopropane
20 miles into the country. These procedures are not practical
in a rural community; neither are they safe when the obstetri-
cian is usually alone or at best is assisted by a single nurse;
when the occasion for anesthesia arises they are both too busy
to bother with gas machines, rectal preparations and subsequent
administration of ether and oil or paraldehyde or anything else.
Since the obstetrician is not able to stay out in the country
long enough to continue observation after intense narcosis, he
should not even attempt their use. It is my experience that
the use of barbiturates does narcotize babies. In about 200
recent deliveries I have not given a single dose of any sort of
analgesia .or any anesthetic. I recognize the use of anesthetics
only for an obstetric emergency, and of these I recognize only
operative intervention, which may be version and extraction,
the necessity of performing and subsequently repairing an
episiotomy or something of the sort. Forceps has not been
used in my last 192 cases. It has never been taken from the
bag. I decry the indiscriminate use of analgesia. If the obstetri-
cian has the confidence of the mother, carefully explains what
she must do to assist, talks to her, stands by her, her labor
is easier, her pains are more tolerable, her baby is healthier,
her labor is quicker and her subsequent course is more normal.

Dr. M. S. Lewis, Nashville, Tenn. : In discussing the effects
of analgesia on the newborn one must recognize first that the
normal fetus exists in the uterus in a constant state of cyanosis.
Cyanosis, then, must be considered the normal state for the

infant at birth and becomes pathologic only if unduly prolonged.
Second, it is important to distinguish between asphyxia result-
ing from the narcotic and that resulting from the hazards of
labor. Third, one must recognize that there is extraordinary
variability in the manner in which different babies will react
to the same drugs. Equally true, all drugs vary widely in the
relative degree with which they depress the respiratory tract.
In ten years I have observed 2,000 infants born to mothers who
had received various analgesics during labor. They were divided
into three groups. The first group of mothers received between
12 and 15 grains (0.8 and 1 Gm.) of amytal and 4.3 per cent of
the babies were narcotized. The second group received bar-
biturates and scopolamine, 1 or 2 units, and 15.1 per cent of the
babies were narcotized. The third group received morphine
and scopolamine and 18.1 per cent of the babies were narcotized.
All labors were terminated under nitrous oxide and oxygen.
It is hard to understand why there would be any narcosis when
a mother received only 1, 2 or 3 grains (0.06, 0.13 or 0.2 Gm.)
of amytal, as has been shown here today, when I use an average
dose of from 12 to 15 grains and only 4.3 per cent of the babies
do not breathe spontaneously. Narcosis of the newborn may
be influenced by a number of factors : First, trauma of labor,
the size of the dose, the interval between the administration of
the analgesia and delivery, and the effects of the drug on the
mother. Infants who have been subjected to a long or difficult
labor are definitely more susceptible to narcosis from all anal-
gesics administered. This is illustrated in my series : In the
operative deliveries 18.3 per cent of the babies were narcotized
while in the spontaneous deliveries only 7.1 per cent were
narcotized. The operative group did not receive any' larger dose
than those in the spontaneous group. When operative pro-
cedures are anticipated the drugs administered to the mother
should be used sparingly and with care, since the infants that
have been traumatized may not tolerate in addition any medica-
tion that may affect the respiratory system.

Dr. Meyer Bodansky, Galveston, Texas : There can be
little question that the use of paraldehyde as an obstetric anal-
gesic carries very little hazard, at least to the adult. Dr. Kotz
has submitted evidence of its relative harmlessness to the new-
born. At the same time, it must be recognized that exceptional
instances do arise. In fact, less than a year ago Dr. Kotz him-
self reported a fatal case which he and his associates described
as one of “idiosyncrasy to paraldehyde” (The Journal, June
25, 1938, p. 2145). A similar case was reported by Drs. J. L.
Jinkins and J. Herrod {Bull. John Scaly Hosp. 1:27 [Feb.]
1939). A primipara aged 27 received 24 cc. of paraldehyde
during labor and shortly thereafter fell into a deep coma last-
ing forty-four hours. The patient after a subsequent stormy
course managed to survive. Dr. Jinkins’ case suggested the pos-
sibility that the intensity and duration of the effect of the drug
were perhaps related to previously coexisting but unsuspected
liver impairment. An experimental study was undertaken to
determine the effect of liver damage on the pharmacologic action
of paraldehyde. In this connection, methods were devised for
the accurate determination of paraldehyde in body fluids and
respired air. My studies thus far indicate that the presence
of liver damage reduces the rate of paraldehyde destruction and
greatly prolongs the blood paraldehyde curve, this being accom-
panied by intensification and prolongation of the narcotic effect.
Although I recognize that in general paraldehyde is a relatively
harmless drug, nevertheless, on the basis of experimental results,
I feel that hepatic insufficiency is a contraindication to its use.
Concerning the effects on the newborn, one can only speculate.
It is conceivable that, though a transient rise in the concentra-
tion of paraldehyde in the blood and tissues of the fetus may be
of little consequence, a high level of concentration sustained for
many hours may produce a quite different effect, of the patho-
logic changes of which nothing is known at present. The prob-
lem is, therefore, of more than academic interest. However
slight the hazard may be, it nevertheless exists, and it is impor-
tant for obstetricians to keep this fact in mind.

Dr. G. D. Rovston, St. Louis : Anesthetics and analgesics
all carry some dangers in their administration. These dangers
however, are outweighed by their advantages. In the Washing-
ton University Clinic, where scopolamine has been used in
more than 20,000 labors, the fetal mortality has been somewhat

2046

Jour. A. M. A.
Dec. 2. 1939

ARTERIAL HYPERTENSION— PAGE

lower than in labors in which no analgesia was employed, pos-
sibly because of closer supervision during this time. Before
we began its use in this institution animal experimentation was
conducted under the personal supervision of the professor of
pharmacology, whose wife was an early patient delivered under
this method. These experimental studies showed that scopol-
amine in doses considerably larger than those used in semi-
narcosis had no effect on either heart or respiration. It was
also found that opium in any form, whether morphine, codeine,
pantopon (hydrochlorides of the alkaloids of opium, principally
morphine) or narcofine (the double salt of morphine and nar-
cotine), depressed the respiratory center and also constricted
the bronchioles, hence was a respiratory depressant. It must
be remembered that other factors, such as dystocia, compression
of the fetal head at the vulval ring, the addition of some anox-
emia from ether or gas and the like, also add to the dangers of
fetal asphyxia. It is important that analgesics be given in
moderate dosage. Among more than 2,000 private patients
whom I delivered under scopolamine personally administered,
my present technic is as follows : As soon as it is determined
that the patient is definitely in active labor she is given from
1)4 to 3 grains (0.1 to 0.2 Gm.) of pentobarbital sodium by
mouth and scopolamine hydrobromide 1 cc. (Viss grain [0.5 mg.])
by hypodermic injection; forty-five minutes later scopolamine
hydrobromide 1 cc. by hypodermic and forty-five minutes later
a third dose of scopolamine hydrobromide 0.5 cc. 0^66 grain
[0.2 mg.]). Thereafter she is given 0.5 cc. by hypodermic
every hour and a half to two hours until delivered. The first
stage of labor is slightly shortened and the second is somewhat
lengthened. The total duration of labor averaged from thirty
minutes to an hour longer with analgesia. Episiotomy and the
avoiding of any protracted compression of the fetal head at the
introitus markedly reduced the occurrence of delayed fetal
respirations and fetal and maternal trauma. The advantages
of analgesia are not limited solely to the relief of pain, as their
judicious employment often permits a better test of labor until
a safer period for intervention (delivery) is reached.

Dr. Jacob Kotz, Washington, D. C. : Dr. Lyons made the
statement that in his last 150 or 200 deliveries he used no
obstetric analgesia, that he merely talked to his patients. I
wonder how many of you have ever had an attack of kidney
colic and had somebody talk to you and remember how much
relief you got from that. We have tried to give an honest
description of what really happens to babies when mothers
receive obstetric analgesia. It is true that the initial respiration
is slightly delayed, but these babies respond rapidly to simple
methods of resuscitation. We believe that paraldehyde, the
McCormick technic, pentobarbital sodium and scopolamine, used
by trained obstetricians in hospitals adequately prepared for the
care of the unconscious patient, are safe methods to be employed
during childbirth and should result in no greater mortality or
morbidity to the mother or the baby than drop ether.

Dr. Wyman C. C. Cole, Detroit: It would be impossible
to answer any important part of these questions in the space at
my disposal. I hope that our position has not been misunder-
stood. We have no thesis that we have been trying to prove
and the data which we have presented are simply presented as
data. In fact, if we had any objective in mind in undertaking
this study it was to show that scopolamine and pentobarbital
sodium were harmless. We were not able to do so. We were
able to show only a small part of our study today. The other
questions that have been asked of us have been answered in the
rest of our study, which I will be glad to let anybody see who
is interested.

Bread in Reducing Diets— This staple article of diet is
probably more responsible for over-fatness than any other- single
item of food. Many adults, brought up in childhood on large
quantities of bread, butter and jam, suffer from a bread habit
and find the limitation of bread which is necessary m reducing
diets extremely irksome. For some it is easier to give up
bread altogether than to have it rationed; they prefer to cat
biscuits or rusks. As a rule, however, a little bread should
be included in every diet, if only for the purpose of teaching
self control.— Christie, W. F.: Ideal Weight: A Practical
Handbook for Patients, London, William Heinemann, 193S.

THE PRODUCTION OF PERSISTENT
ARTERIAL HYPERTENSION BY
CELLOPHANE PERINEPHRITIS

IRVINE H. PAGE, M.D.

INDIANAPOLIS

Perinephritis apparently has not been recognized as
a possible cause of arterial hypertension. Occasionally
hypertension has been recorded for patients whose renal
parenchyma from one cause or another has been chron-
ically compressed. Any genetic relationship seems,
however, to have been ignored.

During the course of experiments designed to pre-
vent the development of renal cortical collateral circu-
lation, cellophane was tried because it was believed
that it would cause little damage to the tissues. It
was soon apparent that arterial hypertension had devel-
oped in the animals in which cellophane had been
wrapped around the kidneys. Examination showed

them to be enclosed within a fibrocollagenous hull from
3 to 4 mm. thick. The cellophane had been fragmented
and taken up, chiefly by the omentum.

The kidney bulged from the hull when it was cut,
indicating that the parenchyma was held fast under
tension.

The .reaction of tissue to cellophane is extraordinary.
Contact for relatively short periods (three to thirty
day's) is enough to evoke a proliferative reaction which
continues for a time, at least, after the cellophane has
been dispersed by' the omentum.

METHOD OF PRODUCING PERSISTENT ARTERIAL
HYPERTENSION

A dog, cat or rabbit is placed under pentobarbita
sodium anesthesia, an incision parallel to the spine is
made and a kidney' is exposed and lifted from its hen-
The fat is removed, and the organ is wrapped gently

From the Lilly Laboratory for Clinical Research, Indtanai'ol
Hospital. „ .

Rend Ik fore the Section on Pathology and Physiology at the * * W

Annual Session of the American Medical Association, St. Louis, . 1

1939. . T |f.:

A preliminary report of this work has .been published (Page, L c
A Method for Producing Persistent Hypertension by Ceiiop&an , ~

S9: 273 [March 24] 1939).

Volume 113
Number 23

ARTERIAL HYPERTENSION— PAGE

204 7

in cellophane sterilized in alcohol. The material may
be applied much as if one were making a bag from
a flat sheet, the ends being twisted together and held
in place by punch paper-clips. String may be employed
if it is not important whether the hull forms around
the hilus of the kidneys or not. The cellophane need
not closely approximate the surface of the kidneys, and
it should exert no constrictive effect. Fluid has easy
egress from the bag. With dogs the kidney may be
dropped back into its bed without fear that its vessels
will kink, but with rabbits and cats it is desirable to
place one stay suture to insure that the kidney will
maintain its proper position. The wound is closed with
silk. The operation should take no more than ten
minutes.

Various kinds of commercial cellophane have been
employed, and most of them provoke an intense fibro-
collagenous reaction. Ordinary Du Pont cellophane
and sylphwrap are among the best for this purpose.
The moisture-proof cellophane seems less reliable. Rub-
ber (surgical glove), tinfoil and oiled surgical silk were
found useless, although plain surgical silk was satis-
factory.

Blood pressure was measured by a mercury manom-
eter connected with a tube filled with heparin solution
to a needle (No. 20) inserted into a femoral artery.

RESULTS

Within three to five days a sharp tissue reaction to
the cellophane occurs, and during the next two or three
weeks the constricting hull forms around the paren-
chyma of the kidney. Hypertension occurs whether
one or both kidneys are placed in cellophane after the
hull has formed. Usually three to five weeks is required
for severe hypertension to occur.

Fig. 2 . — Kidney parenchyma surrounded by hull which does not involve
the renal pedicle. The left hand arrow points to the rim of the hull, which
clears the pedicle by a centimeter. The mean arterial pressure was 180
mm. of mercury. The other kidney was normal.

The hypertension may not be as marked or persistent
if cellophane has been applied to only one kidney,
though this is not always so. Application of cellophane
to the other kidney may reinforce and stabilize the
hypertension. It is usual for the blood pressure to
reach a peak after the first two months, then to fall
from 20 to 30 mm. of mercury and remain at an

elevated level. Dogs have maintained hypertension for
a year, and there is no reason to suppose it will not
continue. The arterial pressure of rabbits and cats
responds in much the same way, but apparently renal
insufficiency as a result of the cellophane develops in
rabbits with greater ease than in other animals.

Fig. 3 . — Section of kidney after fibrocollagenous bull has formed as the
result of wrapping the kidney in cellophane.

Removal of the Offending Kidney. — If hypertension
has resulted from applying cellophane to one kidney
and then this kidney is removed, the blood pressure
falls within a day or two to the control level. In two
experiments the constricting hull was peeled off ; in one
animal the blood pressure also fell to normal, but in
the other the fall was more modest. The longer the
hull remains on the kidney, the more difficult it is to
strip off.

Renal Denervation. — The nerve supply to the kidneys
was removed by stripping the pedicle, with great care,
of all visible nerves, and then cellophane was applied
to the kidneys. Hypertension developed in all of four
animals.

Effect of Stripping the Capsule of the Kidney. — This
procedure did not prevent the hull from forming around
the kidney parenchyma and the development of hyper-
tension when cellophane was applied.

Adrenalectomy. — In some experiments, after the
removal of one adrenal gland, one kidney was wrapped
in cellophane. After hypertension had developed, the
remaining adrenal gland was removed. The blood
pressure fell to normal or slightly hypertensive levels.
Removal of both glands in animals with sustained
hypertension also resulted in a sharp fall in arterial
pressure. If adequate doses of adrenal cortex extract
and sodium chloride were administered, moderate
hypertension (from 150 to 180 mm.) continued.

Occurrence of Renin Activator. — The activating
power of plasma for renin was determined in six dogs
made hypertensive with cellophane. The method of
Kohlstaedt, Page and Helmer 1 was emploved. This
consists of comparing the intensity and duration of con-

j. ivoftistaedt.

and Helmer, O. M.:
tion of Renin by Blood, Am. Heart J., to be published.

ine Acttva-

2048

ARTERIAL HYPERTENSION— PAGE

Jour. A. 31. A.
Dec. 2, 1939

striction produced in an isolated dog’s tail perfused
with Ringer-Locke acacia solution when plasma from
normal or hypertensive animals and purified renin are
mixed and injected into the perfusion fluid.

It was found that the “activator,” e. g. the substance
in plasma which in combination with renin exerts a
constrictor action on blood vessels, was definitely
increased in the hypertensive dogs. The details of
these experiments are contained in a communication
by Kohlstaedt, Page and Helmer. 1

COMMENT

The perinephritis caused by application of cellophane
to the kidneys results in the formation of a fibrocol-
lagenous hull which constricts the renal parenchyma. It
is not necessary simultaneously to constrict the renal
veins, artery or ureter.

The cellophane usually is fragmented and taken up
by the omentum with the result that the omentum
assumes a peculiar golden brown color and is filled with
nodes, each of which contains small bits of cellophane.

lins and Wood s ). Hypertension can be produced by
applying cellophane to one kidney and is intensified and
usually stabilized by applying it to both kidneys or
removing one kidney and applying it to the other. The
same applies to Goldblatt hypertension. And lastly, both
types of hypertension are associated with an increase
of renin activator in the blood (Kohlstaedt, Page and
Helmer 1 ). Removal of the constricting hull often
causes the hypertension produced by cellophane to dis-
appear.

The technic of producing hypertension by cellophane
is simple and seldom results in failure.

Studies of renal function will be the subject of a
separate report in collaboration with Dr. A. C. Cor-
coran of the Lilly Laboratory for Clinical Research.
The morbid tissue changes have been described in a
preliminary communication by Dr. Irving Graef, of the
New York University Medical School, and myself. 8

SUMMARY

1. Severe persistent arterial hypertension has been
produced in animals by means of perinephritis induced
by cellophane and silk. As a result of the
perinephritis a thick, fibrocollagenous, con-
stricting hull is formed around the parenchyma
but avoiding the pedicle. Renal ischemia is
thus produced by a method different in prin-
ciple from clamping the renal arteries.

2. Removal of the offending kidney or the
hull around the kidney abolishes the hyper-
tension.

3. Denervation of the renal pedicle does not
prevent the development of hypertension when
perinephritis is induced.

4. Bilateral adrenalectomy in untreated ani-
mals abolishes the hypertension. If treated
with adequate amounts of sodium chloride and
adrenal cortex extract, slight hypertension
persists.

5. The amount of the substance in the blood
which combines with renin to form a pressor
substance ("renin-activator”) is increased.

6. Perinephritis may be an additional cause
of arterial hypertension in man.

In spite of the disappearance of the cellophane from the
kidney's, the hull continues to thicken for some time,
though how long has not been determined.

Sufficient evidence has been collected to suggest that
the physiologic mechanism responsible for the hyper-
tension is similar to that concerned when hypertension
results from constricting the renal arteries by the Gold-
blatt clamp. As in that type of hypertension, removal
of the offending kidney abolishes the condition (Gold-
blatt, Lynch, Hanzal and Summerville; 2 Blalock and
Levy 3 )’ Similarly, renal denervation does not prevent
its development (Page; 4 Collins 5 ). Adrenalectomy
seriously modifies the capacity of the body to respond
to the hypertensive stimulus (Goldblatt; 0 Page; ' Col-

*7 Goldblatt. Harrv: Lvnch, James; Hanzal, R. F., and Summerville,
Studies on 'Experimental Hypertension : I. T A e Produeuwa of
Persistent Elevation of Systolic mood Pressure by Means of Renal
Ischemia, J. Exper. Med. 59:34/ (March) 1934. p„„_i

3. Blalock, Alfred, and Levy, S. E.: Studies on the Etiologj of Renal

Hypertension. Ann. Sure. 10G: 836 (Nov.) % 193/. n v- r

4. Page, I. H.: Relationship of Extrinsic Renal J^eixes to OnRin of
Experimental Hypertension, Am. J. Physiol. 11^:1 66 (Msg) 1935,

5 Collins. D, A.: H Xpert en si on from Constnctioh of the Artcne. ot

D enervated Kidneys, Am. J- Physiol. 11G:616 nsion* V

6 Goldblatt. Harrv: Studies on Experimental Hypertension. >.
The Pathogenesis of Experimental Hypertension Due to Renal Ischemia,

Ar, 7 ’of' bilateral Adrenalectomy on Arterial

lllooil Pressure of Dors with Experimental Hypertension, Am. J. Physiol.
122 : 352 '(May) J93S.

ABSTRACT OF DISCUSSION
Dr. Alvin G. Foord, Pasadena, Calif.: May I ask wliat
are the changes in the arteries and arterioles, as well as those
in the parenchyma in the kidney, after prolonged constriction
of the kidney by your method?

Dr. Irvine H. Page, Indianapolis: I should not discuss the
question because I am not a pathologist. Dr. Irving Graef o
the New York University College of Medicine is studying t 1C
material. For the most part, he finds relatively little clunC-
except when the malignant stage appears. There may
atrophy of the tubules and areas of fibrosis and infarction.
Some of our animals have been alive for eighteen niont ,s >
but such periods are too short to be certain of the ultima c
morbid changes in the kidneys.

Dr. Foord: Would you expect that a similar tumor gro'Uh
around a kidney in a human being would produce hypertension.
Dr. Page: It did.

Dr. Foord : Yours was unilateral ?

Dr. Page: No, bilateral. The case was described in
by Dr. Blatt and myself in the May issue of the Annals <V
Internal Medicine. .

8. Collins, D. A., and Wood. E. II.: Experimental I Renal I

sion and Adrenalectomy, Am. J. Pliysiol. 1 23:224 (Jut y) 193-. _ ■

9. Page. I. IE, and Graef, Irving: Hypertension Fot!o»m« '*-21,
mental Perinephritis Induced hy Cellophane, Arch. Path. ~S:o '•
1939.

Volume 113
Number 23

KIDNEY STONE— ALBRIGHT ET AL.

2049

NONSURGICAL ASPECTS OF THE
KIDNEY STONE PROBLEM

FULLER ALBRIGHT, M.D.

HIRSH W. SULKOWITCH, M.D.

AND

RICHARD CHUTE, M.D.

BOSTON

Our purpose in this paper is to report some observa-
tions which have been made at the Stone Clinic of the
Massachusetts General Hospital and in the Research
Laboratory since a previous brief report 1 in 1937. This
paper is not meant to be a well balanced discussion of
all the nonsurgical aspects of the kidney stone problem.

The approach to the entire subject has remained
fundamentally the same. It is based on the following
major premise and its corollary :

Premise. — A patient with urine of such composition that
some crystalloid precipitates out of it is predisposed to the
formation of a stone composed largely of the precipitated crystal-
loid (compare cystine stone in cystinuria, uric acid stone in
gout and calcium phosphate or calcium oxalate stone in hyper-
parathyroidism) .

Corollary . — In a case in which there is a tendency for stones
composed predominantly of a certain crystalloid to form, treat-
ment should be directed to altering the composition of the
urine in such a way that solution of the crystalloid is favored.

It is appreciated that the problem is not quite as
simple as the foregoing propositions suggest. Stasis
undoubtedly is a factor. Infection, on the other hand,
while definitely a factor, probably plays its chief role
by changing the composition of the urine (e. g. ammonia
formation producing an alkaline urine and favoring the
precipitation of phosphates and carbonates).

If one is to apply the aforementioned approach, it is
necessary first to know the nature of the stone with
which one has to deal. If mixed stones are disregarded,
there remain four common types — calcium phosphate,
calcium oxalate, uric acid and cystine. Each of these
stones requires its own specific measures. For exam-
ple, the urine should be made acid for calcium phos-
phate stones and alkaline for uric acid and cystine
stones. With oxalate stones the pn of the urine is
unimportant. If no stones are available for analysis,
one must resort to circumstantial evidence. A few
differential points seem worthy of mention.

Staghorn stones are nearly always, if not always,
composed of calcium phosphate or cystine. The latter
in some cases have a pathognomonic appearance in the
roentgenogram (fig. 1). Very suggestive of cystine
stones is the coalescence of several small stones to form
a large one (fig. 1 A). The individual small stones,
furthermore, have a homogeneous, waxlike appearance,
which is most characteristic but hard to describe (fig.
IB). Cystine stones, of course, occur with cystinuria,
so the diagnosis can easily be ruled in or out by testing
the urine for cystine. 2 Phosphate stones, on the other
hand, grow by surface apposition and their lamellar
structure is often discernible in the roentgenogram.
Infection of the urinary tract by an organism which

From the Stone Clinic of the Massachusetts General Hospital and the
Department of Medicine of Harvard Medical School.

Read before the Section on Fhannacotogy and Therapeutics at the
Ninetieth Annual Session of the American Medical Association, St. Louis,
May 18, 1939.

1. Albright, Fuller: Some Medical Aspects of the Renal Stone Prob-
lem, New England J, Med. 217 1 1063 (Dec. 30) 1937.

2. To 5 cc. of urine made alkaline with ammonium hydroxide 2 cc.
of 5 per cent sodium cyanide solution is added and allowed to stand for
from five to ten minutes; a few drops of a freshly prepared 5 per cent
sodium nitroprusside solution is then added; in the presence of cystine a
permanent deep purplish red will develop.

splits urea is strong evidence that any stones which
may be present are composed of phosphates and car-
bonates. Hyperparathyroidism usually causes calcium
phosphate stones but occasionally calcium oxalate ones.
A structure suggestive of a snowflake with spicules
radiating from a central focus (fig. 2) is pathognomonic
of calcium oxalate. Failure of the stone to show in
the roentgenogram is strong evidence in favor of a uric
acid stone.

DISSOLUTION OF KIDNEY STONES

It is, of course, one thing to prevent the formation
of stones and another to dissolve them. A priori one
might hope that, if precipitation of a crystalloid influ-
ences stone formation, the dissolving of the crystalloid
from a stone might cause the disappearance of the stone.
Such indeed seems to be the case. Stones, like teeth,
are made of an organic matrix in which is deposited
a crystalloid. However, there is one important differ-
ence. If the calcium is dissolved out of a tooth there
is still a tooth ; if the calcium is dissolved out of a cal-

. Fig. 1. — Appearance of cystine stones in patient R. E. C. before opera-
tion; A, coalescence of small stone to form large one; B, stones with
waxlike appearance

cium phosphate stone there is no stone. Such being
the case, it becomes apparent that the dissolution of
stones is not an impossibility.

DISSOLUTION OF CYSTINE STONES

If a cystine stone is placed in a weakly alkaline solu-
tion in the laboratory, it very gradually disappears over
a period of weeks or months. Thus a cystine stone
weighing 0.1292 Gm. immersed in a borate buffer solu-
tion of pn S.O at 40 C. lost 14,2 mg. (11 per cent) in
eleven days.

It is very simple to keep the urine alkaline, and there
is no reason why a cystine stone in the kidney pelvis
should not disappear. And it does. Thus a girl aged
15 whose roentgenogram is shown in figure 1 entered
the clinic Feb. 1, 1938. Kidney function was only
moderately impaired and, surprisingly enough, the urine
was not infected. The diagnosis, at once suspected
because of the roentgenogram, was confirmed by the
demonstration of cystine in the urine. It was thought
(we now believe ill advisedly) that surgery was indi-
cated. When this was completed the right kidney was
out ; there were still some stones in the left kidney and
in the perirenal tissues (fig. 3 A), and the urine was
infected with Staphylococcus albus. The patient was

2050

KIDNEY STONE— ALBRIGHT ET AL.

Joire. A. M. A
Dec. 2 , 1939

then put on sodium citrate, 1 teaspoonful three times
a day, to keep the urine alkaline. The intrarenal stones
gradually disappeared (figs. 3 A and B). The urinary
infection has persisted. 2 * The end result will probably
be fairly satisfactory. Another time, however, we would
try medical treatment from the beginning. These obser-
vations with regard to cystine stones, of course, have

been made 3 before
the present reports.

DISSOLUTION OF
CALCIUM PHOS-
PHATE STONES

The problem
with calcium phos-
phate stones is not
so simple. Expose
a calcium phosphate
stone to an acetic
acid solution at a p n
of 5.0 in the labo-
ratory and in a
very few days there is no stone. Keep the urine of a
patient with a calcium phosphate stone in the kidney
pelvis at a p n of 5.0 for several months; the stone
will become no larger but in most cases it will become
no smaller. There is no question that the Higgins
regimen, 4 one of the main features of which is the
production of an acid urine, will cause an occasional
calcium phosphate stone to disappear; the question is
why the regimen does not work better than it does.
The answer is quite apparent. The urine is very nearly
saturated with calcium phosphate when it reaches the
stone. The more acid the urine the more calcium and
phosphate ions it will keep in solution, but the more
acid the urine the more calcium and phosphate ions it
already contains when excreted by the kidney. If one
could cause the patient to excrete an acid urine without

Fig. 2. — Appearance of calcium oxalate
stones from two different patients. B is
that of patient referred to in the text.

Fig. 3 , — Appearance of cystine stones of patient R. E. C. (see figure : i).
A Anrii 16 1938, shortly after right nephrectomy and left nephrolithot-
omy; /?. after ten months on medical regimen. Note that most of stones
in the kidney have disappeared.

at the same time increasing the calcium and phosphate
in the urine, the in vivo results should approach the

in vitro ones.

2a. Urinary

3. Crowell.
$7 (Jan.) 192-*

4. Higgins.
Solution with
(Aug.) 1936.

ifection subsequently cleared up spontaneously.

J.: Cystin Nephrolithiasis, Surg., Gynec. & Obst. 3b.

C.: Urinary Lithiasis: Experimental Production and
inical Application and End Results, J. Urol. .C; 16S

The logical sequel to this discussion is a considera-
tion of the advisability of introducing some dissolving
fluid into the kidney “from below” by a catheter. A
study of what might be the most efficacious fluid to use
has been under way in this laboratory for the past eigiit
months. We are far from having all the answers, hut
a few simple facts seem clear.

The solution should probably be as acid as possible
without being too irritating to the tissues. Urine can
reach a p H of. 4.8. Solutions with a pn of 4.0 seem
to cause but little irritation, and this figure has arbi-
trarily been chosen for the time being.

The next question is what acid to use. Strangely
enough, urologists in the past frequently have attempted
to dissolve phosphatic calculi with phosphoric acid.
This is the one acid not to use (v. infra). Citric acid
has a property other than the fact that it is an acid,
which suggests its use for this purpose. Dr. M. J.
Shear several years ago first called the attention of
one of us (F. A.) to the possibility of using citric
acid for this purpose. It took a few simple test tube
experiments performed in July 1938, however, to show
us how efficacious citrate really is.

nouns

Fig. 4. — Rate of solubility of kidney stones in vitro at different
with sodium citrate, citric acid mixture of 1 54 mm. per liter (isotonic/.
A, calculus consisting mainly of calcium oxalate, citrate solution f« 7' f
temperature 25 C. B, fragment of calculus consisting mainly of caiciw
phosphate, citrate solution pn 8.0, temperature 30 C. C, fragment
calculus from same stone as (B) at pn 5.0, temperature 30 U •
calculus consisting mainly of calcium phosphate, citrate solution pn a. »
temperature 30 C.

Before discussing the test tube experiments, it maj
be helpful to explain the specific property of citric acid
previously mentioned. The following equation will help
make this clear:

3 Ca— + 2 Cits _ CanCit." — » Ca‘+ + 2(CaCit)~

It will be noted from the equation that the net res id
of adding citrate ions to a solution containing C a ion 5
is to divide the number of Ca ions by 3. 1 he other
two thirds of the Ca ions become caught in a complex
(CaCit) - ion. Unfortunately this property of citrate
solutions is at its maximum only at alkaline pnfi ®
more acid p n ’s there is little of the tertiary citra .c
(Ca 3 Cit 2 ) formed and more of the secondary (Ca H y )
and primary (CafH.Cit].,) citrates, neither of wine*
produce (CaCit) - ions. However, both of these sa
are weakly dissociated, so there is a marked reauetto
of calcium ions even at a pn of 4.0. One can caicu a
the calcium ion concentration, given the total calciu ,
the citrate concentration and the pn, from a nomogra
constructed bv McLean. 5

5. McLean, F. C.: Application of the Law
(Law of Mass Action) to Biological Problems,
(Oct.) 1938.

of Clioniei! Equ!

Volume* 1 13
Number 23

KIDNEY STONE—ALBRIGHT ET AL.

2051

The importance of this property of citrate is obvious.
The speed of solution of calcium phosphate salts in any
fluid will be decreased as the calcium or phosphate ions
increase; any property of a fluid which will dispose
of one of the end products of the reaction — in this case
calcium — will speed up the reaction. The objection to
phosphoric acid (v. supra) is, of course, that it supplies

one of ■ the end
products of the re-
action, namely
phosphate ions.

The test tube ex-
periments referred
to, carried out in
the first ten min-
utes of this eight
months investiga-
tion, clarified the
main points. They
were all performed
on a normal acid
urine containing
moderate amounts
of calcium and
phosphate. Table 1
presents the six
experiments.

The most significant of these experiments is 3, in
which a calcium phosphate precipitate is dissolved in
an alkaline urine by adding sodium citrate. Experi-
ment 5 suggests that a citrate solution will not help
to redissolve oxalates, at least of an acid pu, although
it hinders precipitation of oxalates (experiment 6).
More elaborate quantitative studies were designed to
determine the effect of temperature, concentration, /> H ,
other salts and the like, but these are not yet completely
satisfactory and will not be discussed here, especially
since it appears possible that citrates may be super-
seded by hexametaphosphate (discussed later). The
citrate solution which we used for the in vivo experi-

Fir. 5. — Rate of solubility of phosphate
kidney stone in sodium citrate-citric acid
mixture of 154 mm. per liter (isotonic) at
p it 4.0, temperature 25 C. Where loss in
weight is not due to citrate solution points
are not connected with a line.

Table 1. — Six Experiments

1. Urine -f ammonium hydroxide — ► calcium phosphate precipitate

2. Urine 4- ammonium hydroxide — ► calcium phosphate precipitate

4- acetic acid — ♦ clear solution

3. Urine 4- ammonium hydroxide — ► calcium phosphate precipitate

4- sodium citrate — ♦ clear solution

4. Urine 4- oxalate — * calcium oxalate precipitate 4- acetic acid

— ► no change

5. Urine 4- oxalate — > calcium oxalate precipitate 4~ sodium citrate

— ► no change

6. Urine 4* sodium citrate (stand 1 hr.) 4" oxalate — ♦ inhibited

precipitate

ment discussed later had a pa of 4.0 and a concentra-
tion of citrate which was twice isotonic. Its formula
is given in table 2.

This is not altogether nonirritating.

EFFECT OF CITRATE SOLUTION ON CALCIUM
PHOSPHATE STONES IN VITRO

Quite a large number of experiments have been con-
ducted in which phosphate stones have been subjected
to a constant interchange of the citrate solution
at various temperatures, and their reduction in size
has been noted. Some representative experiments
are shown in figures 4, 5 and 6. The speed with
which the stones dissolved was most encouraging.
Some stones crumble; others decrease in size without
crumbling.

IN VIVO EXPERIMENTS ON CALCIUM
PHOSPHATE STONES

To date the solution has been tried on four patients.
There has been only one convincing success. This
patient (C. S.) was a hemophilic youth aged 19 who
had had a hemorrhage into the spinal cord. This had
resulted in a partial paralysis of the lower extremities
and a “cord bladder.” He had been bedridden for three
years and had been on constant drainage for two years.
In the lower extremities osteoporosis had occurred from
disuse. The urine was constantly alkaline, owing to

Table 2. — Citrate Solution Used

Sodium citrate * • 45.2 Cm.

Citric acid 38.0 Gni.

Distilled water to make 1,000.0 cc.

infection, and the bladder contained nine large lamel-
lated stones (fig. 7). One of us (R. C.) saw him in
consultation and thought that any surgical procedure
was contraindicated. Accordingly the citrate solution
was administered to the bladder b}' Munro’s 0 tidal
drainage apparatus. The stones rapidly disappeared,
as shown in figures S and 9. It may be asked how it
is known that the stones were destroyed rather than just
decalcified. Figure 8 answers this. If the matrix
remained intact, the calcified remnants would not he
touching one another.

In the three other cases there was no cause for dis-
couragement, as definite reasons for the lack of success
were present and as these can be avoided in the future.
One of these cases will be discussed later.

Ar Jr AKA I US l'UK DIS-
SOLVING STONES
IN KIDNEY
PELVIS

Needless to say, the
object of these studies is
based on the hope that a
stone in the kidney pel-
vis can ultimately be
dissolved by means of
a ureteral catheter. An
apparatus has been de-
signed for alternately in-
troducing fluid into and
withdrawing it from the
kidney pelvis. The prin-
ciple behind this appara-
tus is the same as that in
Munro’s tidal drainage
apparatus for the blad-
der. Some of the most
important features of this
apparatus and the initial
impetus were furnished
by Dr. William Davis.

If the apparatus proves
practicable, a descrip-
tion will be published

under the authorship of two of us (F. A. and H. W. S.)
and Dr. Davis. In its present form it was tried recently
on a patient with a large stone in the kidney pelvis which

Hi ^. Mu r-r D . onaId ' I> and Hah "-, Joseph: Tidal Drainage of Urinary
Bladder; Prei.m.nary Report of This Method of Treatment as Applied to

*(FW’ 7j f, iM® eSCT,Pt,0n ° f Arparalus ' England J. Med.

HOURS

. Fig. 6. — Rate of solubility. of. kid-
ney stones in sodium citrate-citric
acid mixture of 354 ntm.~ per liter
(isotonic) at pn 4.0, temperature 40
C. A and C, calculi consisting of a
large amount of calcium phosphate
and some calcium carbonate, B , cal-
culus consisting of a large amount of
calcium phosphate and a moderate
amount of calcium oxalate.

2052

KIDNEY STONE— ALBRIGHT ET AL

i

Jour. A. M. A.
Dec. 2. 1939

had resulted from hyperparathyroidism. The apparatus
was run for three days. The kidney filled and emptied
satisfactorily, as determined by introducing 7.5 per cent
sodium iodide into the apparatus and roentgenographing
the patient. The stone showed no change. It was then

Fig. 7. — Stones in bladder before treatment.

Rosenheim and Dr. Howard Suby have shown that
sodium hexametaphosphate has a marked tendency to
produce hemorrhages when introduced into the blad-
ders of dogs.

SUMMARY

The following points are selected as the most
important :

1. Cystine stones can often he diagnosed by their
roentgenographic appearance.

2. A stone which gives the appearance by roentgeno-
gram of a snowflake with spicules radiating from a
central focus is composed largely of calcium oxalate.

3. Attempts to dissolve calcium phosphate stones by
making the urine acid are attended with- little success
because acid regimens increase the amounts of calcium
and phosphate in the urine and thus tend to render it
saturated. The question of introducing a dissolving
fluid “from below,” therefore, is brought up.

4. A solution of sodium citrate-citric acid at a pn
of 4.0 is effective in dissolving calcium phosphate
stones in vitro and in vivo (one case of stones in the
bladder). This solution combines the effect of acids

removed and found to be an oxalate stone, which of
course explains the failure.

The encouraging feature about this case was that
the urine was sterile at the beginning and at the end
of the three clay run. She received sulfanilamide
throughout. After the operation, however, the urine
became infected.

SODIUM HEXAMETAPHOSPHATE
Prof. A. Baird Hastings suggested to us the use of
sodium hexametaphosphate. The principle is the.- same
as with citrate except that, whereas citrate disposes of
only part of the calcium ions, hexametaphosphate dis-
poses of all by merging them into complex calcium
metaphosphate ions.

jrjg- # g, — Appearance o£ stones shown in figure 7 after eighty hours of
treatment.

The equations are as follows : * _

Xar (Nai U'0=/c)>— 2 Xa* 4- (Xu. (FO=)o)-
- 2 1 Ca* > '_

(Car (POo)e)

Sodium hexametaphosphate, as was to be expected,
has been found most effective in the dissolving of stones
in vitro. Best of all. it will actually dissolve calcium
oxalate in a test tube. Of course it is not a biologic
substance and metaphosphates (PCD) do not appear in
the bodv, so considerable caution must be exercised in
its use.' Recent studies in this laboratory by Dr. Max

Fig. 9. — Appearance of bladder shown in figures 7 and 8 after ten
more days of treatment. After still five more days of treatment stones
had entirely disappeared, except for one small shadow, which persisted m
spite of further treatment.

in dissolving phosphates with a specific effect of citrate
in dissolving calcium salts by decreasing the calcium
ion concentration.

5. More recent and less complete studies suggest
that sodium hexametaphosphate solutions may be even
more effective than citrate ones.

ABSTRACT OF DISCUSSION
Dr. Charles C. Higgins, Cleveland: Dr. Albright and bis
associates are to be congratulated on the excellent results they
have secured in the dissolution of bladder stones. In consid-
ering the advisability of utilizing the high vitamin A acid-as 1
diet to produce the dissolution of a calculus which forms m
urine the reaction of which is alkaline, the authors have men-
tioned a fact which I have been aware of for a long tune.
That is, by increasing the acidity of the urine one definite!}
increases the excretion of calcium ; however, to offset this,
have observed that the solubility of the stone-forming S3 ts
increases more rapidly with increasing acidity than docs t ie
amount of calcium excreted. It is necessary to cal! attention
to the fact that chemical formulas indicate only the ultimate
products that may be obtained and in no way suggest, the tint.
required for equilibrium to be reached. Thus, while it is V>-

Volume 113
Number 23

PERFORATION OF. JEJUNUM— RUMBALL

2053

sible to say that by the formation of a complex citrate ion
two thirds of the calcium ions may be removed from solution,
there is no way of knowing that in the concentration of cal-
cium involved and in the presence of the other constituents in
the urine this equilibrium will be reached within a reasonable
length of time. This will be especially true in cases of phos-
phates. When one recalls the work of Holt, LaMer and
Chown, in which they found that equilibrium between calcium
hydroxide and phosphoric acid was reached only after ten days
had elapsed, the seriousness of this problem becomes more
apparent. I have in my possession roentgenograms revealing
stones composed of salts which had precipitated in urine the
reaction of which was alkaline or acid, in which the high
vitamin A acid-ash or alkaline-ash diets have been used. These
roentgenograms have been sent to me by Dr. William Braasch,
of the Mayo Clinic; Dr. W. M. Kearns, of Milwaukee, and
Professor Pyrah, of Edinburgh, Scotland; the last case was a
staghorn cystine stone which has undergone solution by the
alkaline-ash diet in my own hands. I now have a series of
fifty-two collected cases in which renal calculi have undergone
. solution by dietary means. The results of this study_ will be
published in the near future.

Clinical Notes, Suggestions and
New Instruments

PERFORATION OF THE JEJUNUM DURING A GASTRO-
SCOPIC EXAMINATION OF A RESECTED STOMACH
John M. Rumdall, M.D., Rochester, N. Y.

To the. best of my knowledge there is no report in the liter-
ature of a perforation of the stomach or of the jejunum induced
by die Wolf-Schindler- gastroscope with a rubber finger tip.
Five perforations of the stomach have- occurred with the round
rubber or sponge tip of Henning' on the Wolf-Schindler gastro-
scope. 1 Three of these perforations were observed by Dr.
Rudolf Schindfer .of the University of Chicago Clinics. The
Henning, tip. has been discarded by most men doing gastros-
copies since the report of these' accidents.

The subject of the present report had been examined gastro-
scopically .six months before, and at. this time the Henning tip
had been. used. The gastroscope was introduced without any
force into the jejunum and was then withdrawn so that the
stoma could be observed. The patient had had a' resection for
carcinoma, and since it is my policy to examine these cases
gastroscopically at least every six months or oftener if neces-
sary, the examination described here was just . a routine
follow-up.

REPORT OF CASE

Mrs. F. K., aged 68, white, was admitted to the Rochester
General Hospital Sept. 13, 1938, complaining of “stomach
trouble” for the preceding three months. The predominating
symptoms were weakness, constipation and excessive “gas.”
There was a mild secondary anemia and the gastric analysis
showed a low acidity. The free hydrochloric acid reached only
18 degrees thirty minutes after the administration of histamine.
The radiographic study of the stomach revealed a filling defect
involving the antral portion of the stomach on the greater
curvature side and extending back toward the body.

September 26 a gastric resection of the modified Polya type
was done by Dr. D. C. Houghton, senior surgeon in the ward
service. The loop of the jejunum was brought up posterior to
the mesocolon. The resected portion showed a large crater-like
ulcerating tumor, which was classified as a medullary carcinoma
by our pathologist. There were no metastases noted anywhere
in the abdomen. Two omental nodes were removed, but these
showed no evidence of carcinoma. The operation was followed
by a transfusion, and the patient made an uneventful recovery.
She was discharged on her twenty-sixth postoperative day. Since
her discharge she has gained IS pounds (6.8 Kg.) and her
only complaint is occasional “heartburn.”

1. Schindler, Rudolf: Gastroscopy, the Endoscopic Study of Gastric
Pathology, Chicago. University of Chicago Press, 1937, pp. 79-SO; The
Incidence of the Various Types of Gastric Disease as Revealed by Ga^tro-
scopic Study, Am. J. M. Sc. 197: 509-516 (April) 1939.

The- first gastroscopic examination in January 1939 revealed
an adequate stoma, which, however, did not contract rhythmic-
ally. There was some increase in the normal red appearance
about the stoma. The mucosa of the remaining portion of the
stomach showed some atrophic changes. No evidence of recur-
rence of the malignant condition was seen.

The second gastroscopy was done on the morning of, June
15, 1939, at 10 : 30. The patient was prepared in the usual man-
ner, and the Wolf-Schindler gastroscope with a rubber finger
tip was introduced with ease, no force being used. After intro-
duction no pain or discomfort was experienced by the patient.
As is often the case, the gastroscope was believed to have slipped
into the jejunum. The instrument was withdrawn about 4 or
5 inches and air was introduced. The stoma and the remaining
portion of the stomach appeared much the same as on- the
previous examination. No evidence of a malignant growth was
seen. The whole examination was carried out without any dif-
ficulty. Immediately ; after the examination the patient com-
plained of a feeling of distention and faintness. No , shoulder
pain was noted by the patient. She remained in bed in the -out-
patient department for about an hour and as she said she felt
better she was allowed to. go home. . Close to 5 o’clo'ck' the
same day she returned to the emergency department complain-
ing of the same distention and generalized pain in the abdomen.
A roentgenogram of the abdomen taken with the patient on
her left side showed a large amount of air under the right
diaphragm.

Laparotomy was performed by Dr. Christopher D’ Amanda,
senior surgeon in the ward surgical service, approximately nine
hours after perforation. Free air escaped as soon as the peri-
toneum was opened, and the abdo-
men flattened out. Exploration
through the mesocolon in the lesser
sac revealed a perforation about
the size of a dime (18 mm.) on the
posterior surface of the jejunum 2
inches away from the
stoma, as shown in the
accompanying illustration.

The perforation was
closed and the edges were
invaginated. No evidence
of peritonitis could be
seen, nor were there any
metastatic lesions notable.

The patient recovered
from this insult remark-
ably well and was asking
for a full course meal on
her second, postoperative
day. There was a low grade fever for five days, but the tem-
perature returned to normal and she was discharged on -her
fifteenth postoperative day feeling fine. ■

ESOPHAGUS

JEJUNUM

POINT OF PERFORATION

Point oh posterior^ sur-
face of jejunum 1 at' \Vhich
perforation occurred.

COMMENT

The incidence of this type of perforation is very small 'and
should in no- way influence one’s faith in' the gastroscope as a
diagnostic aid; however, it has changed my method of intro-
duction in patients who have had a resection. I believe that
one had better be on the safe side and stop the introduction of
the instrument at a point where the examiner believes he will
best see the stoma. The one important and interesting factor
in this case is that all gastroscopic signs of perforation were
lacking. Usually the stomach collapses and one is unable to see
very much because no air can be introduced. The stomach
retained air sufficiently for me to see practically the entire
mucosa in this case.

This perforation occurred in the 112th gastroscopy that I have
done since October 1938. I feel that the technic that has been
followed is in accord w>ith the teachings of Dr. Schindler. The
cnly other question that can be raised is whether the tissue at
the point of perforation was normal. No biopsy was taken; it
appeared normal to the surgeon, however. With these possibil-
ities eliminated, the only conclusion that one can draw is that
this perforation occurred with reasonably good technic and
through normal tissue.

17 South Goodman Street.

2054

COCCIDIOIDAL PERITONITIS— RUDDOCK AND HOPE

Jour. A. JL A.
Dec. 2, 1939

COCCIDIOIDAL PERITONITIS: DIAGNOSIS BY
PERITONEOSCOPY

John C . Ruddock, M.D., and Robert B. Hope, 1I.D.

Los Angeles

This case is unique in that it is the first case of coccidioidal
peritonitis reported in the literature in which a diagnosis was
proved before death. Coccidioidal granuloma is a rare disease
and one peculiar to the San Joaquin Valley in California. The
first human infection was reported by Wernicke 1 in 1892, and
the organism was described as a protozoa. In 1900 Ophuls
and Moffitt - proved that the infection known as coccidioidal
granuloma was due to a mold (Coccidioides immitis) and were
able to grow it on culture mediums. Many reports have appeared
since this date.

The similarity of this disease to tuberculosis is noted repeat-
edly in the literature. This similarity exists in its clinical
manifestations and body reactions to the infection. Coccidioidal
infections often are miliary and it is impossible without a biopsy
or culture of the organism to differentiate them clinically or
by roentgenogram from tuberculosis. The x-ray appearance of
bone lesions is identical with the appearance of lesions caused
by the tubercle bacillus.

Although coccidioidal infections have identical clinical mani-
festations with tuberculosis, nevertheless intestinal and peri-

Section of tissue.

toneal infections seldom occur and are rarely seen. Greaves 3
has reported the only case of intestinal infection, which he
demonstrated post mortem in a Negro dying of miliary coccid-
ioidal granuloma. Ophuls 4 in 1929 stated that intestinal
lesions have never been discovered in coccidioidal granuloma."

The following case report demonstrates the value of perito-
neoscopy in determining intraperitoneal disease, and the value of
obtaining a biopsy.

History.— Y. S., a man aged 35, Japanese, single, entered
the hospital Dec. 23, 1937, complaining of swelling of the
abdomen and pain in the abdomen of two weeks’ duration. Two
weeks before entry he began to have pain in the epigastrium.
With the onset of pain his abodmen had begun to swell and
was progressing in size. Loss of weight was slight. He did
not have fever or chills. He did not vomit but had occasional
nausea ; no hematemesis or melena was present. There had
been no symptoms of cardiac or respiratory disease. No jaun-
dice was observed. ,

The patient was born in the Hawaiian Islands ; he had lived
in and about Los Angeles for the past eleven years. The

From the Department of Peritoneoscopy, Los Angeles County General
“"T' w'entiche R • Ueber einen Protoroenbefund bei Mycosis Fungoides.
CeI 2 ! a Opbiis B Wmi^. ! and Moffitt. 1 hT C.: A New Pathogenic Mold.
Philadelphia^ M. J. S: .1-1^900. ^ „. !th Le5 ; on !n Small

In,C 4 : ti &'p'huis.^WlHjm M 'in B! dktSfsion 0 ^ on'c^idioidal Granuloma. J. A.
M. A. 93: 1055 (Oct. 5) 1929.

patient stated that he had not resided in the San Joaquin Valley.
He had a lesion of the penis in 1936 for which he received no
treatment. For the past four years he had been a heavy user
of alcohol, drinking both beer and whisky.

No history of familial diseases was given.

Examination . — The temperature was 99.6 F., pulse 96, respi-
ration 20 and blood pressure 140 systolic, 100 diastolic. The
patient was poorly nourished, showing recent loss of weight.
There were no petechiae or cutaneous eruptions. The teeth
were carious. The tongue was coated. There were palpable
epitrochlear and cervical lymph glands. The chest was resonant
throughout, expansion was equal and the bases moved nor-
mally. There were no rales, but hoarse breath sounds were
heard at the right base. The heart showed no enlargement,
regular rhythm and no murmurs. The abdomen was distended
and tense with a definite fluid wave ; no masses or organs
were palpable. There was pitting edema of the ankles, grade 2.

The Wassermann reaction was negative. Blood examination
revealed hemoglobin 75 per cent, red blood cells 3,830,000, white
blood cells 13,500, neutrophils 85 per cent, mononuclears 6 per
cent, lymphocytes 9 per cent, no pathologic cells. Sedimenta-
tion time was 63 mm. in one hour uncorrected, 25 mm. in one
hour corrected. Packed cell volume was 28. The urine was
normal.

The clinical diagnosis was atrophic cirrhosis (Laennec).
December 24, paracentesis was done and 4,000 cc. of straw
colored fluid was removed. The patient continued to have a
low grade fever and to develop more ascites.

December 30, peritoneoscopy revealed dense adhesions of the
omentum to the epigastric peritoneal surfaces. All peritoneal
surfaces were covered with miliary tubercles. The liver and
gallbladder were normal. A section of peritoneum containing
tubercles was removed for biopsy. The abdominal cavity was
filled with oxygen.

The impression was probable tuberculous peritonitis, but
final diagnosis awaited the result of biopsy.

The pathologic examination of the tissue revealed tubercle-
like nodules containing Coccidioides immitis. Culture of the
peritoneal fluid yielded Coccidioides immitis. Immediately fol-
lowing peritoneoscopy an x-ray examination of the chest was
reported negative.

Course . — Ascites returned and the patient had to have para-
centesis performed from time to time. He bad a septic tem-
perature of from 100 to 102 F. and failed steadily. Jan. 21,
1938, he suddenly began to have dyspnea and for the first time
discomfort in the chest. Examination revealed the typical signs
of a bilateral pleural effusion. The fluid was aspirated and
Coccidioides immitis was demonstrated by culture.

The patient died January 25.

Autopsy . — January 27, the left pleural space was found to con-
tain 1,000 cc. of straw colored fluid, the right, 1,100 cc. The
parietal pleura was studded with granulomatous tubercles. The
lungs externally were studded with a granulomatous, fibrinous
exudate. Tiny tubercles were seen in the parenchyma. The
tracheobronchial lymph nodes were only slightly enlarged.

When the peritoneum was opened the entire cavity and intes-
tines were seen to be covered with a thick layer of plastic
exudate, which was diffusely infiltrated with nodular grantiloin
atous tubercles, averaging from 0.5 to 1 cm. thick and ext en
ing from over the diaphragm to the pelvis. The greater
omentum was from 1 to 2 cm. thick and densely infiltrate •
The wall of the lesser curvature of the stomach was infiltrate
from the external surface inward by granulomatous tissue. J ,e
lymph glands in this area were greatly enlarged and caseous,
averaging 2 to 4 cm. in diameter. The duodenum, the 5 ,na ^
intestine and the large intestine were covered with the s ' inl ( j
thick granulomatous tissue. The mesentery was infiltrated an
the glands were enormously enlarged, up to 4 cm. in diametc .
Wet smears showed many Coccidioides immitis organisms.

The liver and spleen showed some infiltration with granu om
atous tissue and tubercles.

The left kidney showed a small collection of tuber c es
cross section. The bladder showed infiltration with grant
atous tissue. , . (V

The anatomic diagnosis was (1) coccidioidal granuloi 1 ;:! , ^ -
coccidioidal lymphadenitis, generalized; (3) coccidioida pc

Volume 113
Number 23

DERMATITIS— LEV ISON AND HARRISON

2055

nitis, generalized ; (4) coccidioidal pleuritis, bilateral with
effusion; (5) coccidioides of spleen; (6) coccidioides, miliary,
of liver ; (7) coccidioides of left kidney.

The clinical course with the development of ascites and a
history of alcoholism supported a diagnosis of cirrhosis. The
conditions as noted with the peritoneoscope were similar to
those of tuberculosis of the peritoneal cavity, and oxyperitoneum
was instituted as a treatment procedure. Differential diagnosis
between tuberculosis and coccidioidal granuloma is not possible
without biopsy or culture. A biopsy of the parietal peritoneum
and a culture of the fluid revealed Coccidioides immitis, thus
establishing the diagnosis.

The technic of the procedure of peritoneoscopy is described
in detail in previous papers by us. 5 •

2202 West Third Street.

INHALATION OF MASSIVE AMOUNTS OF VEGETAL
FOREIGN BODIES

W. A. McNiciiols, M.D., Dixon, III.

On July 4, 1939, a girl aged 7 years jumped from a load of hay
into a bin of finely ground dry feed containing oats, wheat,
corn and corncobs. She sank into this mixture as though it
were a liquid, being completely submerged with the exception
of one hand. Her brother saw her jump and then he heard
two frightened cries. He summoned their father, who with
great difficulty was able to extricate her. It is believed that
she was submerged for at least ten minutes.

When she was removed from the bin she was cyanotic,
unconscious and not breathing. Her mother, who had had
nurses’ training, cleaned out her daughter’s nose and mouth
and gave her artificial respiration. Breathing was restored,
but it was very rapid and shallow and the cyanotic condition
did not improve.

Drs. D. L. Murphy and R. L. Baird, of Dixon, five miles
distant, were summoned. They could not obtain breath sounds
anywhere over the patient’s chest. They wisely elected to
move her to the Dixon Public Hospital, where they would
have oxygen and bronchoscopic assistance.

The patient arrived at the hospital approximately thirty-five
minutes after she jumped into the bin. She was unconscious
and cyanotic and had rapid stridulous breathing; the pulse
was thready and not countable; no breath sounds were audible
anywhere over the chest, and the rate of diaphragmatic move-
ment was from 70 to 80 per minute.

Oxygen was immediately administered by mouth through a
catheter. Drs. Murphy and Baird felt that any new insult
to the lung would be fatal, so they asked me to do a dry
tracheotomy rather than risk losing foreign bodies at the
glottis. This we did without anesthesia, all bleeding being
stopped before the trachea was opened. The tracheotomy did
not improve the patient’s condition.

A 5 mm. bronchoscope was inserted through the tracheotomy
wound. The trachea was filled with a mushy viscid fluid.
After aspiration of the fluid, the bronchoscope was filled with
many vegetal foreign bodies. The condition of the trachea
proved my colleagues’ good judgment in not using a life saver
tube or attempting an emergency tracheotomy, as either pro-
cedure would have been futile and probably disastrous.

In one hour and twenty minutes, 3)4 drachms (IS Gm.)
by volume of oats, wheat, corn and corncobs was removed
from the tracheobronchial tree. Five pieces of corncob that
were too large to go through the 5 mm. bronchoscope were
removed. It was necessary to remove the instrument many
times to clean it of the mushy debris. As the bronchi were
cleaned out, breath sounds would appear over the corresponding
areas. All this time oxygen was being given into the trachea.

Finally no more foreign bodies could be found. The trachea
was stitched open with silkworm sutures anchored to the skin.
Ho tube was used. Thus the patient was able to cough out
the viscid mucus and foreign bodies.

,5. Ruddock, John C.: Peritoneoscopy, West. J. Surg. 42 : 392 (July)
193-!; Sure., Gyncc. & Obst: G5: 623 (Nov.) 1937. Hope. Robert B.:
L^uetenttal Diagnosis of Ectopic Gestation by Peritoneoscopy, ibid. <34:

She was placed in bed with the foot of the bed elevated and
oxygen blowing into her trachea. The cyanosis had com-
pletely disappeared and breath sounds could be heard over the
entire chest. The temperature was 102.8 F., the pulse rate 134,
the respiratory rate 40 and the white blood cell count 21,300.
Two hours later the child was conscious and able to take
liquid nourishment.

The tracheobronchial tree was aspirated as needed, which
was at least hourly. From the tracheotomy wound one whole
oat kernel was recovered, and the suction apparatus brought
out many finer pieces of grain.

The second evening the patient had a chill, with the tem-
perature 103 F., pulse rate 1S6 and respiratory rate 60. The
mucus was blood stained, and pneumococcus type III was found
in it. She was given S minims (0.3 cc.) of digitalis every four
hours for three doses, and 7 l /z grains (0.5 Gm.) of sulfapyridine,
one-eighth grain (0.008 Gm.) of phenobarbital and 5 grains
(0.3 Gm.) of sodium bicarbonate every four hours. She imme-
diately improved, but after the tenth dose she began vomiting
the medicine and refusing food, so all medication was stopped.
By this time her temperature was 100 F., pulse rate 96 and
respiratory rate 36. Her appetite returned as soon as the
sulfapyridine was discontinued.

On the sixth day, with the temperature 100 F., pulse rate
84 and respiratory rate 32, x-ray examination of the lungs
showed them to be clear. A bronchoscope was again inserted
and a careful search was made of the tracheobronchial tree
for vegetal foreign bodies, but none were found. ■ :

On the seventh day, with the temperature 98.6 F., pulse rate
76 and respiratory rate 20, the stitches were removed from
the trachea and it was allowed to close. The patient was
discharged on the ninth day. She has been ’seen from time
to time, and she is perfectly well.

CONCLUSIONS

1. Inadvisable use of life saver tubes or emergency tracheoto-
mies may frequently be of more harm than good.

■ 2. Oxygen is a great adjunct in treatment in all cases of
air deficiency. • ■ - .

3. Sulfapyridine may control nicely an otherwise fatal tracheo-
bronchitis.

101 West First Street.

SEVERE ALLERGIC DERMATITIS FOLLOWING THE
PARENTERAL USE OF THEELIN

Louis A. Levison, M.D., Toledo, Ohio, and Julian J.

Harrison, M.D., Napoleon, Ohio

The following case seems worthy of being reported because
of its rarity and the severity of the reaction.

Mrs. W. G. M., aged 51, a housewife, white, had been under
the observation of one of us (J. J. H.) for several months
before admission to St. Vincent’s Hospital Dec. 29, 1938. She
had been experiencing emotional disturbances incidental to the
menopause, and a course of treatment with theelin had been
proposed and put into effect. She entered the hospital on
account of a marked painful, red, erythematous, swollen involve-
ment of the skin over the anterior surface of each thigh. She
stated that she had never had any similar skin trouble, and
there was no history of allergic dermatitis, hay fever, asthma
or food intolerance. The history revealed diphtheria at 4, a
pelvic operation at 32 and a left-sided renal calculus removed
at operation at the Mayo Clinic at 35. She had three children,
who were living and well. A careful inquiry revealed no
allergic antecedents.

The cutaneous lesions had first appeared four weeks prior to
the hospital admission and during the course of a series of
parenterally administered theelin beginning about Nov. 10, 1938.
She had been given eight injections of theelin (Parke, Davis
& Co.), each 2,000 units, over the anterior aspect of the left
thigh, and one injection of estrone (Eli Lilly & Co.) 2,000
units in the same relative area of the opposite side. The injec-
tions were rather painful and itched from the outset, with the
redness and rash noticeably apparent at the fourth or fifth treat-
ment. This troublesome and distressing reaction progressively

2056

Jour'. A. M. A.
Dec. 2, 1939

COUNCIL ON PHARMACY AND CHEMISTRY

increased in severity and area during the remainder of the
course of treatments.

Examinations before and after the hospital admission did
not revea! relevant manifestations other than the cutaneous con-
dition. Her complaints were subjective, indicating the emo-
tional and nervous instability mentioned. The skin over the
anterior surface of each thigh was red and swollen, itched and
was markedly erythematous. Superimposed on this angry
appearing erythema were many small papules and occasional
small vesicles. The greatest intensity of the inflammation on
each thigh centered at the point of hypodermic injections midway
between the hip and the knee. Practically the entire anterior

Extensive involvement of both legs after parenteral use of theelin.

aspect of each thigh was involved on the date of her hospital
admission. The erythema spread rapidly while she was in the
hospital, quickly progressing at each area of involvement to
an appearance characteristic of allergic dermatitis. It reached
such distant points as the ankles and neck by the fourth day.
The skin was not uniformly involved but the reaction was most
severe over the thighs, both ankles and the lateral aspects of
the neck on each side. There was, however, general erythema
of all body areas. Both ankles showed considerable swelling
with a 2 plus pitting edema. There was no involvement of
the mucous membrane. The itching was extreme and at times
almost intolerable, doubtless accentuated by the nervous and
emotional instability. Fever was not present, the urine remained
normal, and the eosinophil count of the blood never exceeded
3 per cent.

Treatment consisted of palliative measures with most relief
from a constantly applied lotion containing calamine, menthol,
camphor, zinc oxide and solution of calcium hydroxide. Starch
baths in a full tub were given several times a day. Hot or
cold compresses of saturated solution of aluminum acetate were
not apparently helpful. Olive oil relieved the subsequent dry-
ness of the skin.

The patient returned to her home on the eleventh day after
admission to the hospital with the cutaneous lesions greatly
improved. The generalized pruritus persisted and was very
troublesome. The lotion and starch baths gave relief until its
subsidence several weeks later.

Inquiry of Eli Lilly & Co. revealed that the fatty solvent
used in the marketed ampule was highly purified cottonseed
oil, and in the product of Parke, Davis & Co. (theelin) it was
peanut oil. The patient had received eight injections of the
peanut oil product prior to the single injection of the cottonseed
oil preparation. Each company supplied samples of the respec-
tive oils used. Patch and scratch tests of each oil were later
made on the patient and gave negative results. Later, intra-
dermal tests were made on the flexor surface of each forearm,
peanut oil being used on llic one side and cottonseed oil on
the other. The reaction to each was unmistakable, immediate,
severe and widespread. There was a large area of swelling,
redness and ervthcma on each side, spreading over the entire
flexor surface of the arm. There was no appreciable difference
in the degree or extent of area involved on either side. A tew

days later scattered areas of involvement appeared over the
skm generally, especially on the legs, trunk and neck. The
lesions were entirely comparable with the original trouble. A
severe and generalized pruritus followed in the same manner
as before, responding to the same management.

We have not found in the material available to us references
to dermatitis of allergic origin following the parenteral admin-
istration of theelin (estrone) in oil. Inquiry among physicians
in this community with wide and extensive experience has not
supplied a similar instance. It is probably infrequent, although
allergic responses of one type or another are not rare or unusual
following the use of cottonseed oil by ingestion in the prepara-
tion of food. It does not appear that the estrogenic substance
itself was a factor in this reaction. Earlier recognition of
similar cases will permit substitution of other methods of admin-
istration, such as water soluble preparations, tablets or sup-
positories.

421 Michigan Street.

Council on Pharmacy and Chemistry

PRELIMINARY REPORT ON
VITAMIN K: II

Since the publication of a preliminary report on vitamin K
by Albert M. Snell in The Journal for April IS, 1939, there has

BEEN WITNESSED INTENSE INTEREST IN ATTEMPTS TO ISOLATE COMPOUNDS
HAVING VITAMIN K ACTIVITY. VERY DEFINITE PROGRESS HAS BEEN MADE
IN ESTABLISHING THE CHEMICAL NATURE OF NATURALLY OCCURRING COM-
POUNDS, AND MANY SYNTHETIC PREPARATIONS HAVING VITAMIN K
ACTIVITY HAVE BEEN PREPARED. SINCE FURTHER EVIDENCE OF THE
THERAPEUTIC VALUE OF VITAMIN K PREPARATIONS IS ALSO ACCUMULATING
IT SEEMED DESIRABLE TO HAVE A FURTHER REVIEW OF THIS SUBJECT.
The FOLLOWING PAPER HAS BEEN PREPARED BY THE AUTHORS AT THE
REQUEST OF THE COUNCIL, AND THE COUNCIL HAS AUTHORIZED US
publication. During the past few months the Council has con-
ducted EXTENSIVE CORRESPONDENCE RELATING TO THE ADOPTING OF A
SUITABLE NONPROPRIETARY NAME FOR VITAMIN K. NAMES WHICH ARE
ACCEPTABLE TO THE COUNCIL HAVE BEEN PROPOSED BUT THE COUNCIL
IS NOT PREPARED TO MAKE A DEFINITE RECOMMENDATION UNTIL CERTAIN
MATTERS RELATING TO PRIORITY HAVE BEEN SETTLED.

Paul Nicholas Leech, Secretary.

SUPPLEMENTARY REPORT ON
VITAMIN K

ALBERT M. SNELL, M.D.

AND

HUGH R. BUTT, M.D.

ROCHESTER, MINN.

In April 1939 a report on the sources, nature and
clinical use of vitamin K was prepared by one of us
(Snell 1 ) at the request of the Council on Pharmacy
and Chemistry. Since the publication of this report,
attention has been called to inaccuracies in the matter
of defining a unit of the vitamin. Certain investigators
have also questioned some of the statements made with
regard to the fundamental causes of deficiency in pro-
thrombin, the methods of recognizing them and the
means of dealing with them. This supplementary report
has been prepared in an effort botli to clarify these
matters and to bring up to date the present knowledge
of the chemical nature of the vitamin.

DEFINITION OF A UNIT

The Dam unit of activity as defined in some detail
in an article by Dam and Glavind 2 refers to a spccui
preparation of dried spinach, to which a value of bUU
units per gram has been arbitrarily assigned. Two m £-

From the Division of Medicine, the Mayo Clime. . ninic.nl

1. Snell, A. M.: Vitamin K: Its Properties, distribution
mportance: A Preliminary Report, J. A, M. A. 112 : t4S7-14i (

5> 2. 19 Dara, Henrik, and Glavind. Johannes : Determine 1'™°} ^gjj q
v by the Curative Blood-Clotting Method, Biocfcem. J.

Volume 113
Number 23

COUNCIL ON PHARMACY AND CHEMISTRY

2057

of this product therefore constitutes one unit. When
2 mg. ( 1 unit, not 1 mg. as was incorrectly written in
the earlier report to the Council) of this standard prepa-
ration per gram of body weight is given daily to a
highly K-avitaminous chick on three successive days,
normal blood clotting is obtained.

Personal communications with Dann 3 indicate that
her unit of vitamin K is the amount of material, based
on a standard of known potency, which when adminis-
tered to chicks daily will bring about a coagulation time
of the blood equal to that produced by the reference
standard under the conditions of the test. The reference
standard is a special extract of alfalfa which has been
shown to be stable over a long period. 4

Other investigators, including Ansbacher, 5 have
attempted to establish a definition of a unit of vita-
min K. Ansbacher’s unit is established as “the mini-
mum amount [of vitamin K] necessary to render the
blood clotting time of the vitamin K-deficient chick,
weighing 70 to 100 Gm., normal within six hours after
administration.” One of Ansbacher’s units is equiva-
lent to 20 Dam units. Thayer and his associates 6 define
a unit of vitamin K as “that quantity of vitamin [Kj
which produces a clotting time of ten minutes or less
in 50 per cent of a group of ten or more chicks which
has been fed for the fourteen days immediately follow-
ing receipt from the hatchery on a diet practically devoid
of vitamin K.”

Almquist and his associates 7 have also presented a
method of assay of vitamin K, showing that “the
reciprocal of the blood clotting time is a simple linear
function of the logarithm of the level of the vitamin K
level in the ration.” Obviously, there is not complete
agreement among these investigators working in the
same field of biology as to the manner of defining a
unit or as to the best methods of assay. While freely
admitting the inadequacies of this definition of the .unit
in the report prepared for publication by the Council
on Pharmacy and Chemistry, we are of the opinion that
any attempt arbitrarily to establish such a unit of the
vitamin is unlikely to suit all investigators. Indeed, it
would seem wise to postpone consideration of units,
since exact and final knowledge of the chemical structure
of substances exhibiting antihemorrhagic activity now is
close at hand.

THE CHEMICAL NATURE OF VITAMIN K

In the earlier report to the Council, 1 three of the
earlier studies designed to accomplish the purification
and isolation of the vitamin were cited. In the light
of subsequent developments, these earlier reports can
now be omitted from consideration. Recently Almquist
and Klose 8 have prepared a choleic acid derivative,
which is a yellow, crystalline substance with a melting
point of 186 C. Vitamin K can be separated from this
material as a viscous, slightly pigmented oil. Cohn and
Schmidt 9 have shown this preparation to be most effec-
tive in increasing low prothrombin values in rats that
have biliary fistulas. Dam and his collaborators 10 also

3. Dann, Flcmentine P.: Personal communication to the authors.

4. Further details of this method are to be published shortly.

5. Ansbacher, S.: A Quantitative Biological Assay of Vitamin K,
J. Nutrition 17: 303-315 (April) 1939.

6. Thayer, S. A.; McKee, R. W. ; Binkley, S. B.; MacCorquodale,
D. \\\, and Doisy, E. A.: Assay of Vitamin K Concentrates, Proc. Soc.
Evper, Biol. & Med. 40:478-481 (March) 1939.

7. Almquist, H. J.; Mecchi, E., and Klose, A. A.: Estimation of the
Antihemorrhagic Vitamin, Biochem. J. 2 : 1897-1903 (Nov.) 1938.

8. Almquist, H. J., and Klose, A. A.: The Isolation of Vitamin K
as a Choleic Acid. J. Am. Chem. Soc. 61: 745-746 (March) 1939.

9. Cohn, E. T.. and Schmidt. C. L. A.: Effect of Choleic Acid of
vitamin K on Prothrombin Levels of Bile Fistula Rats, Proc. Soc. Exper,
Biol. & Med. 41:443-444 (June) 1939.

*£• pam, Henrik; Geiger, A.; Glnvind. J.; Karrcr, P.; Karrer, W.;
Koths child, E,, and Salomon, H.: Isolierung des Vitamins K in hoch*
geremigter Form, Helvet. chim. acta. 22:310-313, 1939.

have recently prepared, by a process of molecular dis-
tillation and chromatographic methods, a constant prod-
uct of high purity which they believed to be pure
vitamin K. The material, which is a clear yellowish
oil, contains carbon, hydrogen and oxygen and is nitro-
gen free. Elementary analysis has indicated the presence
of two atoms of oxygen in the molecule ; a tentative
composition of carbon 82.2 per cent and hydrogen 10.7
per cent has been established. This material is said
to be extremely potent on biologic assay, containing
about 20,000,000 Dam units per gram.

In an earlier report the prediction was made that
several, closely related .substances having antihemor-
rhagic properties were likely to be found in crude
extracts of alfalfa or putrefied fish meal. It is in inves-
tigations of the type suggested by such a prediction
that developments of great importance' are now taking
place. In May 1939 McKee and his associates 11
reported the isolation of vitamins K, (from alfalfa) and
Ko (from putrefied fish meal) and presented evidence
to indicate a quinoid structure for these vitamins;
further work has substantiated these preliminary state-
ments. 13 Almquist and Klose 13 recently have reported
that phthiocol (2 -methyl -3-hydroxy- 1, 4-naphthoqui-
none) possesses physical and chemical- properties
similar to pure vitamin K. 13!1 Phthiocol. was first
isolated by Anderson and Newman 14 from the; pigment
of Mycobacterium tuberculosis; its ‘synthesis was
announced in 1934. 15 It has been shown by Almquist
and Klose 13 that phthiocol is effective in preventing
hemorrhagic diathesis in chicks subsisting on a K-defi-
cient diet when phthiocol is given at 20 mg. per kilogram
of diet. They have also suggested that phthiocol is the
simplest member of a homologous series of antihemor-
rhagic substances. Later these investigators 10 reported
that the antihemorrhagic activity of phthiocol lay some-
where between that of methyl naphthoquinone and
hydroxy naphthoquinone. Their study indicated that
the methyl group was functionally important whereas
the hydroxyl group seemed to reduce activity. They
agreed that the activity of phthiocol is lower than the
more complex form of vitamin K existing in alfalfa;
Ansbacher and Fernholz 17 were of a similar opinion.
The use of phthiocol in the correction of prothrombin
deficiency in chicks has been studied in detail by Alm-
quist and Klose ; 13 clinical studies with this material
will be mentioned later in. this report.

11. McKee, R. W.; Binkley, S. B.; MacCorquodale, D. W,;* Thayer,
S. A., and Doisy, E. A.: The Isolation of Vitamins Ki and Kr. J. Am.
Chem. Soc. 61: 1295 (May) 1939.

12. Binkley, S. B.; MacCorquodale, D. W.j Cheney, L. C,; Thayer,
S. A.; McKee, R. W., and Doisy, E. A.: Derivatives of Vitamins Ki
and Ke, J. Am. Chem. Soc. 61:1612-1613 (June) 1939.

13. Almquist, H. J., and Klose, A. A.: The ’• * * '•

of Pure Synthetic Phthiocol, J. Am. Chem. Soc. 6 j

33a. It has been thought that phthiocol owes
tion with some impurity, presumably 2 -methyl-1 ,4-naphthoquinone. How*
ever, the most recent report of Fernholz and Ansbacher (Vitamin K
Activity of Synthetic Phthiocol, Science 90:215 [Sept. 1] 1939') indicates
that even after purification, synthetic phthiocol has antihemorrhagic proper-
ties. In this same report they also noted the powerful curative effect of
2-methyl-l ,4-naphthoquinone in chicks deficient in vitamin K.

Anderson, R. J., and Newman, M. S.: The Chemistry of the
Lipids of Tubercle Bacilli: XXXIV. Isolation of a Pigment and of
Anisic Acid from the Ace tone- Soluble Fat of the Human Tubercle Bacillus
J- B^l. (Aug.) 1933; The Chemistry of the Lipids

of Tubercle Bacilli: XXXV. The Constitution of Phthiocol, the Pigment
Isolated from the Human Tubercle Bacillus, ibid. 103: 397-201 (Nov.)

• , 15 * -¥• S c l S\ Qv:< \ tr >J’ and Anderson, R. J.; The Chem*

i tlC t Ll ^ S of Tubercle Bacilli: XXXVIII. A New Synthesis of

105 : 279.281 5SJ) n i934 the Human Tuberc,e Bacillus, J. Biol. Chem.
J939 ' rtainlJ - Va P h! ^“ ,ina ° nnd ^^ J. SC Am! •' Chem Th So^ r 6^T923-?9l4 A Ouly;

2058

COUNCIL ON PHARMACY AND CHEMISTRY

Jour. A. M. A.
Dec. 2, 1939

Recently Thayer and his associates, 18 as well as-Mac-
Corquodale and his co-workers, 19 working in Doisy’s
Laboratory at St. Louis University Medical School,
have found 2 methyl- 1,4-naphthoquinone the most active
compound studied, but when this compound was com-
pared with the natural vitamins K, and K, its activity
was relatively insignificant. They believed the structure
of the vitamin K, molecule to be 2-ethyl-3-phytyl-l,4-
naphthoquinone. Fieser and his co-workers 20 suggested
that the structure of K x was 2,6 ( ? )-dimethyl-3-phytyI-
1, 4-naphthoquinone (or the 2-mono-methyl compound)
and that that of vitamin K, was 2, 3-difarnesyI- 1,4-
naphthoquinone.

Further work by Binkley, MacCorquodale, Thayer
and Doisy 21 at St. Louis "University Medical School
has confirmed, through synthesis, the structural formula
of vitamin R. Their experiments demonstrate conclu-
sively that the structure of vitamin K t is correctly
represented by the formula 2-methyl-3-phytyl-l,4-
naphthoquinone. This work has been further con-
firmed by Fieser, Campbell, Fry and Gates, 22 who
described the synthesis of vitamin IQ.

Since the activity of 2-methyl-l,4-naphthoquinone is
approximately equal to that of pure vitamin K 1; Thayer,
Binkley, MacCorquodale, Doisy, Emmett, Brown, and
Bird 23 have suggested that it be adopted as a basic
standard for assay of vitamin K. The compound does
have desirable qualities for standardization in that it can
be obtained readily in a satisfactory state of purity, has
a definite melting point for characterization and, when
protected from excessive exposure to light, is readily
stable. They suggested that by adopting this substance
as the standard for assay the unit could then be defined
in terms used by the League of Nations committee
as the specific vitamin K activity of 1 microgram of
pure 2-methyl- 1 ,4-naphthoquinone.

THE GENERAL CLINICAL CAUSES OF DEFICIENCY
IN PROTHROMBIN

In the earlier report the methods of Quick, of Dam
and his co-workers and of Warner, Smith and Brink-
hous were mentioned. The method of Quick has found
favorable reception in this country and is now widely
used as a routine method for determining deficiency
in prothrombin in hospital practice; Dam and Glavind
still prefer their modification of Fisher’s method. Zif-
fren and his co-workers 24 have recently described a
simple “bedside” method of comparing the clotting time
of normal blood to that of the specimen in question
after thromboplastin has been added to each. The
unknown is expressed in percentage of the normal.

The principal clinical points to be emphasized here
are: (1) that whichever of these methods for deter-

1S. Thayer, S. A.; Cheney, L. C.; Binkley, S. B.; MacCorquodale,
P W and Doisv, E. A.: Vitamin K Activity of Same Quinones, J. Am.

Ch I9?-J?«Cor q 1 uod 9 alo W.s’SSilfr. S. B.; Thayer, S A., and Doisy,
A.: On the Constitution of \ itamm Xi, J. Am. Lhem. i?oc. bi.

F.^Bowen, D. AL; Oimpheli. W. P.: Fieser Mary ; Fry,

Quinone J s°lfaving Vitamfn' K ActiSty.J^Am'che'm. s” Cl: IMS-Wd

‘^Binidev. S. B. : MacCorquodale, D. W. ; Thayer S. A., and Doi»%
E. A.: The Isolation of \ itamm Xi, J. Biol. Chcm. 1*50 . 219-..J4

^2?.' Vieser! L. F.; Camrbdl. W. P.; Fry, E. M-, and Gates, M. D.. Jr.:
Synthetic Approach to Vitamin Ki, j. Am. Chem. Soc. Gl: »aa9 (Sept.)

W fi' Th-ivcr. S. A.: Binklev, S. B.; MacCorquodale, D. W-: Doisy.
E.'X.. and Emmett, A. D.; Broivn, R. A., and iJ,rd O. D.: Wtam,n K
Potencies of Synthetic Compounds J. Am. Chem- Soc. Gl*^^63 (b i .)

19 n' Ziftrcn. S. E.; Ouen. C. A.: Hoffman. G. K-. and Smith. H. P-:
19J9.

mining deficiency in prothrombin is to be employed
most effectively depends somewhat on the experience
and the facilities of the physician concerned; (2) that
the nature of prothrombin is unknown and that all
methods of measurement thus far proposed are open to
some objections on this score, and (3) that the simpler
the method used, the more likely it is to be used as
frequently as is necessary in the care of patients who
have actual or impending hemorrhagic tendencies.

THE GENERAL CLINICAL CAUSES OF DEFICIENCY
IN PROTHROMBIN

Several investigators have reported a number of con-
ditions in which there exists a deficiency of prothrombin
which can be corrected by the administration' of vita-
min K. Hypoprothrombinemia among human beings
apparently may occur in any of the following circum-
stances :

1. After ingestion of a diet inadequate in vitamin K.
Hypoprothrombinemia from this cause is being reported
by Kark and Lozner ; 25 their patients responded ade-
quately to the administration of vitamin K. This clin-
ical observation is well supported by the experimental
production of low blood values for prothrombin in
rabbits (Dam and Glavind 20 ), in rats (Greaves 27 ),
and in mice (Murphy 28 ) following the administration
of diets deficient in vitamin K.

2. In newborn infants. Waddell and Guerry 20 have
recently reported that among newly born infants there
is not infrequently a deficiency of prothrombin which
responds to the administration of vitamin K by mouth.
The mechanism of this type of prothrombin deficiency
is not entirely clear, although it is suggested that such
a deficiency might be corrected by the administration
of vitamin K to mothers before delivery.

3. With inadequate intestinal absorption. This may
result from: ( a ) lack of bile in the intestine due to
a poor secretion of bile salts, to (b) an obstruction of
the bile ducts from any cause, or to (c) inadequate
absorption due to various intestinal lesions, including
short-circuiting surgical procedures and intestinal
obstruction. All these various factors have been demon-
strated among patients by Osterberg and us 30 and by
Clark and his associates. 31 It has likewise been demon-
strated that severe diarrheal diseases, such as ulcerative
colitis, sprue or celiac disease, may result in a deficiency
in prothrombin.

4. Injury to the liver. There is considerable evidence,
clinical and experimental, to indicate that the liver plays
an active part in the formation of prothrombin. It must
be admitted that some of this evidence is largely circum-
stantial. Smith, Warner and Brinkhous 32 have shown

25. Kark, Robert, and Lozner, E. L. : Personal communication to tlic

authors. (

26. Dam, Henrik, anil Glavind, Johannes: The Clotting rower

Human and Mammalian Blood in .Relation to Vitamin K, Acta md-
Scandinav. 9G: 108-128, 1938. ( ,

27. Greaves, J. D.: Studies on the Vitamin K Requirements ot tic

Rat. Am. J. Physiol. 125:429-436 (March) 1939. . .

28. Murphy, Rosemary: Possible Avitaminosis K Produced in Mice i r

Dietary Means, Science 89: 203-204 (March 3) 1939. • ir

29. Waddell, W. \V., Jr,, and Guerry, Du Pont: Effect of \ tta P 5,n

on the Clotting Time of the Prothrombin and the Blood, with
Reference to Unnatural Bleeding of the Newly Born, J. A- M- A.
2259-2263 (June 3) 1939. _ ^ T .

30. Butt, H. R.: Snell, A. M., and Oterberg, A. E ; : The. 01

Vitamin K and Bile in Treatment of the Hemorrhagic Diathesis in t-a
of Jaundice, Proc. Staff Meet., Mayo Clin. 13:74-80 (Feb. ~) ™ :
Further Observations on the Use of Vitamin fv in the Prevention ^
Control of the Hemorrhagic Diathesis in Cases of Jaundice, ibiu- *
753-764 (Nov. 30) 1938. Footnote 32. ,

31. Clark, R. L-. Jr.; Dixon. C F.; Butt. 11. R-. and Snell. A. M;;
Deficiency of Prothrombin Associated^ with Various Intestinal l 11 ,<or _

Jts Treatment with the Antihemorrha&ic Vitamin (Vitamin K), *

Meet., Mayo Clin. 1 - 1 : 407 -416 (June 28) 1939.

32. Smith. H. P.; Warner. E. IX, and Brinkhous. K. M-: '

Deficiency and the Bleeding Tendency in Liver Intury (Ch r
Intoxication), J. Exper. Med. GG: 801-811 (Dec.) 1937.

2059-

Volume' 113
NUMLER 23

COUNCIL ON PHARMACY AND CHEMISTRY

that in dogs whose livers have been injured by acute
intoxication with chloroform there develops a deficiency
in prothrombin with a definite hemorrhagic tendency.
More recent work by Warner 33 indicates that extirpa-
tion of a large portion of the liver in rats results in a
marked decrease in the concentration of prothrombin
in the plasma, thus supporting the belief that the liver
is perhaps directly concerned in the manufacture of
plasma prothrombin. Warren and Rhoads 34 have per-
formed complete hepatectomies in dogs and have noted
a rather rapid decrease in the concentration of pro-
thrombin in the plasma following this procedure. The;'
concluded that the liver is essential to the formation of
prothrombin in the dog. Their work further supports
the contentions previously mentioned.

Clinically we 35 have seen, as has Warner, 30 that
primary hepatic disease, such as cirrhosis, atrophy or
chronic hepatitis, is not infrequently accompanied by
hypoprothrombinemia. We have encountered several
patients having primary hepatic damage who, in spite
of an adequate diet and ingestion of adequate amounts
of bile salts or bile by mouth, continued to exhibit a
pronounced deficiency in prothrombin. An occasional
patient in such a group as this will not respond even to
large doses of concentrates of vitamin K administered
orally with bile salts or given intramuscularly. These
clinical observations again tend to support the thesis
that the liver is intimately connected with the whole
process of prothrombin formation.

These recent developments show that there are
apparently several conditions other than those previ-
ously reported in which a deficiency of prothrombin
may be encountered. The conclusion seems justified
that at least four basic factors appear to be necessary
in the prevention and control of hypoprothrombinemia
that may occur among human beings, namely (1) the
presence of bile of normal composition in the intestinal
tract; (2) a diet containing the vitamin itself or mate-
rials from which it can be formed; (3) presence of a
normal absorptive surface in the small intestine, and
(4) a liver which is capable of performing adequately
the synthesis of prothrombin.

METHODS OF ADMINISTRATION

Methods for the oral administration of vitamin K
and bile or bile salts in the treatment of deficiency in
prothrombin have been described in recent papers in
Thf. Journal . 37

Dam and his co-workers have shown that definite
beneficial effects on patients having a deficiency in pro-
thrombin follow the intramuscular administration of
emulsions of vitamin K. At the time of our earlier
report we were not able to reproduce the results of
Dam and his co-workers by using preparations of vita-
min K available to us ; we have since fully confirmed
their observations. The response to intramuscular
administration is distinctly less rapid than that which
follows oral administration. Also it is not apparent
that any great advantage accrues to the patient by the

intramuscular procedure except when the jaundiced
individual in question is, for one reason or another,
unable to take or absorb the vitamin by mouth. The
possible advantage of long-continued slow absorption
of injected material must be mentioned. The peroral
method of administration has sufficed for the care of
the great majority of patients having a deficiency m
prothrombin, and in our opinion it is still the best
method for general use.

In the treatment of patients who have hypopro- .
thrombinemia, circumstances occasionally arise in which
the intravenous administration of vitamin. K might be
desirable. However, we have felt that to administer
intravenously the preparations of vitamin K available
to us in the past would have entailed considerable
danger to the patient. Recently Dam 38 has adminis-.
tered emulsions of vitamin K intravenously to human
beings without the occurrence of untoward reactions.
The recent report by Almquist and Klose that phthiocol
exhibited antihemorrhagic properties suggests that this
compound might be well adapted for parenteral adminis-
tration and thus might be useful clinically. Smith and
his associates 30 of the University of Iowa made a brief
report in a note at the conclusion of their recent article
in The Journal concerning the intravenous adminis-
tration of phthiocol to one patient who had obstructive
jaundice, following which there was an increase in the
concentration of prothrombin in the plasma.

We have recently reported the intravenous adminis-
tration of phthiocol to a number of patients having
hypoprothrombinemia. 40 To one individual, 100 mg. of
the material was administered by mouth together with
bile salts, with a resulting elevation in the concentration
of prothrombin as measured by the method of Warner
and his associates. We have also administered intra-
venous preparations of phthiocol in doses of from 25 to
50 mg. to nine patients having hypoprothrombinemia.
These patients had obstructive jaundice or primary
hepatic injury, and one patient had intestinal obstruc-
tion. In each instance following the administration of
phthiocol there was a reduction in the prolonged Quick
prothrombin clotting time. 41 No untoward reactions
were noted following the administration of phthiocol in
any instance. Whether or not the intravenous use of
preparations exhibiting antihemorrhagic activity will
replace the oral methods now in general use must await
further clinical developments.

CONCLUSIONS

Various phases of the chemical, physiologic, biologic
aspects and the clinical usefulness of vitamin K are
developing so rapidly that a number of the views
expressed in the present report may require modifica-
tion within a comparatively short time. Therefore it
would seem wise at the present moment to withhold
any dogmatic statements until the recently developed
chemical products exhibiting vitamin K activity have
been studied more extensively from biologic and clin-.
ical standpoints.

33. Warner, E. D.: Plasma Prothrombin: Effect of Partial Hepa-
tectomy, J. Exper. Med. GS:S31*S35 (Dec.) 1938.

34. Warren, Richard, and Rhoads, J. E. : The Hepatic Origin of the
Plasma-Prothrombin Observations After Total Hepateclomy in the Dog,
Am. T. M. Sc. IBS: 193-197 (Aug.) 1939.

35. Butt, H. R.; Snell, A. M., and Osterberg, A. E.: The Preoperative
and Postoperative Administration of Vitamin K to Patients Having
Jaundice. J. A. M. A. IIS*. 3S3 : 390 (July 29) 1939.

36. Warner, E. D., in discussion on Butt. H. R.; Snell, A.^M», p and

Osterbcrg, A. E.: Oral and Intramuscular Administration of Vitamin K
ir TY * *" 1 ) of Obstructive Jaundice, J, A. M. A.

11“- • ‘ 1939.

, n, S. E. ; Owen, C. A., and Hoffman, G. R.:
C • Studies on Vitamin K. J. A. M. A. 113: 380-

o' , . Stiell and O^tcrberg. 12

38. Dam, Henrik: Personal communication to the authors.

39. Smith, II. P.; Ziffren, S. E.; Owen, C. A., and Hoffman, G. R.;
Note at the Completion of Article “Clinical and Experimental Studies on
Vitamin K" J. A. M. A. 113: 383 (July 29) 1939.

40. Butt, H. R.; Snell, A. M., and Osterberg, A. E.: Phthiocol: Its

Therapeutic Effect in the Treatment of Hypoprothrombinemia Associated
with Jaundice: A Preliminary Report, Proc. Staff Meet., Mayo Clin. 14*.
497-502 . (Aug. 9) 1939. -

41. Since this report was submitted to the Council a synthetic compound,
1 ,4-dih vdroxy-2 mcthyl-3-naphthaldehyde, has been supplied to us by j)r.
E. A. Daisy of St. Louis. When administered intravenously in doses of
from 5 to lOjng. this preparation has been effective in reducing elevated
prothrombin times as calculated by the Quick method, in cases of obslruo
live jaundice. Ten patients have been treated and no untoward reactions
have been noted.

2060

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Medical Association

The American Medical Association advocates:

1. The establishment of an agency of the
federal government under which shall he
coordinated and administered all medical and
health functions of the federal government
exclusive of those of the Army and Navy.

2. The allotment of such funds as the Con-
gress may make available to any state in actual
need, for the prevention of disease, the promo-
tion of health and the care of the sick on proof
of such need.

3. The principle that the care of the public
health and the provision of medical service to
the sick is primarily a local responsibility.

4. The development of a mechanism for meet-
ing the needs of expansion of preventive med-
ical services with local determination of needs
and local control of administration.

5. The extension of medical care for the
indigent and the medically indigent with local
determination of needs and local control of
administration.

G. In the extension of medical services to all
the people, the utmost utilization of qualified
medical and hospital facilities already estab-
lished.

7. The continued development of the private
practice of medicine, subject to such changes as
may he necessary to maintain the quality of
medical services and to increase their a% ail-
abilitv.

8. Expansion of public health and medical
services consistent with the American system
of democracy.

HEREDITY IN INFECTIOUS DISEASES
Since 1923 the role of heredity in infections diseases
has been studied by Webster, 1 who investigated the
behavior of these diseases in mice. Common practice
shows, he says, that if a batch of mice is given an injec-
tion of a virulent agent by some artificial route the
great majority die within a few hours. Observed dif-
ferences in survival rates under the influence of less
virulent agents, smaller doses and like variations have
heretofore been attributed solely to uncontrolled errors
of technic. It was shown in 1923 that batches of labora-
tory bred mice exposed to infectious agents in a way
simulating nature differed from batches of uncontrolled
mice in responding as a group in a relatively predictable
manner. Further, by varying the diet a definite indi-
vidual difference was demonstrable. Progeny from
parents which died early from test infection with mouse
typhoid were more susceptible than those from parents
which survived such test infection. This observation
was regarded as proof that parents which died early
were actually more susceptible by inheritance than those
which survived. From highly susceptible parents, lines
of varying high susceptibility to mouse typhoid and
to encephalitis virus were developed through selec-
tion and brother-to-sister inbreeding. Susceptibility
remained unchanged for twelve generations in lines in
which it was greatest at the outset, while, in lines in
which it was intermediate, susceptibility increased
through selection.

The same circumstances held true for resistant lines.
The crossing of highly susceptible with highly resistant
lines resulted in percentage mortalities approximately
like those which would be expected on the basis of
a single factor type of mendelian inheritance for resis-
tance to mouse typhoid and to encephalitis virus as
well. Resistance proved dominant in each instance.
It was shown, however, that the amount of inherent
resistance displayed by an individual to one infectious
agent could not necessarily be taken as a measure of
resistance to another infectious agent. Under condi-
tions in which mouse typhoid is allowed to spread
naturally among herds of mice composed of different
proportions of individuals of innately high or low sus-
ceptibility, from 85 to 95 per cent of the innately
susceptible succumbed to the infection, in contrast to
less than 5 per cent of the innately resistant. The sur-
viving population becomes composed, therefore, largel)
of individuals known at the outset to be innately resis
tant, although these are nevertheless likely to become
infected and to harbor mouse typhoid bacilli. fUicn
new individuals, chiefly of innately resistant stocks, are
added to surviving populations, mouse typhoid spreads
to both resistant and susceptible. Mortality from the
infection, however, is again almost exclusively limited to
susceptible recruits and is sporadic or epidemic accorf
in g to the numbers and proportions added. _

1. Webster, Leslie T.: Heredity in Infectious Disease, J. lt'rrft'r
SO: JOS (Sept.) 1939.

Volume 113
Number 23

EDITORIALS

2061

Assuming the fact that inherited factors are of basic
importance in determining the character of infection
in both the individual and the herd, present interest
is principally focused, Webster says, on the methods
of modifying the expression of these factors through
environmental ones. Of those tested so far, diet is tire
most important and has been proved capable of chang-
ing susceptibles to resistants and vice versa. Indeed,
epidemics may be started and terminated merely by
altering the dietary factors.

Even if only a few of the implications of these experi-
mental studies can be applied to human conditions, the
effect on medical thought may be revolutionary. The
part which inherited disposition in resistance to infec-
tious disease may play is highly important. A sig-
nificant element may also be introduced into the
understanding of many phases of human epidemiology.
Finally the alteration of what appears to be a hereditary
character by such environmental factors as diet may
exert an unprophesiable effect on the course of many'
human activities. Indeed, even though the results of
these studies cannot as yet be applied to man, they
should serve to stimulate new lines of thought.

TRANSFUSION OF PRESERVED BLOOD

The obvious advantages of storing blood for trans-
fusion have led to the adoption of “blood banks” by
many large hospitals throughout the country. 1 With
grouped and serologically tested blood always available,
precious time is saved in the emergencies that so often
arise in accident and surgical cases. In time of war
this becomes even more important than in civil life.
In addition there is a large financial saving, since there
is less need for professional donors. During the past
two years preserved blood has probably been used for
thousands of transfusions.

While the transfusion of preserved blood has definite
advantages, there are also certain limitations to its
use. Blood is a living fluid, and processes tending
toward autolysis continue even when it is stored at
low temperatures in vitro. It becomes important to
establish, therefore, the maximum length of time during
which such blood can be kept before use, and in this
there seems to be no unanimous agreement. Two
methods of approach have been used, namely the study
of the changes which occur in stored blood and the
results of the transfusion of such blood.

Blood stored in vitro keeps best at temperatures
between 0 and 5 C. But even at low temperatures the
platelets and leukocytes break down within a period
of only a few days. According to Rhoads and Panzer -
the prothrombin time of blood stored even for periods
of from one to two days is greatly prolonged, and
therefore the censensus is that stored blood is not as

1* Fnntus, Bernard: The Therapy of the Cook County Hospital:
Blood Preservation Technic, J. A. M. A. 111:317 (July 21) 1938.

2. Rhoads, J. and Panzer, L. Jf.: Prothrombin Time in "Bank
Blood," J. A. M. A. 112:309 (Jan. S) 1939.

useful as fresh blood in hemorrhagic diseases. Most
of the studies have centered about the behavior of
the erythrocytes, since these after all are the most essen-
tial elements in the treatment of hemorrhage and ane-
mia. A progressive increase in the fragility of the
erythrocytes has been noted as the storage time is
lengthened, but manifest hemolysis is not evident until
the end of the second week. Scudder and his
co-workers 3 have observed a marked shift of the potas-
sium ions from the red blood cells into the plasma
with blood kept more than five days and feel therefore
that such blood should not be used for transfusion.
It seems doubtful, however, that the amount of free
potassium is sufficient to cause toxic symptoms.

With regard to results of transfusion, it has been
found that there is no difference in the incidence of
untoward reactions provided the blood has not been
kept too long. At the Cook County Hospital 1 the time
limit set for the storage of blood is ten days, since a
significant increase in the number and severity of reac-
tions was noted when the blood had been kept for longer
periods. From another angle, Schaefer and Wiener 4
have recently attacked the problem by tracing the fate
of the transfused erythrocytes in the patient’s circula-
tion. With -a method similar to that used by Ashby,
who showed that when fresh blood is transfused the
erythrocytes persist in the circulation for periods up
to three or four months, these authors found that, when
blood less than five to eight days old was transfused,
the period of survival was not significantly different
from that of fresh blood. However, in four cases when
blood stored for periods ranging from ten to twenty-
days was used, the cells could be detected in the patient's
circulation only up to from one to three weeks. In
most of these cases the number of transfused erythro-
cytes dropped rapidly, and this was accompanied by
the appearance of an icteric tint in the patient’s serum.
This could be demonstrated regularly after the injection
of blood more than from eight to twelve days old, pro-
vided the patient's serum was examined at the proper
time.

These investigations indicate that blood more than
from a week to ten days old is not equivalent to fresh
blood. Indeed, with blood that is too old there is even
some danger of hemoglobinuria and serious symptoms
such as are known to result from the transfusion of
incompatible blood.

When the available data are taken into consideration,
it is evident that the transfusion of preserved blood has
acquired an important role. This is a great change
in attitude from the opinion held less than two decades
ago, when the transfusion of citrated blood even when
fresh was looked at askance. However, there are defi-

3. Scudder, John; Drew, C. R.; Corcoran, Dorothy J!., and Bull,
D. C.; Studies m Blood Preseivation: I. Repartition of Potassium in
Cells and Plasma, J. A. M. A. 112:2263 (June 3) 1939.

4. Schaefer, George, and Wiener, A. S.: Limitations in the Use of
tTl939 ^ f ° r Transfus, ° ns - Q ua «- BuU - Sea View Hosp. 5:17

2062

CURRENT COMMENT

Jour. A. M. A.
Dec. 2, 1SJ9

nile limitations to the use of stored blood which should
be taken into account. Pending further investigation,
a safe limit to set for the use of such blood would be
between five and ten days. Perhaps by improving the
method of storing blood it may be possible to extend
the time limit.

Current Comment

NATIONAL PHYSICIANS’ COMMITTEE
FOR THE EXTENSION OF
MEDICAL SERVICE

An item appears in the Organization Section in this
issue of The Journal telling of the organization of
the National Physicians’ Committee for the Extension
of Medical Service. This committee is headed by a
group of physicians, many of whom are widely known
for their work in the American Medical Association.
The organization is not, however, officially connected
with the American Medical Association itself. Infor-
mation elicited from the officials of the National Phy-
sicians’ Committee indicates that this group has been
organized voluntarily to carry on education of the
public regarding the extension of medical service and
preventive medicine. Their work is of the nature of
public relations activities. The National Physicians’
Committee is in a position to accept contributions from
industrial and other organizations in order to aid this
campaign. The American Medical Association itself
has not in the past and does not now accept such con-
tributions. Officials of the organization state also that
it is their intent to include in the various subcommittees
of the main organization groups of dentists, nurses,
hospital executives, pharmacists and all of the other
special groups in the field of medicine.

NORMAL BLOOD PRESSURE

Much difference of opinion prevails as to what con-
stitutes normal blood pressure; obviously the pressure
can vary widely among different individuals of the
same age groups or in the same individual at different
ages and under altered circumstances. A recent study
of this subject by Robinson and Brucer 1 has tended to
revise downward generally accepted normal blood
pressure levels. These authors made an exhaustive
statistical study of 7,47S men and 3,405 women, all
relatively sedentary in their occupations, selected at
random in the Chicago area and economically selected
by being able to afford insurance policies of S1,000 or
more. Eighty-six per cent of the men had systolic
blood pressures of between 90 and 130 mm. of mercury,
54 per cent between 100 and 120, 6 per cent below 100
and 25 per cent below 110. Of the women, 89 per
cent had systolic pressures of between 90 and 130,
56 per cent between 100 and 120, IS per cent below
100 and 44 per cent below 110. The greater tendency
to low blood pressures in the women was found in the
vounger age groups. Up to the age of 60, half or more

1, Ro!):n<on,
IH6c*l Pres -arc.

c-irmri C.. anil Brucer. MaWfcr.lt: Range o£ Normal
At'ch. lot; Mc.l. 04:409 (Sc[.t.) 1929.

of the men had systolic pressures lower than 120, and
that of about three fourths never rose above 130. The
indications are, they say, that hypertensive men are
those who have systolic pressures above 120 appearing
at an early age. The authors also presented the con-
tinuous blood pressure history of 500 apparently well
men examined annually over a period of about ten years,
Blood pressures consistently low did not show as much
change from year to year as those consistently high.
Persons with systolic pressures below 120 rarely
changed their level in the direction of a steady rise.
In the third phase of this study Robinson and Brucer
pointed out that deviations from physiologic norms
represent the most accurate check on degenerative
processes at work and of potential longevity. If the
upper limits of normal pressures are set at 120 systolic
and 80 diastolic, a definite parallelism could be observed
with the actuarial figures of insurance companies. With
a rise in blood pressure there was an abrupt rise in
death rate. Pressures, they' conclude, of 130 to 144
systolic and diastolic pressures of over 80 cannot be
regarded as normal. Accordingly, the popular notion
that low blood pressure is a disease and moderately
high pressure normal and safe is fallacious. On the
contrary', they say', longevity is based on three phys-
iologic levels: low weight, low pulse rate and low
blood pressure.

THE MEDICAL SOCIETY OF DELAWARE
One hundred and fifty years ago, twelve days after
George Washington took the oath of office as first
President of the United States, a group of twenty-seven
physicians brought into being the Medical Society of
Delaware, the third oldest state medical society and
the second oldest medical corporation in the United
States. At a recent banquet in celebration of this occa-
sion the speakers were Hon. Richard C. McMullen,
governor of Delaware, Dr. Rock Sley'ster, of Wauwa-
tosa, Wis., President of the American Medical Asso-
ciation, Dr. L. A. H. Bishop, past president of the
Medical Society of Delaware, and Mrs. Rollo K. P ac ^'
ard, of Chicago, National President of the Womans
Auxiliary to the American Medical Association, The
Delaware Academy of Medicine exhibited books, instru-
ments, photographs and other articles belonging to the
early members of the Medical Society of Delaware.
Furthermore, the president of the society, Dr. MM-
Samuel, prepared a special book in connection "Jj
the sesquicentennial celebration in which are brie
accounts of meetings of the society from year to year,
notations on papers read before the fellows, a list of t ie
members of the many committees of the society, a his
torical account of the early' organization, excerpts from
presidential addresses, biographies and portraits of t | c
society’s presidents, short descriptions of the hospita =>
in the state of Delaware, and records of the he- 1 1 ’
laws and medical practice acts. The cooperation o
the Medical Society of Delaware with the state kE 1 -
Iature has brought about laws which safeguard t’ r -
health of that community and insure to the people u„
standards of medical care.

Volume 113
Number 23

2063

ORGANIZATION SECTION

THE NATIONAL PHYSICIANS’ COMMITTEE FOR THE
EXTENSION OF MEDICAL SERVICE

Oil November 18, in Chicago, a formal meeting of
an executive board officially launched a new organiza-
tion, the National Physicians’ Committee for the Exten-
sion of Medical Service. At this meeting the following
officers were elected : Dr. Edward H. Cary, Dallas,
Texas, chairman ; Dr. Austin A. Hayden, Chicago, sec-
retary, and Dr. N. S. Davis III, Chicago, treasurer.
These officers were given authority to act as a manage-
ment committee for the new organization.

A central committee of more than 800 physicians
is being formed, in which all the states will be repre-
sented. Some of those already listed in the central
committee include Drs. Howard Morrow, San Fran-
cisco ; Charles W. Mayo, Rochester, Minn. ; Herman L.
Kretschmer, Chicago, and Charles Gordon Heyd and
Haven Emerson, New York.

The organization is an independent one, not affiliated
in any way whatever with the committee sponsored by
Mr. Frank Gannett under the management of Dr.
Edward A. Rumely or with the so-called Committee
of Physicians or with the American Medical Associa-
tion. The functions will not, it is stated, overlap or
infringe on those of existing county, state or national
medical organizations. For its finances, this organi-
zation depends wholly on voluntary contributions from
physicians, dentists, nurses, hospitals, pharmacists and
lay groups interested in the maintenance of the private
practice of medicine. In literature released by the Man-
agement Committee, the reasons for forming this new
institution are stated as follows :

Medicine is confronted with two new sets of conditions.
On the one hand, widespread unemployment, low farm income,
and the continuation of conditions of general depression have
made it difficult for an ever increasing number of people to
pay for the best medical service and proper hospitalization out
of earnings.

On the other hand, there is the trend — worldwide in scope —
toward governmental paternalism and the false, suicidal doctrine
that the “state” can provide a service and a security that the
people cannot otherwise obtain. As related to medicine, the
implementing of this concept would effect revolutionary changes
in both the practice of medicine and the underlying philosophy

which has given it the dynamic quality that resulted in world-
wide leadership.

If the ethical and scientific standards are to be maintained,
the independence of American medicine preserved and the public
interest best served, American physicians must:

1. Make possible the providing of medical service to the
indigent and those in the low income groups, and insure the
most widespread distribution of the most effective methods and
equipment in medicine and surgery.

2. Assume the responsibility of countering destructive propa-
ganda by familiarizing the public with the facts in connection
with the methods and the achievements of American medicine.

The objectives are embodied in a motion, unani-
mously adopted by the directors :

Resolved, That the National Physicians’ Committee for the
Extension of Medical Service is a nonprofit, nonpolitical organi-
zation for maintaining ethical and scientific standards and
extending medical service to all the people . . . and for
. . . cooperating with lay and medical institutions and
groups, interested in the preservation of national health, to
make more generally known the achievements and to safeguard
the independence of American medicine.

A broadgage nationwide educational program has
been planned and the preliminary steps have been
taken to put it in operation. An effort will be made
to familiarize the public with the aims, the methods
and the effectiveness of American medicine. It is
believed that this will result in generally improving
health conditions and will tend to offset propaganda that
is altering the point of view of the individual and
adversely affecting the status of the physician.

The Executive Board includes Dr. Edward H. Cary,
Dallas, Texas; Dr. Austin Hayden, Chicago; Dr. N. S.
Davis III, Chicago; Dr. Irvin Abell, Louisville, Ky.;
Dr. F. F. Borzell, Philadelphia; Dr. William F.
Braasch, Rochester, Minn.; Dr. John A. Hartwell, New
York; Dr. Roger I. Lee, Boston; Dr. Alphonse
McMahon, St. Louis; Dr. E. H. Skinner, Kansas City,
Mo., and Dr. Charles B. Wright, Minneapolis.

Mr. John M. Pratt has been secured as executive
administrator. The offices are at 700 North Michigan
Avenue, Chicago.

THE A. M. A. PROGRAM

[Editorial from the Providence Sunday Journal, Nov. 19, 19391

The American Medical Association has come out with a pro-
gram of principles for solving the nation’s health problems with-
out resorting to federal government control and compulsory
sickness insurance. Its own program is set up as a backfire
to the other, against which one of the chief arguments the
Association advances is that it would comprise a trend away
from democracy.

Everybody talks about democracy and the menaces to it these
days. Regimentation of life in certain foreign countries induces
a wholesome, overdue reexamination of the values of individual
freedom and corollary responsibility under democracy’s looser
system. It is seen and keenly appreciated again, as if it were
a new discovery, that the free and responsible individual who
is the unit of government is a far different person than the man
or woman who is the creature of government.

But it is not so clearly seen that regimentation can come to
a people insidiously, in beneficent guise, as well as through the
compulsion of a recognized and feared dictatorship; that, for
example, the eager pursuit of social objectives which are intrin-
sically admirable may require dangerous strengthening and
extension of the federal power, debilitation of the states as
sovereign entities which are closer to the people and further
destruction of individual responsibility, self reliance and freedom
of action.

To the extent that that occurs democracy is damaged, and it is
for that reason that it is decidedly in point to study proposed
approaches to the national health problem with the preservation
of democracy in mind.

The federal government, from motives of paternalism or
bureaucracy, has a well developed penchant for patting the

2064

ORGANIZATION SECTION

Jour. A, JI. A
Dec. 2, 1939

citizen on the head — extracting money from his pocket, of
course, to pay for the gesture. There are some who would now
have it wipe his nose and extract some more money, this pater-
nalism being in the form of compulsory sickness insurance. It
would further decrease his economic freedom of action, but no
thought is given to that. It would further decrease his responsi-
bility and capacity for taking care of himself on his own initia-
tive, and it would alter, perhaps profoundly, his traditional and
important relationship to the medical profession, which exists
for and because of his needs as a private citizen and human
creature rather than as a ward of government. But no thought
is given to that, either.

The fact is that the advocates of head patting and nose wipircr
want, or at least are willing to accept, a socialized nation as the
price of paternalism. The battle with them therefore ought to
be waged on that front. Health is not the issue ; democracy it
As a matter of fact the prime public problem in the United
States today is not at all the health of the citizens; the prime
problem is the decidedly poor health that the federal govern-
ment 'is enjoying. The latter is obese with bureaucracy and
ravenously hungry for more taxes to satisfy its self-generated,
insatiable appetite. It ought to be put on a programmatic diet
before it eats us out of house and home. Is there a doctor in
the house?

OFFICIAL NOTES

ANNUAL CONGRESS ON INDUSTRIAL
HEALTH

Arrangements have been completed for the second Annual
Congress on Industrial Health sponsored by the American

• Medical Association, which will be held Monday and Tuesday,
Jan. 15 and 16, 1940, at the Palmer House in Chicago.

Topics and speakers are as follows:

Opening Session, Monday Morning, 9 : 45

Report of the Council on Industrial Health.

Stanley J. Seeger, M.D., Chairman, Milwaukee.

Vocational Rehabilitation in Relation to Medical Practice and Work-
men’s Compensation Procedure.

Terry C. Foster, U. S. Office of Education, Washington, D. C.
Industrial Psychiatry and Mental Hygiene .

Lydia G. Giberson, M.D., New York.

Adequate Nutrition for the Industrial Worker.

Lela E. Booiier, Pn.D., U. S. Department of Agriculture, Wash-
ington, D. C.

Monday Afternoon, 2 : 15
SYPHILIS IN INDUSTRY

Syphilis in Industry with Special Reference to Its Incidence and Rela-
tion to Trauma.

Earl D. Osborne, M.D., Professor of Dermatology and Syphilology,
University of Buffalo School of Medicine, Buffalo.

Syphilis Case Finding in Industry.

Albert E. Russell, M.D., Surgeon in Charge, Office of Syphilis
Control in Industry, U. S. Public Health Service, Chicago.
Integrating Syphilis Control Between the Industrial and the Private
Practitioner.

Harold A. Vonachen, M.D., President, Central States Society of
Industrial Medicine and Surgery, Peoria, 111.

• Syphilis and Employment.

Harvey Bartle, M.D., Chief Medical Examiner, Pennsylvania Rail-
road, Philadelphia.

Monday Evening, 6 : 30

An informal dinner and round table discussion, intended pri-
marily for members of state and county medical society com-
mittees on industrial health, will be held. The subject matter
for discussion will include problems of organization and plans
for future activity.

Tuesday Morning, 9 : 30
PHYSICAL EXAMINATIONS

Objectives of Health Examinations and Their Industrial Applications.

McIver Woody, M.D., President, American Association of Industrial
Physicians and Surgeons, New York.

The Private Practitioner and Industrial Physical Examinations.

Raymond Hussey, M.D., Chairman of Committee on Industrial Health,
Medical and Chirurgical Faculty of the State of Maryland, Baltimore.

The Wisconsin Plan for Physical Examinations in Industry:

The Point of View of the Industrial Commission.

IIarky A. Nelson, Director, Workmen’s Compensation, Industrial
Commission of Wisconsin, Madison, Wis.

Scope and Methods of Industrial Physical Examinations of the ll'iscon-

yCl'I A?"breiim. M.D., Chairman of the Medical Subcommittee on
Physical Examinations in Industry, Industrial Commission of Wis-
consin, Madison, W is.

Tuesday Afternoon, 2 O'C lock
DISABILITY EVALUATION

Hearing Loss — Estimation of Disability. ,

Austin Hayden M.D.. Chairman Consultants on Audiometers and
Hiring AMs.. Council on Physical Therapy, American Medical
Association, Chicago.

Present Status cf Estimating Disability from Visual Loss.

Harry S. Cradle, M.D., Chicago.

Arc Uniform Standards of Disability Evaluation Practicable!

Earl D. McBride, M.D., Oklahoma City.

Critique of Disability Evaluation.

Henry H. Kessler, M.D., Newark, N. J.

Wednesday, January 17

On the day following the Congress on Industrial Health, the
Chicago Medical Society will conduct all day clinics illustrating
practical problems in industrial medicine and traumatic surgery
at St. Luke’s Hospital in Chicago. These programs are under
the direction of Drs. James A. Britton and Harry E. Mock
respectively.

On the same day the Chicago Medical Society will conduct a
dinner and evening meeting to be addressed by Dr. Vilray P.
Blair, St. Louis, on “Treatment of Facial Deformities Caused
by Injury.”

Further details regarding these presentations will be available
to registrants at the congress, all of whom are invited to par-
ticipate in the programs.

ABSTRACT OF MINUTES OF MEETINGS
OF BOARD OF TRUSTEES

The regular fall meeting of the Board was held during the
day and evening of November 16 and on November 17.

meetings of board of trustees with representatives
of other organizations

A joint meeting of the Board of Regents of the American
College of Surgeons and the Board of Trustees of the Ameri-
can Medical Association was held, at which numerous subjects
of mutual interest were discussed, some of which were referred
for further study to a committee to be appointed by the t"°
organizations.

Arrangements were made for a meeting of representatives
of the American, Catholic and Protestant hospital associations
with the Executive Committee of the Board of Trustees
December and for a meeting of representatives of the Ameri-
can Society of Clinical Pathologists with the Executive Com-
mittee in January.

REPORT OF COMMITTEE ON AMERICAN HEALTH RESORTS

A report from the Committee on American Health Resort'
recommending that information on health resorts in the Unite
States be assembled was presented and adopted.

REPRESENTATION ON COMMITTEE OF AMERICAN FILM CENTO - ,
INC., AND ON ADVISORY' BOARD OF AMERICAN
CAMPING ASSOCIATION, INC.

Dr. W. W. Bauer was authorized to accept membership o.t
the Committee on Public Health Films of the American 1 1,11
Center, Inc., and on the Advisory Board of the American
Camping Association, Inc.

PLATFORM FOR HEALTH AND MEDICAL CARE

A platform for the American Medical Association was csta
lished indicative of the trend which the Association be icr e-
should be followed in the development of health activities a
medical care for the people of the United State', and aut : •
zation was given for its publication in The Journal.

Volume 113
Number 23

ORGANIZATION SECTION

2065

national physicians’ committee for the extension

OF MEDICAL SERVICE

Authorization was given for the publication in The Jour-
nal of a brief statement relative to the organization and pur-
poses of a committee known as the National Physicians’
Committee for the Extension of Medical Service; also for the
publication of a communication relative to the Committee of
Physicians.

CONFERENCE ON NOMENCLATURE

The Board authorized the calling of a conference early in
1940 for the revision of the Standard Classified Nomenclature
of Disease.

OMISSION OF “COL.” AFTER THE NAMES OF NEGRO PHYSICIANS
IN AMERICAN MEDICAL DIRECTORY

Instructions were given for the omission of the designation
“col.” after the names of Negro physicians in tile next edition
of the American Medical Directory.

VOTE OF THANKS FOR SPACE FOR EXHIBIT OF HYGEIA
AT NEW YORK WORLD’S FAIR

A vote of thanks was extended to Dr. Martin A. Couney for
the prominent space made available to the Association for an
exhibit of Hygcia in the Incubator Building at the New York
World's Fair, which was visited by 275,000 persons in 1939.

Other business before the Board was concerned with the
general affairs of the Association.

ADDRESSES BY OFFICIAL STAFF

Dr. W. W. Bauer:

December 4 — Cole County Medical Society Auxiliary, Jeffer-
son City, Mo.

December 5 — Stephens College, Convocation, Columbus, Mo.
December 5 — Boone County Medical Society, Columbus, Mo.
December 7 — Greene County Medical Society, Woman’s
Auxiliary, Springfield, Mo.

December 12 — Emmett Parent Teacher Association, Chicago.
December 12 — Junior Chamber of Commerce, Clinton, Iowa.

Dr. Morris Fishbein:

December 6 — Chamber of Commerce, Duluth, Minn,
December 6 — Industrial Safety Conference, Duluth, Minn.
December 11 — Mothers' Aid, Chicago.

December 13 — Forum and Medical Society, Frankfort, Ky.
December 14 — Louisville District Dental Society and Jeffer-
son County Medical Association, Louisville,
Ky.

Dr. R. G. Leland:

: December 1 — Phi Beta Pi Fraternity, Rush Medical Col-

lege, Chicago.

December 7-10 — American Public Welfare Association, Round
Table Conference on Medical Care, Wash-
ington, D. C.

December 13 — Dcs Moines Public Forum, Des Moines,
Iowa.

Dr. Rock Sleyster:

December 5 — Medical Society of South Carolina, Charleston,
S. C.

Dr. Paul A. Tesciiner:

December 4 — National Committee on Boys and Girls Club
Work, 4 H Movement, Meeting, Chicago.
December 6 — Higli School, Peru, Ind.

December 6 — Junior High School, Peru, Ind.

December 6 — Parent Teacher Association, Peru, Ind.
December S — Milwaukee County Medical Society Auxiliary,
Alilwaukee.

December 13 — Kane County Medical Society, Elgin, 111.

Dr. Nathan B. Van Etten:

December 5— South Carolina Medical Association, Charles-
ton.

December 19— The New York County Medical Society, New
York.

RADIO BROADCASTS

The seventh season of broadcasting by the American Medical
Association over the facilities of the National Broadcasting
Company and affiliated stations is now underway with programs
scheduled each Thursday at 4 : 30 p. m. eastern standard time
(3 : 30 central standard time, 2 : 30 mountain time and 1 : 30
Pacific time). The program is on the Blue network of the
National Broadcasting Company, whose key station is WJZ,
New York.

The title of the program is Medicine in the News. It is a
fast moving, varied, dramatized program based each week on
an important news item from The Journal, a state medical
journal or other reputable medical publication, or Hygcia. Each
program will also include the week’s medical highlight, which
will be either an interesting, amusing or unusual incident, or a
series of brief news items taken from current medical literature.

Each week’s program will include a question received from a
lay inquirier by the American Medical Association. These ques-
tions will be of timely, seasonal interest or of universal appeal.
The question will be asked at the opening of the program and
answered at the close of the program.

It is not possible to state definitely exactly the stations which
are taking the program. A list of stations on the Blue network
was published in The Journal, October 28. Inquiries should
be made of the local station by a committee of the county medi-
cal society or the auxiliary. The advantages of the program
and its interest to the public should be called to the attention of
the station management by the local medical society or auxiliary.

The following radio stations have signified their intention of
broadcasting Medicine in the News, according to information
received from the National Broadcasting Company, Novem-
ber 24:

New Engtay\d States

WNBC

New Britain, Conn.

WLBZ

Bangor, Me.

WEAN

Providence, R. I.

Middle Atlantic States

WABY

Albany, N. Y.

WBEN

Buffalo

WJTX

Jamestown, X, Y.

WJZ

New York

WMFF

PJattsburg, X. Y,

WSAN

Allentown, Pa,

WLEU

Erie, Pa.

WKBO

Harrisburg, Pa.

WGAL

Lancaster, Pa.

WFIL

Philadelphia

KDKA

Pittsburgh

WORK

York, Pa.

East North Central States

WENR

Chicago

WGL

Fort Wayne, Ind.

WBOW

Terre Haute, Ind.

WBCM

Bay City, Mich.

WXYZ

Detroit

WFDF

Flint, Mich.

WIBM

Jackson, Mich.

WJr.M

Lansing, Mich.

WSAI

Cincinnati

WING

Dayton, Ohio

WIBA

Madison, Wis.

West North Central States

KSO

Des Moines, Iowa

KMA

Shenandoah, Iowa

KSCJ

Sioux City. Iowa

WRE.V

Lawrence, Kan.

kans

Wichita, Kan.

KYSM

Mankato. Minn.

WTCN

Minneapolis

KROC

Rochester, Minn.

KFAM

St. Cloud, Minn.

KWK

St. Louis

KSOO

Sioux Falls. S. D.

South Atlantic Stairs
WCOA Pensacola, Fla.

WAGA Atlanta, Ga.

WSOC Charlotte, H. C.

WTAK Norfolk, Vo.

WRTD Richmond, Va.

TVCKV Charleston. W. Va.

WBLK Clarksburg, W, Va.

East South Central States
WAVE Louisville, Ky.

WAPO Chattanooga, Tenn.
WROL Knoxville, Tenn.

West South Central States
WJBO Baton Rouge, La.

KTOK Oklahoma City

KFDM Beaumont. Texas

KTSM El Paso, Texas

KGKO Fort Worth, Texas

KXYZ Houston. Texas

KRGV Weslaco, Texas

Mountain States
KTAR Phoenix, Ariz.

KVOA Tucson, Ariz.

KVOD Denver

KGHP Pueblo, Colo.

KOB Albuquerque, N. M.

KLO Ogden, Utah

KUTA Salt Lake City

Pacific Stairs
KECA Los Angeles

KFSD San Diego, Calif.

KGO San Francisco

KTJIS SaDta Barbara, Calif.
KEX Portland, Ore.

K.JR Seattle

KGA Spokane

Canada

CFCF Montreal

2066

ORGANIZATION SECTION

Jour. A. M. A.
Dec. 2, 1939

WOMAN’S AUXILIARY

Illinois

The auxiliary to the Bureau County Medical Society met at
Spring Valley September 12 at the home of Mrs. M. A. Nix.
A donation of §50 was made to the Crippled Children’s Clinic.

The auxiliary to the Coles-Cumberland Counties Medical
Society met at Mattoon September 20. Mrs. W. R. Rhodes
of Toledo addressed the group on the national and state public
health service.

The auxiliary to the Sangamon County Medical Society held
an Acquaintance Day Luncheon September 11. The first regular
program was held September 25 at the home of one of the
members. A review of the September issue of Hygcia was
given.

New York

The auxiliary to the Nassau County Medical Society met in
the Nassau Hospital Auditorium September 20. The auxiliary
is cooperating with the County Cancer Committee. At the
auxiliary meeting held on September 26 Miss Muriel Bliss,
chairman of the Nassau County Committee on Cancer, was guest
speaker.

The first meeting of the auxiliary to the Medical Society of
Saratoga County was held October 3 in Schuylerville. Addresses
were given by physicians on the subjects colds and pneumonia
and the importance of hospitals to communities. Auxiliaries to
the medical societies of Sullivan County and of Washington
County have recently been organized.

Texas

An executive board meeting of the auxiliary to the State
Medical Association of Texas was held in Dallas September
21. Mrs. S. H. Watson, Waxahachie, president, reports that

forty-one members attended the meeting. Taylor-Jones

Counties Auxiliary will provide one month's maintenance for
a needy student at the Texas State College for Women, Denton.

The Central Texas District Auxiliary met in Cleburne

recently. Mrs. F. F. Kirby, past president of the state auxiliary,

and Mrs. L. B. Leake, treasurer, gave addresses. The auxiliary
was entertained at a joint luncheon with its district medical
society at the First_ Methodist Church. On this occasion Dr.
L. H. Reeves, president of the state medical association, was
the speaker.

Utah

The board of directors of the auxiliary to the Utah State
Medical Association met in Provo October 12. A history of
the pioneer physicians of Utah will be prepared by the auxiliary
under the direction of Mrs. Walter M. Stookey, past president
The auxiliary will send delegates to the Legislative Council,
which meets once each month at the State Capitol in Salt Late
City.

The auxiliary to the Carbon County Medical Society met at
the Carbon Country Club October 7. Mrs. Bliss Finlayson of
Price will arrange radio programs for the auxiliary.

The auxiliary to the Utah County Medical Society held its
first autumn meeting at the home of Mrs. Arnold Robinson in
Provo. Plans were made to place Hygcia in every grade and
high school in the county.

Washington

The auxiliary to the Clark County Medical Society met at
the home of Mrs. Charles Otto on the Evergreen Highway
overlooking the Columbia River October 3. Plans are being
made for the placing of Hygcia in reading rooms of public
schools.

The auxiliary to the Grays Harbor Medical Society held its
September meeting in Aberdeen. Copies of the pamphlet "On
the Witness Stand” were distributed.

The September meeting of the auxiliary to the King County
Medical Society was held at the Woman's University Club,
Seattle. A membership tea was given at the home of Mrs.
L. L. Stephens in October, at which time many new members
were welcomed. Members of the county Hygcia committee
have visited outlying communities near Seattle, securing sub-
scriptions for Hygcia.

MEDICAL ECONOMIC ABSTRACTS

GROUP HOSPITALIZATION IN
WAYNE COUNTY

The Wayne County Medical Society has recommended to
its council that the plan offered by the Michigan society for
group hospitalization be made available to members of the
county medical society.

The Michigan Society for Group Hospitalization was organ-
ized by the hospitals of Michigan. It is a nonprofit organiza-
tion; the members of the board of trustees receive no reim-
bursement for their services; all employees of the society are
on a straight salary basis, and no fees or commissions are
paid to representatives. The seventy-eight participating hos-
pitals guarantee the services provided for in the subscriber's
certificate— no assessment is possible. The subscriber is assured
of hospital service at cost, as the certificate provides that any
surplus accruing in the operation of the plan will be returned
to the subscribers in the form either of reduced rates or of
increased benefits. Ordinarily the plan is available only to
groups of ten or more employed people through their place of
employment, but special arrangements have been made to
make the service available to members of the medical society.

There are no age limits for adults, no physical examination
required and no exemptions for chronic conditions Jn case
of an emergency a subscriber may go to any hospital in the
world, and if he holds a ward certificate he will receive S4.a0
a dav toward his hospital bill or ?6 a day it he holds a semi-
private certificate. The seventy-eight hospitals that guarantee
die service are located in forty-one Michigan cities. During
the five months that the plan has been in operation 4a,t 000
subscribers have been enrolled.

The county medical society members arc now being circu-
larized with an application blank which is also intended as a
referendum to determine whether the members approve the
plan and if so are willing to enroll.

THE ORDER OF PHYSICIANS
IN PORTUGAL

A little more than a year ago the Belgian medical profession
was made a legal organization in which every licensed physician
is required to hold a membership. Similar legislation "as
enacted in Germany and Italy, shortly- after these became
totalitarian states. Portugal has now enacted a similar
a copy of which appears in the Prcssc medicalc lor August )->
1939, page 1239.

The provisions of the Portuguese law creating an ''integrate'
profession make legal some of the provisions of medical ctlncs.
This is true also in the legislation of the other countries. 1°
example, the physician is required “to respect the customs an
local traditions with relation to his patients, and to act ">
loyalty with regard to his colleagues, and to conduct c0 ^
scientiously his professional and social duties.” Ah species
advertising, including interviews with the press which ten'
attract a clientele, arc absolutely forbidden. Pharmacists, c ic
icai laboratories, drug stores or any establishments ior H ,c s
of pharmaceutic products and all similar institutions arc f * rlc
forbidden to give any sort of medical consultations or P
scriptions. , .i..

The form of organization, including the management
order by regular conventions and the form of admmislra wt
be set up, arc prescribed in the law.

Volume 113
Number 23

MEDICAL ' NEWS

20 67

Medical News

(Physicians will confer a favor by sending for

THIS DEPARTMENT ITEMS OF NEWS OF MORE OR LESS

general interest: such as relate to society activ-
ities, NEW HOSPITALS, EDUCATION AND PUBLIC HEALTH.)

ALABAMA

Regional Meeting. — The Northwestern Division of the
Alabama State Medical Association will meet in Parrish Decem-
ber 7. At this meeting plaques will be awarded by the Walker
County Medical Society to Dr. Charles B. Jackson, Jasper,
posthumously, for fifty-three years of distinguished service
to the medical profession and to Dr. Hugh W. Stephenson,
Oakman, commemorating sixty years of active practice. The
speakers will include Drs. Glenn I. Jones, Washington, D. C.,
on “Railroad Medical Service” ; James A. Meadows and Karl
F. Kesmodel, Birmingham, “Diagnosis of Cancerous Lesions” ;
Thompson F. Wickliffe, Jasper, “Virus Diseases”; Sam P.
Wainwright, Birmingham, “The Thymus Gland,” and Gilbert
B. Greene, Birmingham, “Surgical Management of Thyro-
toxicosis.”

CALIFORNIA

Course for Practitioners. — The University of California
Medical School, San Francisco, will offer a course for general
practitioners at the University of California Hospital, San
Francisco, Jan. 3-6, 1940. The course has been designed to
meet the needs of the physician in private practice. Patients,
lantern slides and pathologic material will be used to illustrate
the discussions.

Society News. — At the annual meeting of the Los Angeles
County Medical Association, December 7, Dr. George Franklin
Farman will discuss the “History of the Urologic Section and
Its Relationship to the Los Angeles County Medical Asso-
ciation,” and Dr. Herman L. Kretschmer, Chicago, “The Pres-
ent Status of Transurethral Resection.”— — The Los Angeles
Society of Neurology and Psychiatry was addressed November
15 by Drs. Clarence W. Olsen on “Injury to the Spinal Cord
Incident to Hypodermic Injection,” and Samuel D. Ingham,

“Neurologic Interpretations of Convulsive Symptoms.” At

a meeting of the Los Angeles Society of Ophthalmology and
Otolaryngology November 27 the speakers were Drs. Leland
R. House on “Cysts in the Maxillary Sinus” and Cyril B.
Courville, “Prodromal Syndrome of the Intracranial Extension
of Middle Ear and Mastoid Infection.”

COLORADO

Society News. — Dr. Robert K. Dixon, Denver, discussed
gastro-enterology before the Northeast Colorado Medical

Society in Sterling October 12. At a meeting of the Delta

County Medical Society in Delta October 27 Dr. Lawrence L.
Hick discussed “Recent Advances in the Treatment of Pneu-
monia.” The Larimer County Medical Society was addressed

in Fort Collins November 1 by Dr. Foster L. Matchett on
“Orthopedic Approach to Low Back Pain” and “Internal Fixa-
tion of Broken Hips.” The Washington- Yuma Counties

Medical Society met in Yuma October 20; the speakers were
Drs. Lyman W. Mason on "Pelvic Infections” and Ward Dar-
ley Jr. on “Advancement in Diagnosis and Treatment of Car-
diac Diseases.” Dr. Henry A. Buchtel, Denver, discussed

“Urology and Treatment of Urologic Diseases” at a meeting
of the Weld County Medical Society in Greeley November 6.

CONNECTICUT

Society News. — Arne Tiselius, Ph.D., Institute of Physi-
cal Chemistry, University of Uppsala, Uppsala, Sweden, dis-
cussed “The Application of Electrophoresis Methods to Some
Problems in Biochemistry and Medicine” before the Yale Medi-
cal Society October 25 under the auspices of the Jane Coffin

Childs Memorial Fund for Medical Research. Dr. Lee E.

Farr, New York, discussed “Studies of Nitrogen Metabolism
in Children with the Nephrotic Syndrome” before the Yale
Medical Society November S.

Discussions on Pneumonia. — The Connecticut State Medi-
cal Society and the state department of health announce a
series of programs on the treatment of pneumonia to be given
in cooperation with the following medical societies: Bridgeport,
Central, Danbury, Greenwich, Hartford, Manchester, Meriden,

New Britain, New London, New Haven, Norwalk, Norwich,
Torrington and Waterbury. Dr. Louis H. Nahum, New
Haven, opened the series November 16. Other speakers will
include :

Dr. Chester S. Keefer, Boston, December 4, in New Britain.

Dr. Russell L. Cecil, New York, December 6, in Hartford.

Dr. Francis G. Blake, New Haven, December 7, in Norwich.

Dr. Blake, December 13, in Danbury.

Dr. John A. Wentworth, Hartford, December 14, in Waterbury.

Dr. Theodore S. Evans, New Haven, December 19, in Greenwich.

Dr. Thomas P. Murdock, Meriden, December 20, in Middletown,

Dr. Blake, December 20, in Norwalk.

Dr. Samuel J. Goldberg, New Haven, January 3, in Meriden.

Dr. Clarence L. Robbins, New Haven, January 3, in Litchfield.

Dr. Blake, January 26, in Manchester.

In Bridgeport March 5, speaker to be announced.

DISTRICT OF COLUMBIA

Society News. — Forest Ray Moulton, Ph.D., permanent
secretary, American Association for the Advancement of
Science, Washington, D. C., discussed “A Jaundiced Look at
the Human Machine” before the Academy of Medicine of

Washington October 27. Dr. Louis H. Clerf, Philadelphia,

discussed “Diagnostic Information Derivable from Bronchos-
copy” before the naval medical and dental officers on duty in
the district at a meeting in the naval medical school Novem-
ber 6.

New Professor of Psychiatry at Georgetown. — Dr.
Harry Stack Sullivan, New York, president of the William
Aianson White Psychiatric Foundation and faculty' chairman
of the Washington School of Psychiatry, has been appointed
professor of psychiatry and director of the department of psy-
chiatry and neurology at Georgetown University School of
Medicine. He succeeds the late Dr. Daniel Percy Hickling,
who was a member of the faculty of Georgetown for more
than forty years. Dr. Sullivan graduated at the Chicago Col-
lege of Medicine and Surgery in 1917. He served as associate
professor of psychiatry at the University of Maryland School
of Medicine from 1923 to 1930 and concurrently . as director
of clinical research at the Sheppard and Enoch Pratt Hospital,
Baltimore.

ILLINOIS

Postgraduate Conference. — Physicians of the seventh,
eighth and eleventh councilor districts in cooperation with the
Illinois State Medical Society are cooperating in a postgraduate
conference to be held in Champaign December 7. The subjects
planned for discussion in this conference, which is the second
of a new program planned by the state society, include:

The Fundamental s in the Use of Sulfanilamide and Its Allied Com-
pounds in Infection, Dr. Oswald H. Robertson.

Recent Developments in the Treatment of Diabetes Mellitus, Dr. Robert
W. Keeton.

Cardiac Emergencies and Their Treatment, Dr.. Carlo S. Scuderi.

The Treatment of Athlete’s Foot and Other Fungous Infections of the
Skin, Dr. Francis E. Senear.

The Treatment of Common Ailments in Children, Dr. Robert A. Black.

Physical Therapy, Dr. John S. Coulter.

The Management of the Male and Female Climacteric, Dr. James H.
Hutton.

The Treatment of Head Injuries, Dr. Harry Mock.

Why, When and How to Immunize, Dr. Harry Leichenger.

Treatment of Common Disorders of the Upper Respiratory Tract,
Dr. Francis L; Lederer.

All the speakers are from Chicago.

Society News. — Dr. James H. Hutton, Chicago, addressed
the Lawrence County Medical Society at Lawrenceville Novem-
ber 1 on “Classification and Management of the Nervous

Hypotensive Patient.” At a meeting of the Sangamon

County Medical Society in Springfield November 2 Dr. Ver-
non C. David, Chicago, spoke on "Carcinoma of the Sigmoid

and Rectum.” Dr. Milton H. Kronenberg, Chicago, read a

paper before the Winnebago County Medical Society at Rock-
ford November 3 entitled "The General Practitioner’s Approach

to Industrial Hygiene.” Dr. Benjamin M. Levin, Chicago,

discussed “Surgical Diseases of Childhood” before the Bureau

County Medical Society in Princeton November 21. Dr.

Irving L. Turow, Peoria, was elected president of the Physi-
cians’ Association of the Illinois State Department of Public
Welfare at its meeting in Peoria October 12; Dr. George L.
Perkins, Manteno State Hospital, was chosen vice president
and Dr. Jacob W. Klapman, Chicago State Hospital was

reelected secretary-treasurer. Dr. Roland M. Klemme, St.

Louis, discussed “Surgical Treatment of Parkinson’s Disease”
before the Champaign County Medical Society, November 9

Chicago

Society News. — Among the speakers before the Chicago
Laryngoiogical and Otological Society December 4 were the
o owing. Drs. J. Allan Weiss on “Mucocele of the Frontal

2068

MEDICAL NEWS

Jour. A. M. A.
Dec. 2, 19)9

Sinus”; Robert Henner, “Endaural Complete Mastoidectomy
and Attico-Mastoidectoinv,” and Frank J. Piszkiewicz, “Naso-
pharyngeal Tuberculosis”; all are members of the staff of the
Illinois Eye and Ear Infirmary. A symposium on the treat-

ment of prostatism was presented before the Chicago Urologi-
cal Society November 30 by Drs. Herman L. Kretschmer,
Harry C. Rolnick and Gustav Kolischer.

University News.— Ralph H. Muller, Ph.D., New York,
opened a series of six lecture-conferences and demonstrations
at the University of Chicago November 6 on “Electronics in

Chemistry and Technology.” The Tuberculosis Institute of

Chicago and Cook County through the Theodore B. Sachs
Memorial Fund has made §1,000 available to support a study
on bronchiectasis and pulmonary abscesses at the University of
Illinois College of Medicine. The work is being conducted by
Drs. Felix Basch of the department of pediatrics and Paul H.
Holinger of the department of otolaryngology.

INDIANA

University Aids City Dispensary. — The Indianapolis
Board of Health has approved an arrangement whereby the
Indiana University Medical Center, Indianapolis, will give the
city hospital dispensary §10,000 annually to improve the ser-
vice and the teaching facilities for the school of medicine. Two
full time physicians have been named to the dispensary by the
university, Drs. Joseph Edward Tether Jr. and August M.
Hasewinkle, and two more will be added. With the increased
full time staff it is hoped to make unnecessary the return
visits by patients to the dispensary. The staff also will be
able to treat the patients more rapidly by systematizing appoint-
ments. For its assistance, the medical school will be compen-
sated by improved and increased teaching facilities in the
dispensary for medical students.

Society News. — Dr. James A. Britton, Chicago, discussed
“Medicine in Industry” before the Indianapolis Medical Society
October 24. At a meeting October 31 the speakers were
Drs. Ethelbert R. Wilson on "The Coroner’s Role in Medico-
legal Investigation”; John T. Day, “Causes of Chronic Gonor-
rheal Infection,” and Verne K. Harvey, “The Epidemiology of
Rocky Mountain Spotted Fever.”— — At a meeting of the
Fountain-Warren Counties Medical Society in Kingman in'
October Dr. James O. Ritchey, Indianapolis, discussed goiter.

The Fort Wayne Medical Society was addressed October 3

by Drs. Lester L. Eberhart, Angola, on “Treatment of Hip
Fracture by Internal Fixation”; Max M. Gitlin, Bluffton,
“Undulant Fever,” and Thomas O. Dorrance, Bluffton, “Scurvy

in Infants.” Drs. Matthew Winters, Indianapolis, and

Charles F. Thompson, Indianapolis, discussed “Diarrheas in
Infancy” and “Causes of Delayed Walking” before the Shelby
County Medical Society in Shelbyville October 4.

KANSAS

Postgraduate Course. — A postgraduate course on syphilis
and gonorrhea was started early in November under the
auspices of the state board of health and the committee on
control of venereal disease of the Kansas Medical Society. It
is planned to devote three months to this program so that two
lectures each on syphilis and gonorrhea will be presented at
a central location in each of the twelve councilor districts.
Dr. Arthur D. Gray, Topeka, is the lecturer.

LOUISIANA

Extension Program. — The Graduate School oi Medicine
of Louisiana State University, New Orleans, inaugurated its
1939-1940 extension program with a symposium on pneumonia
before the Franklin Parish Medical Society at Winnsboro
November 15. The speakers were Drs. John R. Schenken on
“Pathology and Pathogenesis of Pneumonia"; Robert H. ^Bay-
lev “Diagnosis and Differential Diagnosis of Pneumonia, and
Joseph O. Weilbaecher Jr., “Treatment of Pneumonia.”

MARYLAND

Society News. — Dr. John M. McDonald. Baltimore, dis-
cussed “Occupational Health Hazards of the Industries in
Marvland” before the Medical and Chirurgiral Faculty of

Marl-land October 24. At a meeting of the Baltimore Lit}

Medical Societv October 20 Drs. John Sheldon, Eastland spoke
on “Use of Vitamin K in Obstructive Jaundice and Nicholson

7 Eastman, “Vitamin K and the Newborn The Maryland

Acndcniv of Medicine and Surgery was addressed October 1/
in Baltimore bv Drs. Maurice Feldman, Baltimore, on Aneu-

rysms of the Abdominal Aorta”; Charles W.' Maxson, “Eariy
Treatment of Fractures,” and J. Bernard Wells, state’s attor-
ney, “The Doctor on the Stand.”

Dr. Corner to Head Department of Embryology.—
Dr. George W. Corner, since 1924 professor and chairman of
the department of anatomy of the University of Rochester
School of Medicine, Rochester, N. Y., has been appointed
director of the department of embryology of the Carnegie
Institution of Washington, effective May 1, 1940, on the retire-
ment of Dr. George L. Streeter, who joined the Carnegie staff
in 1914 and became director of the department of embryology
in 1917. The Carnegie laboratory of embryology is located in
Baltimore. Dr. Corner was born in Baltimore. He graduated
at Johns Hopkins in 1913. Before going to Rochester in 1924
he served as assistant professor at the University of California
Medical School and associate professor at Johns Hopkins. He
has been curator of the Rochester Medical Library since 193S,
was secretary-treasurer of the American Association of Anat-
omists from 1930 to 1938 and since early this year has been
managing editor of the American Journal of Anatomy.

MASSACHUSETTS

Postgraduate Courses. — The Massachusetts Medical
Society, cooperating with the state department of health, the
U. S. Public Health Service and the Federal Children’s Bureau,
opened its fall series of medical postgraduate extension courses
in October. They will continue at weekly intervals until
December.

Harvard Will Not Abandon Dental School. — To cor-
rect a rumor that has been circulating, Harvard University
announces that plans are not under way to abandon its dental
school after seventy years’ existence. According to Dr. Leroy
M. S. Miner, dean of the dental school, a plan is under con-
sideration involving a new program of dental education, but
this does not include the abandonment of the dental school.
The usual first year class was accepted this year with a full
quota of students and this class will be carried through the
entire four years under the present framework, it was stated.
According to a release from the university, there is no truth
in the statement as applied to the present situation, or to the
contemplated new plan, that “All candidates contemplating the
study of dentistry must first enroll and qualify by acquiring
the degree of doctor of medicine, before entering on the study
of dentistry.” It was pointed out that whatever new plan n
adopted it will still be possible for men to qualify for general
dental practice and to satisfy requirements for licensure. Ine
statement that the university is going to discontinue teaching
prosthetic and other forms of restorative dentistry and confine
itself simply to preparing men for surgery and other specialties
is not true. The dental profession may rest assured that an)
modifications in the curriculum now under consideration win.
if put into effect, be expected to elevate the importance o
dentistry as a profession and neither to lower its standards
nor to diminish its effectiveness, it was stated.

MICHIGAN

Symposium on Poliomyelitis. — The Wayne County Medi-
cal Society sponsored a symposium on poliomyelitis at ‘J
Detroit Institute of Art November 13. The speakers uere.

Dr. Edgar E. Martmer, Clinical Af-pects and Diagnosis.

Dr. Franklin H. Top, Epidemiology. . i;,;,.

Dr. Joseph A. Kasper, Virology and Pathology of Anterior Jolioml

Dr. Alfred D. LaFerte, After-Treatment from Orthopedic Standp

Hospital Day. — Woman’s Hospital, Detroit, sponsored a
“hospital day” November 8. The speakers included Drs. Leo K
M. Curtis, Columbus, on “The Iodine Metabolism m **ij
Disease, Emphasizing the Clinical Aspects”; William d j :
Toronto, Canada, “Some Reasons for the Recent Increase
Bronchial Carcinoma”; John L. McKelvey, professor ot on
rics and gynecology, University of Minnesota Medical bci >
Minneapolis, “A Study of the Remote Lesions oi the
nancy Toxemias and Their Clinical Significance”; Artttu •
Parmelec, Chicago, “Practical Points in the Managcmcn
the Newborn.” Dr. Boyd discussed “Cause and Effect w
case” at the dinner meeting in the evening.

Changes in Health Officers.— Dr. Fred O. Tonney, ''ash-
ington, D. C., and formerly with the city health depa --
of Chicago, has been assigned as health commissioner ot -
County during the leave of absence of Dr. Roelot L M
Escanaba. Dr. Clifton F. Hall, Topeka, Kan., director
division of tuberculosis control lor the state board of .
will serve as director of the Mecosta-Osccola hcaUlt < -> _. .
ment during the absence of Dr. Max C. Igloo, Big “

¥°LO.\ ie Jj,

A[, ««es 23

zttJ/U

MEDICAL NEWS

Jour. A. M. .V
Dec. 2 , J9U

G. Boudreau, executive director of the Milbank Memoria!
Fund, New York, will speak on “New Health Frontiers.”
Greetings will be brought to the university and medical school
by various alumni and friends.

OKLAHOMA

Society News. — The Tulsa Cancer Society presented a
symposium on "Malignancies of the Breast” before the Garfield
County Medical Society, Enid, October 26; the speakers were
Drs. Ralph A. McGill, Davy L. Garrett, Carl J. H. Hotz,
Ivo A. Nelson, Arnold D. Piatt and Harry D. Murdock.
All are from Tulsa.

New County Health Officers.— The state health commis-
sioner recently announced appointment of the following new
health officers :

Dr. William E. Seba, Leedey, of Deivey- County.

Dr. Rudolph H. Duewall, Miami, of Ottawa County.

Dr. Leo R. Evans, Pryor, of Mayes County.

Dr. James T. Mclnnis, Muskogee, of Muskogee County.

Dr. O. Hiram Cowart, Bristow, of Creek County.

Dr. Ivan E. Bigler, Ada, of Pontotoc County,

OREGON

Society News. — A program on common eye diseases, spon-
sored by the Oregon Academy of Ophthalmology and Oto-
laryngology, _ was presented before the Multnomah . County
Medical Society, Portland, November 1 by Drs. Edgar Merle
Taylor, Augustus B. Dykman and Frederick A. Kiehle. All
are of Portland. Drs. Joyle O. Dahl, and Morton J. Good-
man, Portland, addressed the county medical society, Portland,
November 15 on “Significance of Serological Reports for
Syphilis” and "Prevention and Management of Reactions and
Complications of Syphilotlierapy” respectively.

PENNSYLVANIA

Postgraduate Meeting at Danville. — The annual fall post-
graduate assembly at Geisinger Hospital, Danville, was held
October 20 with the following program:

Dr. Charles \V. Mayo, Rochester, Minn., Carcinoma of the Right Half
of the Colon.

Dr. Arthur W. Allen, Boston, Diagnostic Clinic.

Dr. Russell L. Cecil, New York, Treatment of Pneumonia.

Dr. Harold L. Foss, Danville, End-Results Following Surgical Treat-
ment of Carcinoma of Rectum.

Dr. Roy E. Nicodemus, Danville, Management of Occiput Posterior
Positions.

Philadelphia

Tuberculosis Conference. — The annual Philadelphia Tuber-
culosis Conference, sponsored by the Philadelphia Health Coun-
cil, the department of public health, the Philadelphia County
Medical Society, the Pennsylvania Tuberculosis Society and
the Philadelphia Association of Tuberculosis Clinics and other
agencies, was held November 14 at the Ritz-Carlton Hotel.
At the morning session Dr. Esmond R. Long led a discus-
sion of “Tuberculosis Testing and X-Ray Examinations”; Mrs.
Sadie Orr Dunbar, Portland, Ore., president of the General
Federation of Women’s Clubs, was among the speakers at the
luncheon, and Dr. Samuel J. Dickey, director of the tuber-
culosis division of the state department of public health,
Harrisburg, spoke on “Tuberculosis from an Administrative
Standpoint."

Pittsburgh

Society News. — Speakers at a meeting of the Allegheny
County Medical Society November 21 were. Drs. James Leroy
Foster on “The Feeding of Infants and Children”; Joseph M.
Cameron, “An Autogenous Serum for the Treatment of Men-
strual Migraine”; Eben W. Fiske, “Functional Treatment of
Fractures and the Combined or Rotating Traumatic Service,”
and George J. ICastlin, “Effects of Certain Drugs on the Hema-
topoietic System.”

SOUTH CAROLINA

County Society to Celebrate Sesquicentennial.— The
Medical Socictv of South Carolina, which embraces the terri-
tory of Charleston County, will celebrate its sesquicentennial
anniversary in Charleston December 5 with a historical exhibit
and a banquet. The exhibit will be at the Gibbes Art Gallery,
showing paintings, books, prints and other- material relating
to the societv’s background and its early members. Mayor
Henrv W. Lockwood of Charleston and Governor Burnet K.
Mavbank will make addresses of welcome at the banquet, which
is to be held at tlie Francis Marion Hotel. Dr. James J.
Ravenel. Charleston, president of the society, will give a his-
torical sketch of the society. Dr. Douglas Jennings, Bennetts-

viHe, president of the South Carolina Medical Association,
will bring greetings, and Dr. William Weston, Columbia, will
present a tablet from the state association. Dr. Nathan B, Van
Etten,_ New York, President-Elect of the American Medical
Association, will speak on “An American Health Program"
and Dr.. Francis R. Packard, Philadelphia, editor of the riiiiiafj
of Medical History, on “Scientific Links Between Charleston
and_ Philadelphia in the Eighteenth Century.” The Medical
Society of South Carolina was founded Dec. 24, 1789, the first
and for many years the only medical organization in the state.
The society from its beginning conducted a public dispensary
and now owns and operates the Roper Hospital. It also started
a collection of books in its early days. In 1822 a medical
college was established under the auspices of the society, which
conducted the school until it assumed its present status and
name, the. Medical College of the State of South Carolina.
Two medical journals, the Carolina Journal and the Southern
Medical and Surgical Journal, were products of the members
of the medical society, according to an announcement. The
society still has the original minutes of its meetings from the
time of its establishment and the new member today signs his
name in the book in which the minutes of the first meeting
were written.

TEXAS

Personal. — Dr. Houston H. Terry, formerly of Fort Worth,
has been appointed director of the health unit of Cooke County.

Dr. John G. Young, Dallas, has been selected as chief of

staff of the Texas Children’s Hospital now under construction,
it is reported.

Society News. — At a meeting of the Dallas County Medi-
cal Society November 9 the speakers were Drs. Charles D.
Bussey on “Meckel’s Diverticulum — a Pathological and Clinical
Study of IS 5 Cases”; James Howard Shane, “Cold Punch Type
Transurethral Prostatic Resection,” and Merritt B. Whitten,
“Midaxillary Leads in the Electrocardiogram in Infarction and
Hypertension.”

WASHINGTON

Children’s Library Is Memorial to Physician.— A
library of children’s books is being placed in the Spokane unit
of the Shriners’ Hospital for Crippled Children as a memorial
to the late Dr. Mitchell Langworthy. A fund was collected
shortly after Dr. Langworthy’s death in 1929 but was saved
until a new hospital was built. From this fund a room has
been furnished as a library and schoolroom and books have
been bought. Dr. Langworthy was chief surgeon of the hos-
pital from 1926 till 1929, when he was shot and killed at the
age of 38 by a patient.

Society News. — Dr. Kenneth K. Sherwood, Seattle,
addressed the Walla Walla Valley Medical Society,

Walla, at its November meeting on “Pathology and Treat-
ment of Chronic Arthritis.” A symposium on cardiac con-

ditions was presented at a meeting of the King County Medics
Society', Seattle, November 6 by Drs. Charles E. Matts,
who discussed “Cardiac Arrhythmias” ; Raymond H. Somers,
“Approach to the Cardiac Problem in Children,” and Austin
G. Friend, “The Heart Patient.”- — yDr. Frank S. Mu‘ e
addressed the Spokane County Medical Society, Spokan .
November 9 on tuberculosis.

Executives’ Conference. — The second annual meeting
the Pacific States Medical Executives’ Conference will he lie
in Seattle December 10. Membership in this conference include
officials of the state medical associations of California, Orego ,
Idaho, Washington and Montana. It is expected that repr-
sentatives mav come this year from Arizona, Nevada an
Utah. Dr. Harry E. Rhodehamcl, Spokane, . is president-
Matters selected for discussion include : professional socicu ?
(the Oregon Plan), medical service plans, malpractice dclcns
problems, prospective health legislation, public relations, P
spective public health and practice laws of the Pacific sta cn
postgraduate medical education.

WISCONSIN

County Secretary for Thirty-Five Years. — Dr. 5 fin® J}-
Glasier, Bloomington, resigned as secretary of the Grant Cot
Medical Society October '31 after serving continuously
thirty-five years. Dr. Glasier was a member of the smew*
of health for fourteen years. In 1932 she received the Co
Award of the State Medical Society of Wisconsin lor me
rious service. .

Society News. — Dr. David R. Lvman, Wallingford, Coo .
was guest speaker at the banquet during the annual tnee -
of the Wisconsin Anti-Tuberculosis Association in .Mil- - *

Volume 113
Number 23

MEDICAL NEWS

2071

October 26, giving a memorial address on the late Dr. Hoyt
E. Dearholt, for many years executive secretary of the asso-
ciation. Dr, Paul A. Teschner, assistant director, Bureau of
Health Education, American Medical Association, Chicago, led
a panel discussion on the problem of finding early diagnosis.

Dr. David A. Cleveland, Milwaukee, addressed the

Marinette-Florence County Medical Society, Menominee, Octo-
ber 18 on “Head and Spinal Injuries.” Drs. Milton Traut-

mann, Madison, and Frances A. Cline, Rhinelander, addressed
the Oneida-Vilas County Medical Society, Rhinelander, Novem-
ber 2 on “Modern Treatment of Venereal Disease” and “Polio-
myelitis” respectively.

GENERAL

Fraternity Convention. — The Phi Delta Epsilon Medical
Fraternity will hold its thirty-sixth annual convention at the
Waldorf-Astoria Hotel, New York, December 29, 30 and New
Year’s Eve. About 600 physicians and medical students from
this country and Canada will attend. Dr. Morris Fishbein,
Editor of The Journal, who is national president, will preside
at the sessions.

Help Wanted in Finding Illegal Practitioner. —The
prosecuting attorney of the Seventeenth Judicial District of
Indiana requests the help of the medical profession in appre-
hending a man wanted on charges of abortion and illegal prac-
tice of medicine. Under the name of Ferdinand Werner, this
man has maintained an office in Richmond, Ind., as a pathol-
ogist and bacteriologist and has practiced medicine without a
license. After many efforts, evidence was obtained recently

to support thirteen charges of illegal practice against him and
later charges of abortion were filed. The abortion charge was
set for trial in the Wayne Circuit Court November 13, but
Werner did not appear, forfeiting a $2,000 bond. No date
has been set for trial on the other charges, but authorities
believe Werner will forfeit a $1,300 bond on these charges.
Routine check of the man’s fingerprints revealed that he had
been convicted of a crime involving moral turpitude in Cleve-
land in 1923, sentenced to the state penitentiary, from which
he escaped in February 1924. Shortly afterward he was
employed in the department of pathology and bacteriology at
Indiana State University School of Medicine for less than
three months and later at the State Hospital for the Insane
at Richmond. He was discharged from the latter position
when the superintendent learned Werner was not his real name
and when his services were found unsatisfactory. He then
opened his own laboratory in Richmond. When Werner was
convicted in Cleveland he was using the name Sternisa and
further inquiry brought out the fact that he had come to the
United States under the name of Hribar. The Indiana authori-
ties believe that because of Werner’s medical work he will
undertake such work again and will have contact with the
medical profession. If he is identified, the person making
identification is asked to telegraph the information collect tc
the prosecuting attorney’s office at Richmond. The description
given by police is as follows: 42 years old; 5 feet lljd inches
tall; weight 197 pounds; black hair, brown eyes and fair
complexion.

Fellowships for Study of Crippled Child. — For the third
year the Nemours Foundation will award five or six one-year
fellowships for laboratory or clinical studies on the crippled
child, to begin on or after July 1, 1940. The term “crippled
child” is used in its broadest sense, according to the announce-
ment. The amount of each individual award will be from
$1,000 to $2,400 and will be determined on the basis of the

previous training of the applicant and the type of research
project selected. Application blanks may be obtained from the
secretary of the research committee, Dr. Alfred R. Shands Jr.,
803 Delaware Trust Building, Wilmington, Del.

Southern Surgical Meeting. — The fifty-second annual ses-
sion of the Southern Surgical Association will be held in
Augusta December 5-7 with headquarters at the Forest Hills
Hotel. Among the speakers will be :

Dr. Whitman Walters, Rochester, Alinn., Operative and Postoperative
Infections with Special Reference to Air-Borne Bacterial Contamina-
tions.

Dr. Barney Brooks, Nashville, Tenn., Present Status of the "Radical
Operation” for Carcinoma of the Breast.

Dr. Carrington Williams, Richmond, Va., Hysterical Edema of the
Hand and Forearm.

Dr. Warfield M. Firor, Baltimore, Treatment of Addison’s Disease by
Implantation of Synthetic Hormone. _ .

Dr. Thomas D. Sparrow, Charlotte, N. C., Leukoplakic Vulvitis.

At the annual dinner Dr. Hubert A. Royster, Raleigh, N. C.,
will be toastmaster and Dr. Albert O. Singleton, Galveston,
Texas, will deliver the presidential address on “The Surgeon
in the Romantic Story of Texas.”

Grants for Research in Endocrinology. — Requests to the
National Research Council committee for research in endo-
crinology for aid during the fiscal period from Sept. 1, 1940,
to June 30, 1941, will be received until Feb. 29, 1940. In
addition to a statement of the problem and research plan or
program, the committee desires information regarding the pro-
posed method of attack, the institutional support of the inves-
tigation and the uses to be made of the sum requested. No
part of any grant may be used for administrative expenses.
Applications for aid of endocrine research on problems of sex
in the narrower sense cannot be given favorable consideration,
but the committee will consider support of studies on the effects
of hormones on nonsexual functions, for instance, on metabo-
lism. Application blanks may be obtained by addressing the
division of medical sciences, National Research Council, 2101
Constitution Avenue, Washington, D. C.

CANADA

Personal- — Dr. Allan C. Rankin, dean of the University of
Alberta Faculty of Medicine, Edmonton, has joined the mili-
tary forces of Canada and Dr. John James Ower has been
made acting dean for the present session.

Society News. — Prof. George Grey Turner, London,
England,, addressed the Academy of Medicine of Toronto,
October 12, on “Difficulty in Swallowing.” A symposium on
the problem’s related to automobile driving was presented before
a joint meeting of the section on preventive medicine and
hygiene and the section of neurology and psychiatry by Drs.
Kenneth G. Gray on the medicolegal and financial aspects;
Robert G. Armour, the neurologic problems, and L. Joslyn

Rogers, M.A., the problem of alcohol. Dr. Howard C.

Taylor Jr., Philadelphia, addressed the Academy of Medicine
of Toronto November 7 on “Relationship of the Ovarian Hor-
mone to Reproductive Tract Tumors.”

LATIN AMERICA

Poliomyelitis in Brazil. — A cable to the New York Times
October 20 reported that 115 cases of poliomyelitis with six
deaths had occurred in Rio de Janeiro. It was announced that
the government was taking measures to prevent spread of the
disease.

Society News. — Dr. Francisco Ferreira has been elected
president of the Society of Ophthalmology and Otolaryngology
of Bahia, Brazil, and Dr. Adroaldo de Alencar secretary.
Correspondence should be addressed to the president, Pitan-
gueiras 15, Brotas, San Salvador, Bahia, Brazil.

Leprosarium in Cuba. — The cornerstone was laid recently
for a new hospital for lepers near Alto Songo, Orienta, Cuba.
It is expected that the new institution will be completed by
September 1940. It will accommodate 400 patients and will
be designed to permit enlargement to care for 400 more. The
building will cost about $380,000.

FOREIGN

Nobel Prizes Awarded.— The 1939 Nobel Prize in chem-
istry was recently awarded jointly to Prof. Adolph Butenandt
of the University of Berlin and Prof. Leopold Ruzicka, Zurich,
Switzerland, for their work on hormones. The 1938 chemistry
prize was awarded at the same time to Prof. Richard Kuhn
of the Kaiser Wilhelm Institute, Berlin, for his work on caro-
tinoids and vitamins. The New York Times reported Novem-
ber II that Professor Butenandt and Professor Kuhn had
declined the prizes because of the ban placed on the Nobel
rrizes bv the Aazi government.

2072

FOREIGN LETTERS

Jour. A. M. A.
Dec. 2, 1W

Foreign Letters

LONDON

(From Our Regular Correspondent)

Nov. 1, 1939.

The Teeth of the Nation Are Bad

The excellent physique of our people and the great improve-
ment in health in recent years, as shown by a lower death rate,
infant mortality, maternal mortality and tuberculosis mortality
are frequent themes. The good physique of the many thousands
of young men called up when this country had recently to
adopt conscription is the latest confirmation. But there is one
profoundly unsatisfactory condition. Addressing the Public
Health Services Congress last year the minister of health said
“The teeth of this country are bad; you might almost say they
are rotten.” In his presidental address to the British Dental
Association Mr. T. Walkinshaw laid the blame on our insuf-
ficient public dental-health service. We have a school dental
service but prevention should begin with the pregnant woman
and young children and there is little or no provision for this.
Hence the average child enters school with his teeth in an
appalling condition. Further, no provision is made for treat-
ment during adolescence. It is curious that in all the discussion
of this pressing problem, including that by a leading medical
journal, no attempt seems to be made to get to the root of the
matter. Why is dental caries so prevalent in civilized countries,
while it is absent in people living under primitive conditions?
Recent studies in diet appear to furnish an answer. About the
middle of the nineteenth century the stone grinders for wheat
gave place to steel rollers which remove the whole of the germ
and almost all the bran, giving a flour deficient in protein, fat,
vitamins A and B and minerals (calcium, phosphorus and iron).
In an important book recently published, “The Englishman's
■Food: A History of Five Centuries of English Diet,” the
authors (Prof. J. C. Drummond and A. Wilbraham) attribute
the appalling prevalence of dental caries to the poorness of white
bread in minerals, the reduction in the consumption of milk
(with the use of the cheaper forms of condensed milk) and the
decline of breast feeding. “Time and again examples can be
found of communities with excellent teeth so long as they lived
on natural and unrefined foods, but soon after the introduction
of highly milled white flour caries appeared.”

The Complications of Intranasal Surgery

In a discussion on the complications of intranasal surgery
at the Section of Laryngology of the Royal Society of Medicine,
Mr. E. D. D. Davis said that a good view of the interior of
the nose was essential for operations and that anything in the
nature of a blind operation was undesirable. He called atten-
tion to four kinds of injuries that had happened in spite of
careful technic: perforations and injuries to the roof of the
nose or to the cribriform plate, injuries to the orbit and its
contents, injury to the optic nerve and injury to the nasolacrimal
duct.

Six cases of perforation of the roof of the nose had been
recorded and he had seen seven in consultation. They occurred
during removal of nasal polypi with forceps or during operation
with forceps on the ethmoidal cells for sinus suppuration. The
perforation in the removal of polypi was always in the region
of the posterior ethmoidal cells, when the forceps was directed
upward and backward. It was avoided by directing the point
parallel to the roof of the nose. The operator might be unaware
that the roof of the nose had been perforated, but escape of
cerebrospinal fluid or profuse hemorrhage would be a warning.
The patient suffered from shock and after delayed recovery
from the anesthetic complained of intolerable headache and was
restless and drowsy. Coma rapidly supervened and death
occurred within three days, before meningitis had time to develop.

The necropsy showed hemorrhage from the posterior ethmoidal
artery into the anterior fossa of the skull. The treatment was
the external ethmoidal operation and covering the opening in
the dura by a fascial graft. The perforation was inaccessible
through the nose.

Hemorrhage into the orbit following perforation of the thin
os planum of the ethmoid was the commonest injury. It fre-
quently happened during the ethmoidal operation, particularly
on the anterior cells and also in the intranasal frontal sinus
operation. The “black eye” was typical and the ecchymosis was
maximal at the inner canthus, but if the hemorrhage was con-
siderable the eyeball might protrude. This might be increased
by emphysema. All that was necessary in most cases was to
keep the patient at rest in the sitting posture, with the eye
covered by a pad and bandage. The patient should be forbidden
to blow his nose for a few days.

Injury to the optic nerve in ethmoidal operations produced
immediate blindness. Davis had been able to collect reports
of five cases and had seen two of the patients. One injury ivas
caused by evulsion of the middle turbinal and part of the ethmoid
in an operation for polypi. Optic atrophy followed, with per-
manent loss of sight. Such cases showed the need for care in
the use of the forceps for evulsion. It was safer to use cutting
or punch forceps kept in a plane parallel to the outer wall oi
the nose.

Injury to the nasolacrimal duct had been seen on two occa-
sions following an intranasal antral operation. The window
made in the nasal wall of the antrum extended into the middle
meatus above the attachment of the inferior turbinal, severing
the duct. On recovering from the operation the patients com-
plained of blood leaking into the eye. Epiphora and lacrimal
obstruction followed. After injection of the lacrimal sac with
iodized oil, x-ray examination showed stricture of the duct m
the middle meatus of the nose. The epiphora was relieved by
a dacrocystostomy done above the stricture.

PARIS

(From Our Regular Correspondent)

Oct. 25, 1939.

Plasma Transfusion

P. Brodin and F. Saint Girons, before the Societe medicak
des Hopitaux de Paris, stressed the advantage of using not
the whole blood but only the plasma in severe hemorrhages.
According to their view the danger of hemorrhage lies less m
the loss of the erythrocytes than in the loss of the volume ot
blood. When this is reduced to one fourth, death is inevitable.
In war times it may not be possible to use only living bio
and recourse to stored blood may be necessary. This invoke*
dangers. R. Benda, at the same meeting, reported the history
of a woman aged 52 who had undergone five transfusions
fresh blood within six months in large doses and who died six
hours after slow injection of 100 cc. of stored blood of group
taken sixteen days previously. This indicates that stored bio®
may become toxic and cause fatal hemolysis after a certain
time, varying according to the particular case. To avoid
accidents, the origin of which is probably determined by the t;H
of the blood, only the plasma is kept, after centrifugation
separation from the red corpuscles. The plasma can be stor
for weeks and months. Unlike the serum, the plasma is 11
toxic, even if applied to different blood groups. Prof es.nr
Pittaluga, of Madrid, before the Societe de chirurgie, c 1
tiated on the lessons learned regarding blood transfusion durWt,
the three years of civil war in Spain. Whether intended
immediate use or for conservation, the blood was subjcetec n
the customary tests including the test for malaria. The
of universal donors never caused accidents. It is
he said, to store the blood at a constant temperature of '

which required special equipment. Under these condition? >
usefulness could be extended to two weeks. Reheated at

Vo MM! E 113
Number 23

FOREIGN LETTERS

2073

and slowly injected, shocks rarely resulted from the transfusion,
Neumann, of Brussels, added confirmation to these observations
from his extensive experience.

Effect of Radium on the Tubercle Bacillus
In otic of the last sessions of the Academie des sciences, P.
Bonet-Maury and H. R. Olivier discussed the effects of the
use of radium on the behavior of tubercle bacilli. Their method
consists in dissolving the total radiation of the radon in a
microbial suspension. With powerful doses the respiration of
the irradiated bacillus continues, though reduced to about one
sixth, for several days. The bacilli are in a state of “post-
poned death,” still alive but no longer virulent. Owing to the
destruction of bacillary virulence while keeping the bacilli
alive, the authors were able to bring about the immunization
of guinea pigs. In man they obtained encouraging therapeutic
results with safety. This “radium vaccine” engenders hopes
of interesting developments in the immunization against tuber-
culosis and in its treatment.

BUCHAREST

( From Our Regular Correspondent)

Oct. 14, 1939.

The Closing of Some Dental Laboratories
The minister of public health has ordered the closing of
123 dental laboratories which were conducted by dental tech-
nicians in violation of the law. In 1923 dental technicians
obtained permission to practice. However, the law issued by
former Minister Saveanu deprived some of them of practice
on the ground that they obtained their permission illegally.
The dental technicians attacked the law on the ground that
it violated their rights, but the supreme court upheld the law.
Thereupon a long controversy arose between dental surgeons
and dental technicians. The litigation came to an end by the
issue of the Moldovan law in 1930. This law favored some
dental technicians in that those who in 1930 had been in prac-
tice for fifteen years, could take a one year theoretical and
practical course and then be examined for license to practice.
Those who had practiced fifteen years and already were 42 or
more years of age were absolved from attending the course
and needed only to pass the examination. As 123 dental tech-
nicians did not fulfil this requirement, the minister of health
ordered their laboratories to be closed.

Committees Appointed by the Ministry of Health
The government some time ago empowered the Ministry of
Health to appoint technical committees to study public health
problems and to make proposals regarding most urgent mat-
ters needing attention. In all, nineteen committees have been
appointed to study typhus fever, malaria, eugenics, maternity
and child welfare, insurance against tuberculosis, cancer, vene-
real diseases, rheumatism, malnutrition and deficiency diseases,
and dentistry with especial attention to the function of dental
technicians. Committees are also being appointed to stimulate
the campaign against alcoholism and trachoma, to promote the
standardization of biologic products and to investigate means
of fostering international relations in health matters.

Professor Daniel Honored

The Faculty of Medicine of the University of Bordeaux
celebrated the conferring on Constantin Daniel, professor of
obstetrics and gynecology at the Bucarest University, of the
degree of doctor honoris causa. The diploma and the insignia
were handed to him in the presence of the deans of all the
faculties of Bordeaux University and notables of the city of
Bordeaux. Prof. Gabriel Boussagol, rector of the Bordeaux
Academy, and Prof, Josef Guyot eulogized the Rumanian
savant. Thereupon Prof. Constantin Daniel read an elaborate
paper on the influence of French medical sciences on the
Rumanian universities.

BERLIN

(From Our Regular Correspondent)

Nov. 1, 1939.

Homeopathy and Lay Practitioners

The Deutscher Centralverein homoopathischer Aerzte recently
commemorated its hundredth session. Among the speakers was
Prof. Paul Martini, clinician in Bonn, who is known for his
thorough critical reexaminations of the therapeutic value of
substances designated as medicaments. Retests were necessary,
he said, because homeopathy had been vindicated of late years
in a number of cases at the hands of the national socialist party,
converting some physicians from an attitude of rejection to one
of uncritical assent. Plans are being made by the public health
department of the reich to conduct an extensive examination
of all homeopathic curative procedures.

Recently a meeting also took place of the movement for
German public health in Stuttgart. This body represents the
so-called lay practitioners (heilpraktiker). Their status in the
reich was recently regulated by law (The Journal, June 10,
p. 2449). The presiding officer made several peculiar state-
ments; e. g., that the union between medicine taught in schools
and lay medical practice was now completed, the former in
future taking over the experiences of lay practitioners ; that
lay practitioners rejected occult methods as employed in healing
by prayer and in remote treatment in accordance- with specimens
of writing, but not magnetic therapy. Besides they adhered, he
said, to ocular diagnosis in spite of medical objections. The
5,000 legalized lay practitioners in Germany are determined to
be distinguished from the quacks.

The law regarding lay practitioners also affects all persons
who treat speech defects with or without psychic methods, those
who professionally occupy themselves with psychotherapy and
the psychology of healing, with curative gymnastics and with
respiratory cures; likewise professional teachers of vision
(seh-lehrer), proprietors of schools of vision (seh-schulen)
and those who treat fractures (exclusive of purely orthopedic
measures) and those who profess to cure leg and foot troubles
(exclusive of pedicures).

Significant for the social alinement of lay practitioners, who
come from the lower strata of society, was the announcement of
one of the highest medical functionaries of national socialism,
Dr. Blome, at last year’s congress for internal medicine that it
was planned to admit lay practitioners to the sick funds.
Whether this was feasible was another question, since lay
practitioners might not desire it on account of the low com-
pensations granted by the sick funds. Moreover, he and the
medical leadership of the party in power would welcome their
admission. In this way, he said, it would not always be the
sick fund physician on whose back professional questions are
fought out; for, in addition to his low fees, many patients hold
him responsible for alleged inferior services provided by the
sick funds and for many other things. This frank avowal is
quite significant for the attitude of those insured toward the
sick fund system in Germany. Dr. Blome is the representative
of the state medical leader for medical continuation training.
In the meantime, lay practitioners have signified their willing-
ness to participate in sick fund insurance with the declaration,
however, that they did not surrender their conviction that their
services would before long receive a more just compensation.
This implies that they expect better fees than the physicians.
Privately managed sick funds, which compensate on a higher
scale than those of the state, have already admitted lay prac-
titioners. In the Rudolf Hess Hospital in Dresden an
“academy for new German medicine” is to be established. Hess,
who is close to Hitler, is the great promoter of all unscientific
paramedical movements.

2074

MARRIAGES

Jour. A. M. A.
Dec. 2. 1939

AUSTRALIA

(From Our Regular Correspondent)

Oct. 25, 1939.

Community Plan for Medical Services
Contract practice as a private enterprise has now been com-
menced in Australia. Medical services at Canberra (the fed-
eral capital city of Australia) have been reorganized by the
introduction of a community plan on a voluntary basis. Five
of the doctors who reside in the capital are conducting the
scheme, which is open to all residents earning up to 1520 a
year and their dependents. Contributions are planned on a
sliding scale, with a maximum of £3-3-0 a year for persons
with an annual income of £520 and £6-6-0 for these people
with their dependents. Liberal benefits are to include unlim-
ited medical benefits during illness, a complete medical over-
haul every year, a full service for obstetric cases, assistance
when necessary at operations, and medical attendance at doc-
tors’ offices or in the homes of contributors between the hours
of 8 a. m. and 8 p. m. on week days and until 1 p. m. on
Saturdays. Disabilities due to misconduct and injuries or
sickness already provided for by insurance are not covered
by the scheme. Additional fees may be charged for traveling
beyond a 4 mile limit and for urgent attention outside specified
hours. The British Medical Ascociation in Australia is fol-
lowing the experiment closely. The city already has a
government-controlled compulsory hospital benefit scheme.

War Time Measures in Australia
The spread of war in Europe and the potential danger of
war in this country have been responsible for greatly increased
activity in air raid precaution work and in other schemes for
the protection of civilians in times of emergency. Government
and voluntary organizations have instituted instruction classes
both for officials and for civilians, and plans for the evacua-
tion of each of the larger cities are well in hand. Extensive
plans have also been made for the organization of an emer-
gency blood transfusion service. These include provision for
the storage of blood if necessary and the grouping, testing and
listing of a large number of donors from both the military
and the civilian ranks. Special attention is being given to the
feeding of the military forces in Queensland. An increased
supply of salad vegetables, fruit, eggs and milk, the substitu-
tion of whole meal for white bread, and milk and fruit bars
in the canteens are new departures at present under considera-
tion. Consideration has also been given to the emergency
organization of the medical profession with due regard to both
military and civil needs. Special lectures have been arranged
for numbers of the profession on war time medicine and
surgery.

Birth Rate Recovery by Australia
While many countries at present are faced with the national
problem inherent in a net reproduction rate of less than 1,
recent statistics reveal that births in Queensland are well above
the level required to fill the places of the present generation.
Figures for the whole of Australia show that there has been
a recovery practically to the displacement level. A separate
calculation for Queensland was first made on the 1938 birth
registrations and gave the result of 1.09. A calculation for
South Australia gave the low figure of 0.85. The latter may
be associated with the fact that 54 per cent of the population
of that state lives in the metropolitan area. The latest figure
for Australia (1937) is 0.99. Comparisons with the net repro-
duction rates of other countries give Japan (1930) 1.57, Canada
(1931) 1.32, Italy (1937) 1.13, the Netherlands (1937) 1.12,
Queensland (193S) 1.09, New Zealand (1938) 1.02, Australia
(1937) 0.99, the United States (1935 white population) 0.96,
Denmark (1937) 0.95, Germany (1936) 0.93, France (1937)
0.S7, Great Britain (1937) 0.80, Sweden (1936) 0.76.

Nutrition in New Zealand

New Zealand has the reputation of being a country that
produces a healthy' and virile people. Recent inquiries have
tended to throw some doubt on this generalization. The “pro-
tective foods are still fairly' expensive and -as a consequence
New Zealanders tend to consume meat as their main first class
protein and to bulk their diet with white bread, cakes, cane
sugar and tea. New Zealanders are the largest meat eaters
in the world (about 250 pounds a head annually). This state-
ment is amply borne out by a survey of food consumption for
the last few y'ears. Total food consumption divided by total
population shows that each person consumes daily from 6 to
7 ounces of sugar, approximately 1 pound of red meat, a half
pound of white flour, two thirds of a pint "of milk, two thirds
of an egg, one-third ounce of cheese and from 2 to 3 ounces
of butter (not margarine). Most of the milk is taken by
adults in tea and the egg in cakes.

The available evidence suggests that about 97 per cent, of
the school children show signs of dental caries and that more
than 50 per cent of the adults have false teeth. It is also
reported that one in every twenty persons in the country is
in the hospital every year, chiefly for such complaints as
appendicitis, tonsils and goiter. The adult population also
suffers to no inconsiderable degree from digestive complaints,
rheumatism and neuritis.

It is interesting to note at what age the breakdown in the
health of the children begins to occur. Up to the age of 8
or 10 months most of the children seem to be in good condi-
tion. After that age it is customary to cut down the amount
of milk, cod liver oil and orange juice, with the result that the
calories are obtained mainly from refined starches and the resis-
tance of the child tends to decrease. By the time the children
are going to school, dental decay lias become common. But
for the past two years an additional half pint of milk has
been supplied daily in the schools, and this is having a bene-
ficial effect.

Another factor which has an influence on the nutrition of
New Zealand is the quantity of cakes and pastry that are con-
sumed. No morning, afternoon or evening gathering is com-
plete without an array of these delicacies, and with the great
majority of the population (largely- female) they constitute the
mainstay of the day. The tea drinking habits are the surprise
of every visitor; strong tea, often plentifully' sugared, accom-
panies every' meal, even dinner.

Summing up the nutritional problems of New Zealand, it is
suggested that (1) calories are adequate, (2) first class protein
is adequate but ill chosen, and (3) vitamins Bi and D are sub-
optimal, as are iron, calcium and iodine. This situation is
brought about by a combination of poor knowledge of nutri-
tional science and of the relatively high price of many of the
protective foodstuffs. Home science has always been a feature
of the University' of Otago, and extension activities are w
operation. Nutrition education has been furthered by the
Women’s Food Value League, on the executive committee o
which are British Medical Association members. There are
scattered foci of reform such as the Auckland Boy’s Grammar
School the results of which have been stimulating.

Marriages

Elsie G. Westlev, San Antonio, Texas, to Capt. E. E.
Adams of Fort Sam Houston, September 2.

Oscar Milton Marchman Jr., Dallas, Texas, to Miss Mary
Alice Yates of Longview, September 7.

Warren D. Hansen to Miss May Winthers, both of Visncr,
Neb., August 25. .

Woodrow W. Schmela to Miss Dora Larson, both of Omain,
September 3.

Volume 113
Number 23

DEATHS

2075

Deaths

Martha WoU stein, Grand Rapids, Mich.; Woman’s Medical
College of the New York Infirmary for Women and Children,
New York, 1889; at one time demonstrator in histology and
demonstrator in pathology at her alma mater; formerly assis-
tant clinical professor of diseases of children and pathology,
Columbia University College of Physicians and Surgeons, New
York; member of the American Pediatric Society; associate of
the Rockefeller Institute for Medical Research from 1906 to
1921 ; for many years on the staff of the Babies Hospital, New
York; aged 70; died, September 30, in the Mount Sinai Hos-
pital, New York.

Allan Joseph Hruby © Chicago ; University of Illinois
College of Medicine, Chicago, 1913; fellow of the American
College of Physicians; school health officer, 1916-1917; dis-
pensary physician to the Chicago Municipal Tuberculosis Sani-
tarium, 1917-1918, superintendent, 1918-1923, and secretary and
member of the board of directors since 1931 ; aged 49; at various
times on the staffs of Cook County Hospital, St. Anthony’s
Hospital and the Washington Boulevard Hospital, where he
died, November 18, of lobar pneumonia.

Herbert Preston Leopold, Philadelphia; Hahnemann
Medical College and Hospital of Philadelphia, 1896; clinical
professor of surgery at his alma mater; fellow of the American
College of Surgeons ; surgeon to the Homeopathic State Hos-
pital, Allentown; consulting surgeon to the Coatesville (Pa.)
Hospital, West Jersey Homeopathic Hospital, Camden, and the
Homeopathic Hospital, Wilmington, Del. ; aged 65 ; died, Sep-
tember 21, at his summer home in Tannersville, Pa., of acute
coronary thrombosis.

Milford Levy ® Baltimore; College of Physicians and
Surgeons, Baltimore, 1915 ; member of the American Psychiatric
Association; assistant professor of neurology at the University
of Maryland School of Medicine and College of Physicians and
Surgeons; served during the World War; on the staffs of the
Mercy, University, South Baltimore General, Sinai, Bon
Secours and St. Agnes’ hospitals; aged 47; died, October 10,
in Pikesville, Md., of rheumatic cardiovascular disease and
aortic stenosis.

Michael Matthew Jordan ® Worcester, Mass.; University
of Minnesota College of Homeopathic Medicine and Surgery,
Minneapolis, 1905; member of the American Psychiatric
Association and the New England Society of Psychiatry;
served during the World War; aged 55; on the staffs of
St. Vincent’s Hospital and the City Hospital, where he died,
September 30, of coronary thrombosis.

Harry Roland Lickle © Baltimore; Maryland Medical
College, Baltimore, 1909; assistant in medicine from 1920 to
1923 and instructor in medicine 1923-1924, University of Mary-
land School of Medicine ; on the visiting staffs of the University,
Mercy, St. Agnes’, Maryland General, Women’s and the West
Baltimore General hospitals; aged 50; died, September 13, of
cerebral hemorrhage.

Oran Idnire Cutler © Loma Linda, Calif.; College of
Medical Evangelists, Loma Linda, 1924; professor of pathology
and bacteriology at his alma mater; member of the American
Society of Clinical Pathologists ; on the staffs of the Los
Angeles General Hospital, Riverside County Hospital, Arlington,
and San Bernardino (Calif.) County Hospital; aged 39; died,
September 15.

Frank M. Register, Kinston, N. C. ; Kentucky School of
Medicine, Louisville, 1S93; member of the Medical Society of
the State of North Carolina ; for many years connected with the
state board of health; formerly health officer of Wayne County;
medical superintendent of the Caswell Training School; aged
69; died, September 28, of intestinal obstruction and chronic
myocarditis.

Edward McCarty Armstrong © Houston, Texas ; Uni-
versity of Virginia Department of Medicine, Charlottesville,
1892; fellow of the American College of Surgeons; member of
the visiting staff of St. Joseph's Infirmary and Methodist Hos-
pital ; surgeon to the Memorial Hospital ; consulting surgeon to
the Jefferson Davis Hospital; aged 6S; died, October 7.

Charles Tilden Howard, Hingham, Mass. ; Boston Uni-
versity School of Medicine, 1898; professor emeritus of surgery
at his alma mater ; member of the Massachusetts Medical
Society ; fellow of the American College of Surgeons ; con-
sulting surgeon to the Massachusetts Memorial Hospitals ; aged
b / ; died, September 6.

Winfield Harrison Ammarell ® Birdsboro, Pa. ; Univer-
sity of Pennsylvania School of Medicine,. Philadelphia, 1909;
past president of the Berks County Medical Society; at one
time county coroner ; president of the board of health and mem-
ber of the school board; aged 56; died, September 1, of Hodg-
kin’s disease.

Albert Ridgeley, Washington, D. C. ; Howard University
College of Medicine, Washington, 1900; associate professor
emeritus of anatomy at his alma mater; for many years health
inspector in the public schools; served during the World War;
aged 63; died in September at the Veterans Administration
Facility.

Albert Edwin Leach, Mount Morris, N. Y. ; New York
Homeopathic Medical College and Hospital, New York, 1891 ;
member of the Medical Society of the State of New York;
health officer; aged 73; died, September 8, in the Wyoming
County Community Hospital, Warsaw, of coronary thrombosis.

Fred Allen Fuller, Jacksonville, Texas ; University of the
South Medical Department, Sewanee, Tenn., 1908; member of
the State Medical Association of Texas; aged 55; on the
staff of the Nan Travis Memorial Hospital, where he died,
October 7, of chronic hypertension and nephritis.

George Holt Barksdale © Charleston, W. Va. ; North-
western University Medical School, Chicago, 1908; served
during the World War; fellow of the American College of
Physicians ; on the staffs of the Charleston General and
St. Francis hospitals; aged 57; died, October 8.

Lorenzo W. Swope ® Pittsburgh; Western Pennsylvania
Medical College, Pittsburgh, 1896; fellow of the American
College of Surgeons; for many years on the staff of the
Western Pennsylvania Hospital; aged 76; died, September 14,
of cerebral hemorrhage and arteriosclerosis.

Winfred Wylie © Phoenix, Ariz. ; Rush Medical College,
Chicago, 1877; Long Island College Hospital, Brooklyn, 1878;
fellow of the American College of Surgeons ; past president of
the Arizona State Medical Association; also a lawyer; aged
84; died, September 23, in Glendale, Calif.

Louis Augustus Fuerstenau, Milwaukee; Northwestern
University Medical School, Chicago, 1909; president of the
Milwaukee Society of Clinical Surgery; aged 58; on the staff
of St. Mary’s Hospital, where he died, September 21, of benign
tumor of the pyloric end of the stomach.

George Washington Cassady, Chicago; Jenner Medical
College, Chicago, 1900; College of Physicians and Surgeons of
Chicago, School of Medicine of the University of Illinois, 1908;
aged 72; on the staff of St. Elizabeth's Hospital, where he died,
October 10, of pernicious anemia.

Lot Richard Henry, North Middletown, Ky.; Kentucky
University Medical Department, 1902 ; member of the Kentucky
State Medical Association; formerly mayor and member of the
school board; aged 65; died, October 9, of coronary occlusion,
mitral stenosis and hypertension.

William Stephen Beck, Indianapolis; Medical College of
Indiana, Indianapolis, 18S8; member of the Indiana State Medi-
cal Association; formerly a lawyer; at one time county coroner
and secretary of the county board of health; aged 76; died,
October 6, of heart disease.

Mary Angela Spink, Indianapolis; Medical College of
Indiana, Indianapolis, 1887; member of the Indiana State Medi-
cal Association ; president and medical director of the Dr. W. B.
Fletcher’s Sanatorium; aged 75; died, September 3, in Lisbon,
N. H., of heart disease.

Robert Swift Patten, Danville, Pa.; Jefferson Medical
College of Philadelphia, 1901 ; member of the Medical Society
of the State of Pennsylvania; for many years physician for the
public schools; aged 65; was found dead in bed, September 26,
of coronary thrombosis.

John Macaulay Gunning, Spokane, Wash.; College of
Physicians and Surgeons of Chicago, School of Medicine of the
University of Illinois, 1902; aged 72; died, October 7, at the
Deaconess Hospital of chronic myocarditis, mitral regurgitation
and cholangeitis.

Sarah Louise Weintraub, Philadelphia; Woman’s Medical
College of Pennsylvania, Philadelphia, 1883; member of the
Medical Society of the State of Pennsylvania; formerly a
medical missionary in Syria; aged 78; died, September 11 in
Avalon, N. J. .’

Joseph Lawrence Morrissey, Elmhurst, N. Y.; Long
™ College Hospital, Brooklyn, 1916; served during the
World War; aged 48; on the staff of the Flushing (N. Y.)
Hospital, where he died, September 12, of acute pancreatitis.

2076

DEATHS

Jour. A. M. X

Drc. 2, im

Lawson Walter McKenzie, Washington, D. C.; Medical
College of Indiana, Indianapolis, 1904; formerly physician in
the insurance sendee of the Veterans Administration ; aged 61;
died, September 20, of coronary occlusion and ateriosclerosis.

George R. Herkimer, Dowagiac, Mich. ; Hahnemann
Medical College and Hospital, Chicago, 1890; served during
the World War; at various times member of the school board,
and mayor; aged 73; died, October 1, of cerebral embolus.

Irving C. Wood, Omaha; Jefferson Medical College of
Philadelphia, 1880; at one time mayor of Logan, Iowa; aged
82; died, September 7, in the Nebraska Methodist Episcopal
Hospital and Deaconess Home of myasthenia gravis.

John Jacob Dossier, Millard, Neb.; University of Nebraska
College of Medicine, Omaha, 1907 ; for many years a member
of the school board; aged 62; died, September 27, in the
Immanuel Hospital, Omaha, of myasthenia gravis.

Loring Watson Turrell, Smithtown Branch, N. Y. ; Yale
University School of Medicine, New Haven, Conn., 1936; mem-
ber of the Medical Society of the State of New York ; aged 30 ;
died, September 8, of idiopathic pneumothorax.

William Dana Pursel © Phillipsburg, N. J. ; University of
Pennsylvania Department of Medicine, Philadelphia, 190 1 ;
aged 64; died, September 18, in the Easton (Pa.) Hospital of
an overdose of morphine, self administered.

John Franklin Calbreath, Portland, Ore.; University of
California Medical Department, San Francisco, 1875 ; member
of the Oregon State Medical Society ; aged 85 ; died, October 4,
of hemorrhage from an esophageal varix.

Kenneth Israel Hoffman © New York; Cornell Univer-
sity Medical College, New York, 1921 ; on the staff of the New
York Polyclinic Medical School and Hospital ; aged 42 ; died,
October 10, in a local hospital.

George Yerkes Woodland, Philadelphia; Medico-Chirur-
gical College of Philadelphia, 1895 ; for many years a medical
inspector in the public schools; served during the World War;
aged 72 ; died, September 10.

William S. Higbee, Philadelphia; Jefferson Medical Col-
lege of Philadelphia, 1883; member of the Medical Society of
the State of Pennsylvania ; aged 77 ; died, September 12, in
the Methodist Hospital.

Owa O. Hausch, Painesville, Ohio ; Cleveland Medical
College, 1891 ; member of the Ohio State Medical Association ;
for many years county coroner; aged 74; died, October 14, of
coronary thrombosis.

Clifford Mitchell, Chicago; Chicago Homeopathic Medical
College, 1878; formerly professor of renal diseases and clinical
urology at the Hahnemann Medical College and Hospital ; aged
85; died, October 19.

Earl Edgar Miller, Culbertson, Neb. ; University of
Nebraska College of Medicine, Omaha, 1924 ; aged 40 ; died,
September 21, in St. Catherine’s Hospital, McCook, of increased
intracranial pressure.

Benjamin Garleaf Benson, Webster Groves, Mo. ; St. Louis
College of Physicians and Surgeons, 1888; served during the
World War; aged 72; died, October 8, of coronary occlusion
and arteriosclerosis.

Welland A. Peck, Scranton, Pa.; Medico-Chirurgical Col-
lege of Philadelphia, 1899; member of the Medical Society of
the State of Pennsylvania; aged 70; died, September 20, of
acute endocarditis.

Albert Warren Stearns Jr., Billerica, Mass. ; Tufts College
Medical School, Boston, 1939; aged 25; died, September 5, in
the Huntington Memorial Hospital, Boston, of Ewing's sarcoma
of the left ileum.

Amelia Weicksel, Perkasie, Pa.; Woman’s Medical College
of Pennsylvania, Philadelphia, 1904; aged 78; died, September 1,
in the Grand View Hospital, Sellersville, of cerebral thrombosis
and myocarditis.

William Henry Christian, Pittsburgh; Leonard Medical
School, Raleigh, N. C., 1905; member of the Medical Society
of the State of Pennsylvania ; aged 61; died September 23, of
aortic stenosis.

Joseph B. Cowen, Hamilton, Ohio; Medical College of
Ohio, Cincinnati, 1S97 ; aged 63 ; on the staffs of the Fort
Hamilton Hospital and Mercy Hospital, where be died,
October 2.

William M. Wilson $ Wcaverville, Calif. ; College of
Medical Evangelists, Los Angeles, 1931 ; aged 40; died, Septem-
ber 10, of chronic nephritis, hypertension and cerebral hemor-
rhage.

Guy Ross Caley, Princeton, Minn.; University of Minne-
sota College of Medicine and Surgery, Minneapolis, 1900; aged
63; died, September 26, of heart disease and chronic nephritis.

John William Adams, Waterville, Wash.; Jefferson Medi-
cal College of Philadelphia, 1887; formerly county health
officer; aged 78; died, October 10, in a hospital at Wenatchee.

William Lamar Law, Prattville, Ala.; Tulane University
of Louisiana School of Medicine, New Orleans, 1894; aged 6S;
died, October 13, in a hospital at Atlanta, Ga., of myocarditis.

John William Greer, Franklin, Tenn. ; Memphis Hospital
Medical College, 1899; member of the Tennessee State Medical
Association ; aged 69 ; died, October 16, of coronary thrombosis.

Ira A. Griffin, Snyder, Texas ; Memphis (Tenn.) Hospital
Medical College, 1908; member of the State Medical Association
of Texas; aged 55; died, October 2, of cirrhosis of the liver.

Charles A. Haefner, Youngstown, Ohio; Central College of
Physicians and Surgeons, Indianapolis, 1905; aged 64; died,
October 10, in St. Elizabeth’s Hospital of diabetes meliitus.

William D. Wilkinson, Boston; Middlesex College of
Medicine and Surgery, Waltham, Mass., 1928; aged 40; was
found dead, September 23, of a self-inflicted bullet wound.

Frederick Rutherford Warnock, Pembroke, Mass.;
Columbia University College of Physicians and Surgeons, New’
York, 1937; aged 28; died, September 12, of appendicitis.

Carlyle Junius Edwards, Raleigh, N. C. ; Medical College
of Virginia, Richmond, 1917 ; member of the Medical Society
of the State of North Carolina; aged 50; died, September 30.

Edwin Justus Haster, Dardanelle, Ark.; Kansas City
(Mo.) College of Medicine and Surgery, 1924; mifmber of the
Arkansas Medical Society; aged 39; died, September 24.

Charles Gowen Buchanan Klophel, Ontario, Calif.; Col-
lege of Physicians and Surgeons of Chicago, 1887 ; aged /-.
died, September 17, of heart disease and arteriosclerosis.

William E. Jinkins, Charleston, Miss.; Louisville (Ky)
Medical College, 1887; at one time mayor of Eupora; formerly
county health officer; aged 73; died, September 2 S.

Daniel E. Richards, San Diego, Calif.; Western Pennsyl-
vania Medical College, Pittsburgh, 1S94 ; aged SI ; died, Septem-
ber 4, of arteriosclerosis and coronary occlusion.

Mark Johnson Williams, Oxford, Ala.; Birmingham Medi-
cal College, 1902; member of the Medical Association ot 1
State of Alabama ; aged 61 ; died, September 23.

Eugene Wolcott Whitney, La Mesa, Calif.; Rush Medical
College, Chicago, 1878; past president of the Utah State Me
cal Association; aged 85; died, September 26.

Edward Gardner De Wolf, Somerville, Mass.; Darimout'
Medical School, Hanover, N. H., 1893; aged 70; died, Sept
ber 29, in Worcester of bronchopneumonia.

John Albert Wilson © New York; Columbia University
College of Physicians and Surgeons, New York, 111'.

52 ; died, September 5, in Nantucket, Mass. _ f

Harold Kirby, Minneapolis; University of the City «
New York Medical Department, 1891 ; aged 71 ; died, Sept
ber 23, in Louis Park, Minn., of sarcoma,

Rasmus Hansen Madsen, Palo Alto, Calif. ; Umver.^y
of California Medical Department, San Francisco, 12Ui,
September 22, in the Palo Alto Hospital. _

Harvey Jason Hassard, Portage la Prairie, Man., >

Trinity Medical College, Toronto, Onf., 1901; aged 6 ,
September 29, of coronary occlusion. „ ....

Willis J. Evans, Denver; Long Island College Hosp .-
Brooklyn, 1905; veteran of the Spamsh-Aniencan War,

65; died, October 3, of myocarditis. . . of

James Edward Childs San Diego, Calif.; Dnncrs J^^
Michigan Department of Medicine and Surgerj, Ann ,

1S89; aged 78; died, September 5. , mtlece

Frank L. Harold, Richmond Bid. ; Physio-Medical Col #f
of Indiana, Indianapolis, 1904 ; aged 60; died, October
acute nephritis and enterocolitis.

Daniel Alfred Stubbs, Oxford Pa.; in

College of Philadelphia, 3S74; aged 8/; died, September -
\Yest Chester of pneumonia. r , (b;

Frank Dudley McCulloch, Moose Jaw, Sasl E. ^ •
McGill University Faculty of Medicine, Montreal, Q u ••
aged 40; died, September 8.

Ernest Maxwell Fine, Crescent City Cab f. ; Cooper .
cal College, San Francisco, 1898; aged 66; died, Se[t
of cerebral hemorrhage.

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2078

CORRESPONDENCE

Jour. A. M. A.
Dec. 2, im

Correspondence

THE PSYCHOLOGY OF THE BIRTH
CONTROL CONTROVERSY

To the Editor:— In The Journal October 21 appears an
article by Dr, George Kosmak with regard to birth control.

Dr. Kosmak refers to the “hysteria" of some one or other
connected with the birth control movement • he refers to an
“insane” approach and the “agitation” of many people. He
refers to “loose thinking” and again to their “hysteria,” to their
“viciousness” and to their “inadequate reasoning.”

Dr. Kosmak uses these psychiatric designations as if to con-
trast his own mental poise with the mental ill health of those
with whom he doesn’t agree. I am well acquainted with the
persons who are chiefly responsible for having brought the
problem of birth control to the more serious attention of our
profession and of the public generally, and in my capacity as a
psychiatrist I must offer the opinion that no signs of hysteria,
insanity, viciousness or agitation have made their appearance.
On the contrary, I should say that far more quiet, intelligent
reflection and far less emotion have been manifested by them
than by Dr. Kosmak in his somewhat excited diatribe against
them.

Dr. Kosmak is entirely correct in saving that the question
deserves scientific study, and this is precisely what the non-
professional advocates of birth control have sought. There is
nothing to prevent Dr. Kosmak’s doing this without denounc-
ing those earnest and honest individuals, all of them friends of
the medical profession, who have brought this problem out of
the realm of prudish and bigoted suppression to the point
where the scientific intelligence of Dr. Kosmak and others can
be applied to its solution.

Karl Menninger, M.D., Topeka, Kan.

[Dr. Menninger’s letter was submitted to Dr. Kosmak, who
replied as follows

To the Editor: — I had fully expected reactions to my paper
such as those enunciated by Dr. Menninger. Notwithstanding
his doubts about my designation of certain groups of “birth
control” enthusiasts as hysterical and given to exaggeration and
loose thinking, I feel that my judgment of their activities will
be generally endorsed by many fair minded members of the
profession as well as by laymen who can trace the connection
between their propaganda and the widespread results of the
desire for avoiding pregnancy under all circumstances. In this
connection one might also refer to the disgusting commercial
exploitation of contraceptive devices which is encountered on
every hand and which may be regarded as a response to the
public dissemination of the literature and utterances of propa-
gandist groups. One cannot question the sincerity of the rational
advocates of birth control for medical and, perhaps, limited social
indications, but my particular condemnation applies to the more
radical groups who have fathered the extensive newspaper,
magazine and other publicity with which a perfectly legitimate
movement has been surrounded and which has worked to its
detriment. The terms which I employed in my paper to desig-
nate those activities would be applicable in common parlance,
although they may not agree with the more scientific (?) diag-
nostic designations of the psychiatrist. In view of the many
commendatory letters received, my views evidently met. the
approval of those less hampered by such academic distinctions.

As for any expressions of friendliness toward the medical
profession from certain advocates of the unrestrained dissemina-

tion of birth control information as claimed by Dr. Menninger,
this has been developed, in my opinion, largely as a matter of
expediency only in more recent years.

A careful reading of my paper would have disclosed to Dr.
Menninger that I made no accusations whatever against those
earnest and sincere persons who have approached the problem
as a health or social measure in a purely professional sense. But
these are not the people to whom I refer, and one need not
seek very far to learn the identity of the others.

Physicians as a class must be accused of indifference and
laxity in their attitude toward the important questions involved
in the subject of wliat is popularly but erroneously designated
as “birth control.” If they can be stimulated to assume their
responsibilities in the matter, this would prove a satisfactory
ending to the discussion and constitute a sufficient reason for
the attention which my own small effort may have generated.

George W. Kosmak, M.D., New York.

REDUCTION OF MOTOR ACCIDENTS

To the Editor: — The most serious medical problem in the
United States today is the motor accident. A special committee
should study this problem from all angles, such as (1) road
construction, (2) proper universal marking of roads, (3) car
construction, (4) education of the public, and (S) proper medical
care.

As coroner of a small county of 80,000 population, I have
tried to reason “the why of accidents” in this locality. Con-
trary to most people’s belief, alcohol and too fast driving are
not the chief causes. The usual cause is lack of proper judg-
ment on the part of the driver. Judgment depends on the con-
dition of the driver, the condition of the road, road markings,
construction of the car, the weather and an estimate of the
speed of an approaching car.

In the fatal accidents of this county I have noted the part
of the car that I thought responsible for the accident. If all
coroners would report such observations to an American Medi-
cal Association committee, I believe that, through recommenda-
tions, the automobile death toll in the future might be reduced
in place of gradually rising higher and higher.

The following suggestions are based on my persona! study
of accidents resulting in death in Linn County, Iowa, during
the past four years.

Compulsory Driver’s Test After an Accident. — The driver in
an accident case should be compelled to take a driver’s test.
The committee might advise all states to frame a law making
it compulsory for any driver involved in an accident to take
another driver’s test before driving a car again. Those failing
to pass should be refused a new license until the defect in tl' e
car is corrected or the driver's abnormality is properly remedied-

Road Markings . — Knowing that many drivers have defective
vision — not properly corrected — and that persons with good
vision often cannot read letters of 6 inches through dirty wind-
shields off the side of the road when traveling in a ear at
40 miles an hour, I suggest that the signs for traffic safety
should be on the pavement, directly' in the lane of best vision.
No fatal accident, which any sign could prevent, happens "hen
snow covers the pavement, the only objection to “on pavement
signs.

Safer Car Construction. — Desiring more safety for myscU am
family I shall herewith order the first 1941 popular priced cat
(any' make) constructed according to the following safety ideas.

1.’ Bumper All Around: A bumper running: entirely around
the car (removable section to change tires). In most fata

Volume 113
Number 23

CORRESPONDENCE

2079

accidents the bumper of one car catches into the front or rear
wheels of the other car and both turn over, or the end of the
front bumper is pushed into the front wheel and the car darts
off the road.

2. Turtle or Helmet-Shaped Body: Artists have streamlined
the tops of cars, but the bottom still has protruding fenders
and door handles. The body should be brought out to the
bumper on the sides at the bottom so that the fenders are entirely
beneath the body. The running board— if any— should also be
covered by the body of the car. Door handles should be hinged
and dropped into a well in the door.

3. Knock Out Windshield: With safety glass in the wind-
shield, the doctor now sees severe head and neck injuries. The
windshield should be so designed that a force of SO pounds from
the inside would loosen the entire windshield without break-
ing it.

Other desirable features are the steering wheel constructed
of material that will bend but not break. There should be no
sharp corners on the instrument panel. A strong support should
be placed behind the engine to keep the • engine from being
pushed back against the front seat in case of collision. There
should be no sharp ornaments near the front of the car.

B. L. Knight, M.D., Cedar Rapids, Iowa.

Coroner of Linn County.

THE ERYTHROCYTE SEDIMENTATION
TEST

To the Editor : — In a recent issue of The Journal (Sep-
tember 2, p. 942) appeared an editorial on the technic of the
erythrocyte sedimentation test. In this editorial an article by
Hambleton and Christianson (Aw. J. M. Sc. 198:177 [Aug.]
1939) was cited in which the authors concluded that the “most
commonly used sedimentation technic, without involving com-
plicated corrective procedures, is the most valuable for clinical
purposes.” The editorial closes with the remark that “this
furnishes welcome news to the vast majority of those using
the blood sedimentation test in their office and hospital work."

Of course, any report which purports to simplify the technic
of a laboratory procedure to such an extent that the general
practitioner can carry out the test in his office is welcome
news to him and also to the technicians who must do the
test. Unfortunately, in most cases the so-called simplification
entails the omission of vital steps in the procedure, and this
seriously detracts from the reliability of the results. In the
case of the apparently simple sedimentation test there are many
factors which must be taken into account if results worth the
effort are to be obtained.

In an article on the sedimentation rate of erythrocytes,
Ham and Curtis ( Medicine 17:447 [Dec.] 1938) have indi-
cated some of the technical factors responsible for variations
in the results obtained in tests made on a single specimen of
blood, based on a review of the literature and careful experi-
ments carried out by themselves. The following are some of
the points in the technic which affect the sedimentation rate:
1. Tiie rate has been found to be more rapid at higher tem-
peratures. 2. If the tube is inclined away from the vertical,
the rate is considerably increased. 3. Other things being equal,
the sedimentation rate is higher for lower concentrations of the
erythrocytes.

For an understanding of the significance of the results of
sedimentation tests, it is essential to know on what properties
of the blood the rate of sedimentation depends. It is obvious
that the greater the difference in specific gravity between the
red cells